Medial Branches Of Dorsal Rami Research Articles

Perineural Therapy in Treatment of Chronic DegenerativeLumbosacral Lesions

AbstractBackground: Low Back Pain (LBP) is the most frequenttype of musculoskeletal pain. “It is often recurrent and oftenhas important socio-economic consequences.Aim of Study: The aim of this study is to evaluate efficacy of perineural injection in treatment of chronic low back pain due to degenerative lumbosacral lesions among sample of Egyptian population.Patients and Methods: A prospective randomized casecontrolled study was performed on forty patients with subacuteand chronic low back pain; they were diagnosed clinicallyand radiologically as having degenerative disc lesion. Thepatients were randomly divided in two groups. In group 1,twenty patients received PNI sessions, the injection was doneonce weekly for 8 sessions with dextrose 5% (500ml) bufferedwith 2.4ml sodium bicarbonate (8.4% concentration). In eachsession; 5-10ml was injected subcutaneously with insulinsyringe with angle of introduction 30-40 degrees which targets:Pain located in thoraco-dorsal fascia, the fascia of the erectorspinae muscles along T10 to L2 dorsal rami, interspinoustenderness from medial branches of dorsal rami, superiorcluneal nerve at 7-8 cm from middle line cross the iliac crest& T10 cross over iliac crest at a distance 8-10cm. In group2, twenty patients received physical rehabilitation programTranscutaneous Electrical Nerve Stimulation (TENS), Ultra-sound (US), infrared light (IR) and massage if needed+ homeexercise) 3 days per week 1 day apart for 4 weeks.Results: Our forty cases were 17 males and 23 females;their mean age was 36.8±4.7. Significant improvement inROM post-treatment in the group 1 compared to group 2. Ahighly statistically significant difference in VAS (VisualAnalogue Scale) and Oswestry Disability Index (ODI) scorespost-treatment in group 1 compared to the group 2. PNI wassignificantly associated with higher improvements measuredby VAS, ROM and ODI when compared with group 2. Signif-icant positive correlation between age and disease durationin the 1st group. Significant positive correlations betweenROM & VAS. ODI change showed significant positive corre-lation with age and VAS change in group 1. In the 1st group;VAS change showed significant positive correlations witheach of flexion tips to floor change and lateral flexion. In the 2nd group; VAS change showed positive correlations withflexion change, flexion tips to floor change and lateral flexion.Group 1 showed more positive correlations regarding ROMdue to improvement of pain score.Conclusion: PNI with Dextrose 5% achieved short termimprovement in pain and functional abilities in patients withlow back pain secondary to degenerative lumbosacral disclesions at least for a short-term. The degree of improvementof pain and functional abilities was higher in the group thatreceived PNI compared to the group that received physicalrehabilitation program.

Facet Joint Injection versus Radiofrequency Facet Neurotomy for Treatment of Lumbar Facet Joint Arthropathy

Background Data: The facet arthropathy is the source of persistent low back pain that could refer to both lower limbs. The referred lower limb pain of facet origin may refer to the proximal lower extremities, buttocks, and/or back. The medial branches of the dorsal rami are the main innervations of the facet joints. Blocking pain transmission through these medial branches can be performed by conventional nerve block, intra-articular injection, and radiofrequency ablation.Purpose: The aim of this study was to compare the therapeutic benefits of the conventional facet joint block and the non pulsed radiofrequency denervation to the medial branches of dorsal rami in the treatment of facet arthropathy in non-surgical patients.Study Design: This study was a randomized clinical study included 58 patients suffering from chronic back pain due to facet joint arthropathy.Patients and Methods: Fifty-eight patients were included in this study. The outcome measure was: the visual analogue score (VAS) for low back pain. Patients were randomized into two groups: Group A: included 29 patients who were subjected to conventional facet join injection with steroids. Group B: included 29 patients who were subjected to radiofrequency denervation of the facet joints. All patients were regularly assessed through the follow up period of six months post intervention.Results: The study included 58 patients, 26 males; the mean age was 42.2±9.57 years. In group A, who had facet steroids injection, the mean preoperative VAS was 4.86±0.97, the mean post injection at one-week VAS was reduced to 4.29±0.94, at three months the mean VAS was 4.11±0.84, and at the sixth months; it dropped to 2.64±0.91. Preoperative and after six months VAS changes were not significant (P=0.1654). In group B, who had facet radiofrequency ablation, the mean preoperative VAS was 4.73±0.2, the mean post injection at one-week VAS was reduced to 3.40±0.12, at three months the mean VAS was 2.63±0.18, and at the sixth months it dropped to 1.8±0.14. Preoperative and after six months VAS changes were significant (P=0.0012).Conclusion: Both facet joint steroids injection and radiofrequency ablation have a significant result in non-surgical management of low back pain due to facet arthropathies. None-pulsed radiofrequency ablation has better results in pain relief at the third and sixth month post intervention when compared to facet steroids injection. (2018ESJ164)

Lordosis manoeuvre in the diagnosis of lumbar facet syndrome

In lumbar pain patients an aetiopathogenic diagnosis leads to a better management. When there are alarm signs, they should be classified on an anatomical basis through anamnesis and physical examination. A significant group is of facet origin (lumbar facet syndrome [LFS]), but the precise clinical diagnosis remains cumbersome and time-consuming.In clinical practice it is observed that patients with an advanced degenerative disease do not perform extension or rotation of their lumbar spine when prompted to extend it, but rather knee flexion, making the manoeuvre meaningless. For this reason, a new simple and quick clinical test was developed for the diagnosis of lumbar facet syndrome, with a facet block-test as a confirmation. HypothesisThe new test is better than a classic one in the diagnosis of facet syndrome, and probably even better than imaging studies. Materials and methodsA prospective study was conducted on a series of 68 patients (01/01/2012–30/06/2013). A comparison in between: classic manoeuvre (CM), imaging diagnostics (ID), and the new lordosis manoeuvre (LM) test. Examination and block test by one author, and evaluation of results by another one. Exclusion criteriaDeformity and instability using a physical. ObjectiveTo determine the effectiveness of a new clinical test (LM) for the diagnosis of LFS (as confirmed by a positive block-test of medial branch of dorsal ramus of the lumbar root, RMRDRL). StatisticsR package software. ResultsThe LM was most effective (p<.0001; Kappa 0.524, p<.001). There was no correlation between either the CM or ID and the block-test results (Kappa, CM: 0.078; p=.487, and ID: 0.195; p=.105).There was a correlation between ID (CAT/MR) and LM (p=.024; Kappa 0.289 p=.014), although not with CM. There was no correlation between ID (plain X-rays) and CM or LM. ConclusionsA new test for diagnosis of LFS is presented that is reliable, quick, and simple.Clinical examination is more reliable than imaging test for the diagnosis of LFS.

Minimally Invasive Pain Procedures

Preserving normal tissue during surgery has become increasingly important for better outcome after operation. Because of this, minimally invasive procedures have been developed. There are many pain procedures with minimally invasive method to aid fluoroscopy. The percutaneous vertebroplasty or kyphoplasty instead of screw fixation for many kinds of compressed fractures with 90% success rate is a good example (1). The percutaneous radiofrequency ablation of medial branch of dorsal ramus for facet mediated vertebral pains is another example with good results (2). The percutaneous trigeminal ganglion radiofrequency ablation instead of microvascular decompression in elderly people has success rate of 80% 90% (3). Spinal column stimulator and intrathecal pump implantation are expensive and useful methods of treating persistent pains such as failed back surgery syndrome and CRPS (4). Recently, the percutaneous transformational decompression of disc with ozone or laser or coblation in bulging or moderate protrusion of lumbar or cervical discs or in disco genic pain instead of discectomy or screw fixations, have become popular. In 1973, Kambin (originally Iranian orthopedic surgeon) started percutaneous decompression of disc by nucleotomy in USA (5). Later, he reported 72 percent success rate with modified Hijikata approach (6). In 1985, Onik et al. introduced nucleotomy with motorized shaver (7). Ascher performed the first laser discectomy in mid-1980s. He used Nd: YAG laser and the good to fair range response to that method was 78% (8). Minimally invasive percutaneous transforaminal endoscopic discectomy was initiated by Kambin in 1988. Kambin described The triangular safe zone in transforaminal approach in 1990 (4). Tsou and Yeung, in 2002 , reported the same efficacy for endoscopic discectomy and conventional open surgery (9). They reported 91% success rate for this approach (10). Nevertheless, there are some failed cases such as migrated fragments or high canal compromised herniation (11). With recent advances, endoscopic discectomy will gradually replace open discectomy in near future.

Efectividad de la maniobra lordosante en el diagnóstico del síndrome facetario lumbar

In lumbar pain patients an aetiopathogenic diagnosis leads to a better management. When there are alarm signs, they should be classified on an anatomical basis through anamnesis and physical examination. A significant group is of facet origin (lumbar facet syndrome [LFS]), but the precise clinical diagnosis remains cumbersome and time-consuming.In clinical practice it is observed that patients with an advanced degenerative disease do not perform extension or rotation of their lumbar spine when prompted to extend it, but rather knee flexion, making the manoeuvre meaningless. For this reason, a new simple and quick clinical test was developed for the diagnosis of lumbar facet syndrome, with a facet block-test as a confirmation. HypothesisThe new test is better than a classic one in the diagnosis of facet syndrome, and probably even better than imaging studies Materials and methodsA prospective study was conducted on a series of 68 patients (01/01/2012-30/06/2013). A comparison in between: classic manoeuvre (CM), imaging diagnostics (ID), and the new lordosis manoeuvre (LM) test. Examination and block test by one author, and evaluation of results by another one. Exclusion criteriaDeformity and instability. using a physical. ObjectiveTo determine the effectiveness of a new clinical test (LM) for the diagnosis of LFS (as confirmed by a positive block-test of medial branch of dorsal ramus of the lumbar root, RMRDRL). StatisticsR package software. ResultsThe LM was most effective (p<.0001; Kappa 0.524, p<.001). There was no correlation between either the CM or ID and the block-test results (Kappa, CM: 0.078; p=.487, and ID: 0.195; p=.105).There was a correlation between ID (CAT/MR) and LM (p=.024; Kappa 0.289 p=.014), although not with CM. There was no correlation between ID (plain X-rays) and CM or LM. ConclusionsA new test for diagnosis of LFS is presented that is reliable, quick, and simple.Clinical examination is more reliable than imaging test for the diagnosis of LFS.

Clinical Anatomy and Measurement of the Medial Branch of the Spinal Dorsal Ramus.

Percutaneous block and neurotomy of the medial branch of the spinal dorsal ramus has shown excellent results in treating facet joint-mediated low back pain. This study aimed to describe the clinical anatomy of the medial branch and its measurements.We dissected the lumbar spine of 12 adult cadavers (24 sides) and measured the distances between the medial branch and various anatomical landmarks. The distances were compared between L1 and L5 vertebrae.The distance between the dorsal ramus bifurcation and the superior border of the root of the transverse process was 3.52 ± 1.15 mm, 3.63 ± 1.36 mm, 3.46 ± 1.31 mm, 3.38 ± 1.24 mm, and 1.87 ± 0.88 for L1 to L5, respectively. The medial branch of the dorsal ramus is enclosed in a fibro-osseous canal bounded by the accessory process, the mammillary process, and the mammilloaccessory ligament.For the percutaneous treatment of block and neurotomy, the first choice of target is the medial branch fibro-osseous canal near to the accessory process. The accessory process is not displayed in x-ray films; therefore, the junction of the superior articular process and the root of the transverse process can be targeted.

Unusual clinical presentations of cervical or lumbar dorsal ramus syndrome.

ObjectivePatients with cervical (CDRS) or lumbar dorsal ramus syndrome (LDRS) are characterized by neck or low back pain with referred pain to upper or lower extremities. However, we experienced some CDRS or LDRS patients with unusual motor or bladder symptoms. We analyzed and reviewed literatures on the unusual symptoms identified in patients with CDRS or LDRS.MethodsThis study included patients with unusual symptoms and no disorders of spine and central nervous system, a total of 206 CDRS/LDRS patients over the past 3 years. We diagnosed by using double diagnostic blocks for medial branches of dorsal rami of cervical or lumbar spine with 1% lidocaine or 0.5% bupivacaine for each block with an interval of more than 1 week between the blocks. Greater than 80% reduction of the symptoms, including unusual symptoms, was considered as a positive response. The patients with a positive response were treated with radiofrequencyneurotomy.ResultsThe number of patients diagnosed with CDRS and LDRS was 86 and 120, respectively. Nine patients (10.5%) in the CDRS group had unusual symptoms, including 4 patients with motor weakness of the arm, 3 patients with tremors, and rotatory torticollis in 2 patients. Ten patients (8.3%) in the LDRS group showed unusual symptoms, including 7 patients with motor weakness of leg, 2 patients with leg tremor, and urinary incontinence in 1 patient. All the unusual symptoms combined with CDRS or LDRS were resolved after treatment.ConclusionIt seems that the clinical presentationssuch as motor weakness, tremor, urinary incontinence without any other etiologic origin need to be checked for unusual symptoms of CDRS or LDRS.

The effectiveness of endoscopic radiofrequency denervation of medial branch for treatment of chronic low back pain.

ObjectiveThe aim of this study is to evaluate the clinical results of endoscopic radiofrequency ablation of medial branch in patients with chronic low back pain originating from facet joints.MethodsBetween October 2010 and December 2013, 52 consecutive patients had suffering from chronic low back pain had undergone endoscopic radiofrequency denervation of medial branch of dorsal ramus. The clinical outcomes of these 52 patients were reviewed retrospectively. Preoperative and postoperative Visual Analogue Scale (VAS) and Korean version of Oswestry Disability Index (K-ODI), and patients' satisfaction with the procedure were assessed.ResultsThe pain scores on the VAS for back pain had improved significantly from a preoperative mean of 7.1 to a postoperative mean of 2 at the last follow-up (p<0.001). The clinical outcomes based on the K-ODI had also improved significantly from a preoperative mean of 26.5% to postoperative mean of 7.7% at the last follow-up (p<0.001). 80% of patients were satisfied with the procedure. There were no complications associated with the procedure.ConclusionOur preliminary results demonstrate that endoscopic radiofrequency denervation of medial branch could be an effective alternative treatment modality for chronic back pain originating from facet joints that provides long-term pain relief.

Anatomical analysis of medial branches of dorsal rami of cervical nerves for radiofrequency thermocoagulation.

Cervical medial branch blocks are used to treat patients with chronic neck pain. The aim of this study was to clarify the anatomical aspects of the cervical medial branches to improve the accuracy and safety of radiofrequency denervation. Twenty cervical specimens were harvested from 20 adult cadavers. The anatomical parameters of the C4-C7 cervical medial branches were measured. The 3-dimensional computed tomography reconstruction images of the bone were also analyzed. Based on cadaveric analysis, most of the cervical dorsal rami gave off 1 medial branch; however, the cervical dorsal rami gave off 2 medial branches in 27%, 15%, 2%, and 0% at the vertebral level C4, C5, C6, and C7, respectively. The diameters of the medial branches varied from 1.0 to 1.2 mm, and the average distance from the notch of inferior articular process to the medial branches was about 2 mm. Most of the bifurcation sites were located at the medial side of the posterior tubercle of the transverse process. On the analysis of 3-dimensional computed tomography reconstruction images, cervical medial branches (C4 to C6) passed through the upper 49% to 53% of a line between the tips of 2 consecutive superior articular processes (anterior line). Also, cervical medial branches passed through the upper 28% to 35% of a line between the midpoints of 2 consecutive facet joints (midline). The present anatomical study may help improve accuracy and safety during radiofrequency denervation of the cervical medial branches.

Corresponding Scapular Pain with the Nerve Root Involved in Cervical Radiculopathy

To correspond scapular pain with the nerve root involved in cervical radiculopathy. In the anatomic study, 11 Japanese adult cadavers were dissected to examine the numbers and courses of the cutaneous nerves from C3 to C8 dorsal rami. In the clinical study, 14 men and 11 women aged 34 to 77 years who presented with scapular pain as well as pain, numbness or motor weakness in the upper limbs secondary to cervical radiculopathy were assessed. The involved nerve roots were identified based on the symptoms and signs in the arm and/ or fingers, the radiological diagnosis, and the pain response to cervical nerve root blocks. The sites and characteristics of radicular pain were assessed. In the anatomic study of 22 cutaneous nerves from medial branches of dorsal rami, 18 involved the C5 nerve root, 0 the C6 root, one the C7 root, and 8 the C8 root. In the clinical study, the radicular pain often occurred in the suprascapular region involving the C5 root, in the suprascapular to posterior deltoid region involving the C6 root, in the interscapular region involving the C7 root, and in the interscapular and scapular regions involving the C8 root. All patients with C5 or C8 radiculopathy had both superficial and deep pain, whereas almost all patients with C6 or C7 radiculopathy had deep pain only. No patient had superficial pain only. Cervical radiculopathy can cause scapular pain. Pain sites and characteristics are related to the affected nerve root.

A Comparison of Conventional and Pulsed Radiofrequency Denervation in the Treatment of Chronic Facet Joint Pain

The goal of this study was to compare the effects of conventional radiofrequency (CRF) and pulsed RF (PRF) denervation to medial branches of dorsal rami in the treatment of facet joint pain. The patients greater than 17-year old, with continuous low back pain with or without radiating pain with focal tenderness over the facet joints, pain on hyperextension, absence of neurologic defect, unresponsiveness to conservative treatment, no radicular syndrome, and no indication for low back surgery were included in the study. Local anesthetic was applied in the control group (n=20), whereas 80 degrees C CRF were applied in the CRF (n=20) and 2 Hz PRF were applied in the PRF group (n=20). Pain relief was evaluated by visual analog scale (VAS) and Oswestry Disability Index (ODI) at preprocedure, at procedure, at 6 months and 1 year after the procedure. Reduction in analgesic usage, patients' satisfaction, and complications were assessed. Mean preprocedural VAS and ODI scores were higher than postprocedural scores in all groups. Both VAS and ODI scores of PRF and CRF groups were lower than the score of the control group at the postprocedural evaluation. Although decrease the pain score was maintained in the CRF group at 6 months and 1-year period, this decrease discontinued in the PRF group at the follow-up periods. The number of patients not using analgesics and patient satisfaction were highest in CRF group. PRF and CRF are effective and safe alternatives in the treatment of facet joint pain but PRF is not as long lasting as CRF.

Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain

BACKGROUND CONTEXT: Chronic zygapophyseal joint arthropathy is a cause of back and neck pain. One proposed method of treating facet joint pathology is ablation of medial branches and dorsal rami with pulsed radiofrequency (RF) waves. PURPOSE: Assessment of efficacy of pulsed RF application for treatment of chronic zygapophyseal joint pain. STUDY DESIGN/SETTING: Retrospective study of 114 patients at a pain management clinic. PATIENT SAMPLE: A total of 114 patients with clinical signs of facet joint involvement and a favorable response to a diagnostic medial branch block using local anesthetic, including 82 females and 32 males with a mean age of 52.8±12.6 years. Mean duration of pain was 7.52±5.26 years. Twenty-seven had previous back surgery, 83 patients had low back pain and 31 had cervical pain. Pain was on the left side in 47 patients, on the right side in 45 patients, bilateral in 22. OUTCOME MEASURES: Result was regarded as successful if pain reduction was more than 50% on visual analog scale and the duration of effect was more than 1.5 months. METHODS: After obtaining positive stimulation, pulsed RF was applied to medial branches of dorsal rami for 120 seconds with temperature at the tip of the electrode 42 C. RESULTS: Of 114 patients, who had positive response to diagnostic block, 46 patients did not respond favorably to pulsed RF application (pain reduction less than 50%). In 68 patients, the procedure was successful and lasted on average 3.93±1.86 months. Eighteen patients had the procedure repeated with the same duration of pain relief that was achieved initially. Previous surgery, duration of pain, sex, levels (cervical vs. lumbar) and stimulation levels did not influence outcomes. CONCLUSION: The results of our study showed that the application of pulsed RF to medial branches of the dorsal rami in patients with chronic facet joint arthropathy provided temporary pain relief in 68 of 118 patients.