Prevalence of facet joint pain in chronic spinal pain of cervical,thoracic, and lumbar regions

Background

Facet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice.

Methods

Five hundred consecutive patients with chronic, non-specific spine pain were evaluated. The prevalence of facet joint pain was determined using controlled comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by 0.25% bupivacaine), in accordance with the criteria established by the International Association for the Study of Pain (IASP). The study was performed in the United States in a non-university based ambulatory interventional pain management setting.

Results

The prevalence of facet joint pain in patients with chronic cervical spine pain was 55% 5(95% CI, 49% – 61%), with thoracic spine pain was 42% (95% CI, 30% – 53%), and in with lumbar spine pain was 31% (95% CI, 27% – 36%). The false-positive rate with single blocks with lidocaine was 63% (95% CI, 54% – 72%) in the cervical spine, 55% (95% CI, 39% – 78%) in the thoracic spine, and 27% (95% CI, 22% – 32%) in the lumbar spine.

Conclusion

This study demonstrated that in an interventional pain management setting, facet joints are clinically important spinal pain generators in a significant proportion of patients with chronic spinal pain. Because these patients typically have failed conservative management, including physical therapy, chiropractic treatment and analgesics, they may benefit from specific interventions designed to manage facet joint pain.

     

Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain

Lumbar zygapophysial joint arthropathy is a challenging condition affecting up to 15% of patients with chronic low back pain. The onset of lumbar facet joint pain is usually insidious, with predisposing factors including spondylolisthesis, degenerative disc pathology, and old age. Despite previous reports of a "facet syndrome," the existing literature does not support the use of historic or physical examination findings to diagnose lumbar zygapophysial joint pain. The most accepted method for diagnosing pain arising from the lumbar facet joints is with low-volume intraarticular or medial branch blocks, both of which are associated with high false-positive rates. Standard treatment modalities for lumbar zygapophysial joint pain include intraarticular steroid injections and radiofrequency denervation of the medial branches innervating the joints, but the evidence supporting both of these is conflicting. In this article, the authors provide a comprehensive review of the anatomy, biomechanics, and function of the lumbar zygapophysial joints, along with a systematic analysis of the diagnosis and treatment of facet joint pain.     

Single photon emission computerized tomography (SPECT) scan–positive facet joints and other spinal structures in a hospital-wide population with spinal pain

Background contextThe current criterion standard for zygapophyseal (facet) joint pain diagnosis is placebo-controlled triple comparative local anesthetic facet joint or medial branch blocks. Single photon emission computerized tomography (SPECT) scanning is a less invasive modality that has been widely used in patients with spinal pain for the diagnosis of facet joint arthritis. Previous studies have shown that SPECT results correlate well with response to facet joints steroid injections.PurposeTo evaluate the prevalence of SPECT scan–positive facet joints and other spinal areas in different age groups in a hospital-wide population with spinal pain.Study designRetrospective study.MethodsThis study included 534 patients who underwent a SPECT scan for spinal pain over 7.5 years in our hospital. All referrals from all doctors for any cervical or lumbar spinal pain were included, and the results were reviewed.ResultsA total of 486 patients (91.1%) had at least one positive abnormality on SPECT scan; 81.3% had increased uptake in different structures and regions of the spine. This included 42.8% increased uptake in the facet joint 29.8% in the vertebral bodies/end plates, and 5.9% in sacroiliac joints. The prevalence of increased uptake in the lumbosacral and cervical spine was 44% and 37%, respectively. When patients were divided into five age groups (below 40, 40–49, 50–59, 60–69, and 70 years and older), there was a significantly higher increased prevalence in advancing age groups.ConclusionsIn a hospital-wide population with spinal pain, there is a 42.88% prevalence of increased uptake in the facet joint on SPECT. The incidence increases significantly with advancing age. SPECT can play a role in investigating patients with spinal pain.     

脊柱内窥镜下腰脊神经背内侧支射频消融术治疗慢性腰椎小关节源性腰痛

目的探讨脊柱内窥镜下腰脊神经背内侧支射频消融术治疗中老年慢性腰椎小关节源性腰痛的近期疗效。方法采用回顾性队列研究的方法,选取2015年9月—2017年9月杭州市中医院收治的28例慢性腰椎小关节源性腰痛患者,其中14例采用脊柱内窥镜下腰脊神经背内侧支射频消融术治疗(手术组),14例采用经皮腰椎关节突关节封闭治疗(非手术组)。分别对2组患者进行电话、门诊随访,记录治疗前及治疗后1周、1个月、3个月、6个月、1年的腰痛视觉模拟量表(VAS)评分、日本骨科学会(JOA)评分和Oswestry功能障碍指数(ODI)并进行比较,评估2种治疗方案近期疗效的差异。结果治疗前2组患者VAS评分、JOA评分和ODI差异均无统计学意义(P 0.05)。治疗后2组患者各时间点VAS评分、JOA评分和ODI均较治疗前改善,其中手术组与治疗前相比差异有统计学意义(P 0.05);手术组患者VAS评分、JOA评分和ODI的改善情况均优于非手术组,差异有统计学意义(P 0.05)。结论脊柱内窥镜下腰脊神经背内侧支射频消融术治疗慢性腰椎小关节源性腰痛能够显著缓解患者症状、改善预后,近期疗效较好,相比经皮腰椎关节突关节封闭具有一定优势。     

Steroid injections: effect on pain of spinal origin

Pain originating from the spine is a common clinical problem that is often difficult to manage. This chapter considers the evidence supporting the use of corticosteroid injections for pain of spinal origin. Clinical problems considered in this review are radicular pain, zygapophyseal joint pain, discogenic pain and non-specific pain from the cervical, lumbar and thoracic spine. Issues of efficacy and adverse events are considered.No useful data were found concerning the treatment of any type of thoracic pain with corticosteroid injections. In the lumbar spine, there is evidence to support the use of transforaminal injections for radicular pain. Intradiscal and intra-articular injections in both lumbar and cervical spines have not been shown to be effective. Sacroiliitis responds well to intra-articular corticosteroids. There is insufficient evidence to support the use of atlanto-axial or atlanto-occipital joint injections.     

Persistent local pain after posterior spine surgery for thoracic lesions

Many surgeons have investigated local pain associated with posterior spine surgery for cervical or lumbar lesions. However, little information is available concerning local pain after posterior thoracic spine surgery. This prospective study was, thus, performed to investigate the frequency and clinical features of local pain after posterior spine surgery for thoracic lesions. In 29 consecutive patients undergoing posterior spine surgery for various thoracic spinal disorders, local pain was investigated before and after surgery. In all 19 patients with preoperative back pain presumably due to thoracic lesions, pain was well alleviated after surgery. In contrast, 6 patients (21%) newly developed persistent shoulder angle pain after surgery, which resembled axial pain after cervical laminoplasty. In 5 of these 6 patients surgical exposure was extended to the cervicothoracic junction, whereas persistent shoulder angle pain was independent of disease etiologies and surgical procedure, and all of the 5 patients had no other etiologies of local pain such as surgical site infections, hardware failures, pseudoarthrosis, other metastasis, and vertebral fractures. These results suggest that dissection of muscle attachments to the cervicothoracic junction would play some part in the development of persistent local pain after posterior spine surgery for thoracic lesions, although surgical exposure of the zygapophysial joints at the cervicothoracic junction might be a possible source of postoperative shoulder pain. Therefore, to minimize such surgical complications, muscle insertions into the cervicothoracic junction should be preserved as far as possible.     

Correlation of clinical examination characteristics with three sources of chronic low back pain.

BACKGROUND CONTEXT: Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac (SI) joint sources of pain. No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated. PURPOSE: To identify significant components of a clinical examination that are associated with symptomatic lumbar discs, zygapophysial joints and SI joints. STUDY DESIGN: A prospective, criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics. PATIENT SAMPLE: The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections. OUTCOME MEASURES: Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections. Statistical analysis included chi-squared test for independence, phi and odds ratios with confidence intervals. METHOD: Patients received blinded clinical examinations by physical therapists, and diagnostic injections were used as the criterion standard. RESULTS: Significant relationships were found between discogenic pain and centralization of pain during repeated movement testing, and pain when rising from sitting. Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting. Sacroiliac joint pain was related to three or more positive pain provocation tests, pain when rising from sitting, unilateral pain and absence of lumbar pain. CONCLUSIONS: Significant correlations exist between clinical examination findings and symptomatic lumbar discs, zygapophysial and SI joints. The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests, centralization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints.     

Morphological changes of cervical facet joints in elderly individuals

To better understand the role of facet joint degeneration in chronic neck and back pain epidemiological and morphological data are needed. For the cervical spine, however, such data are rare. Therefore, the aim of this study was to determine the degree of cartilage degeneration of cervical facet joints with respect to spinal level and age, to investigate whether any region of the joint surface is more often affected by degeneration and to determine the localisation of osteophytes. A total of 128 left-sided facet surfaces from 15 fresh frozen cervical spine specimens (59-92 years) including in maximum C2-C7 were inspected in a way to ensure a direct comparability to data reported for the lumbar spine. First, the macroscopic degree of cartilage degeneration was determined and correlated to spinal level and age. Then, each facet surface was divided into five regions (anterior, posterior, lateral, medial and central) to check whether cartilage degeneration occurs more often in any of these regions. Finally, the localisation of osteophytes was determined. The results showed that the mean degree of cartilage degeneration was 2.8 (+/-0.6) on a scale from Grade 1 (no degeneration) to 4 (severe degeneration). None of all 128 facet surfaces was classified as Grade 1. All spinal levels had about the same degree of degeneration (in mean 2.5-3.0). The youngest age group (<70 years) had a somewhat lower degree of degeneration (2.6) than the oldest (> or = 90 years) (3.1). Cartilage defects were found all over the joint surfaces, none of the five regions was more often affected than the others. Least osteophytes were found on the medial border of the facet joints. In conclusion, the prevalence of cervical facet joint degeneration is probably very high in individuals aged 50 years and more, with a tendency to increase in severity with age. All levels of the middle and lower cervical spine were affected to almost the same degree, whereas in the lumbar spine an increase in degeneration towards the lower levels was reported. Also, in the cervical spine in most cases the cartilage was evenly degenerated all over the joint surface while in the lumbar spine certain regions were reported to be affected predominantly.     

CT in low back pain syndrome

CT has become the imaging modality of choice for diagnosing the specific cause of low back pain syndrome. This article describes and illustrates those abnormalities commonly associated with low back pain: disk herniation, spinal stenoses, facet joint abnormalities, spondylosis, inflammatory conditions of the lumbar spine, and sacroiliitis.     

Water-diluted local anesthetic for trigger-point injection in chronic myofascial pain syndrome: evaluation of types of local anesthetic and concentrations in water

BACKGROUND AND OBJECTIVES: We have recently demonstrated that a mixture of 1% lidocaine with water in a 1:3 ratio has less injection pain and is more effective than unaltered 1% lidocaine in treating chronic myofascial pain syndromes. Yet, the most suitable local anesthetic and the most effective dilution in water have not been evaluated. METHODS: Various mixtures of local anesthetics and water or saline were injected intramuscularly into the shoulder of 40 female volunteers, and pain scores on injection were evaluated in a randomized and double-blinded manner. In another portion of the study, 0.25% or 0.2% lidocaine in water were injected randomly into 1 side of 21 outpatients with chronic neck, shoulder, or lumbar myofascial pain to the same degree in both sides. The other solution was injected into the other side of the same patients. RESULTS: Less injection pain was experienced with the water-diluted 0.25% lidocaine and water-diluted 0.25% mepivacaine than the saline-diluted 0.25% lidocaine and water-diluted 0.0625% bupivacaine. Also, less injection pain was experienced with the water-diluted 0.25% and 0.2% lidocaine than the water-diluted 0.3% and 0.15% lidocaine. In the other study, there were no differences in either the effectiveness or duration of analgesia between the 0.25% and 0.2% water-diluted lidocaine. CONCLUSIONS: The suitable type of local anesthetic may be lidocaine or mepivacaine, and the most effective water-diluted concentration is considered to be 0.2% to 0.25%.     

A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain.

BACKGROUND CONTEXT: Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent. PURPOSE: To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome. STUDY DESIGN: Evidence-based medicine analysis of current literature. METHODS: A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data. RESULTS: This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III. CONCLUSIONS: Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.     

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.     

When gout involves the spine: Five patients including two inaugural cases

Spinal involvement is uncommon during gout and may raise diagnostic challenges. We describe five cases seen at a single center.MethodsWe retrospectively reviewed the medical charts of the five patients with spinal gout seen over a 3-year period.ResultsThere were four men and one woman with an age range of 52 to 87 years. One patient presented with acute neck pain and visualization by imaging studies of a discovertebral tophus, another had febrile arthritis of a lumbar facet joint, and a third presented with a synovial cyst in a lumbar facet joint. The remaining two patients had acute febrile discitis confirmed by magnetic resonance imaging, at the cervical spine and lumbar spine, respectively. Laboratory tests showed systemic inflammation in four patients and marked serum uric acid elevation in two patients. Only three patients reported a previous history of peripheral acute gout attacks. Specimens of the spinal lesions were obtained in three patients and consistently showed monosodium urate crystals with tissue inflammation or a tophus. The outcome was rapidly favorable, either with colchicine therapy alone in four patients or after surgical resection of a facet joint cyst (during surgery to stabilize the lumbar spine) in the remaining patient. The patient with neck pain due to a tophus experienced nerve root pain at the acute phase. No other neurological manifestations were recorded.ConclusionThese case reports illustrate the diagnostic challenges raised by spinal involvement due to gout. The spinal lesions can be inaugural, as seen in two of our five patients.     

The cervical zygapophysial joints as a source of neck pain

Diagnostic cervical medial branch blocks and zygapophysial joint blocks were used to test the hypothesis that the cervical zygapophyseal joints can be the source of pain in patients with idiopathic neck pain. Complete temporary relief of all symptoms was obtained in 17 out of 24 consecutive patients. Two major groups of patients were those with neck pain and headache stemming from the C2-3 joints, and those with neck pain and shoulder pain stemming from the C5-6 joints. Internal-control observations in nine of the 17 patients established the diagnostic validity of the blocks used. The high yield of positive responders in this study probably reflects the propensity of patients with zygapophysial joint syndromes to gravitate to a pain clinic when this condition is not recognised in conventional clinical practice.     

Thoracic and lumbar spine in diastrophic dysplasia: a clinical and magnetic resonance imaging analysis

STUDY DESIGN: Cross-sectional study to evaluate the thoracic and lumbar spine in patients with diastrophic dysplasia (DD). OBJECTIVES: To find the causative factors behind the spinal deformities and restricted mobility of the spine. SUMMARY OF BACKGROUND DATA: Typical findings in this skeletal dysplasia are short-limbed stature, multiple joint contractures, early degeneration of joints, and spinal deformities such as cervical kyphosis, scoliosis, and exaggerated lumbar lordosis. The pathogenic mechanism of scoliosis is unknown. METHODS: A physical examination was performed on 88 patients (55 females, 33 males) with an average age of 31 years (range, 3-56). Magnetic resonance (MR) images from T2 to S1 and radiographs were obtained. Degree of scoliosis was measured according to Cobb from standing radiographs.The anatomy of the medulla and the size of the spinal canal were assessed. The transverse dural tube area was measured from L2 to S1. Disc space, degeneration, and protrusions were evaluated. Vertebral abnormalities, if any, facet joint degeneration and the state of the spinal muscles were also assessed. RESULTS: Physical examination showed diminished mobility of the spine. Scoliosis was noted in 70 patients with an average of 42 degrees (range, 11-188 degrees ). The mean transverse area of the dural tube ranged from 94 mm(2) at L2-L3 to 57 mm(2) at L5-S1. The area was smaller at all levels compared with reference values (P < 0.001). One patient had severe thoracic and lumbar spinal stenosis. Five patients had compression of neural structures in the lumbar spinal canal in MR images, but had no clinical symptoms. All patients exhibited narrowed disc heights and a decrease in the signal intensity of discs on T2-weighted images. The prevalence of disc protrusions was low; three patients had a prolapse in the lumbar spine. Two patients displayed vertebral anomalies. All patients also had muscular atrophy and degenerative-like facet joint hypertrophy. The severity of these changes increased with age. CONCLUSIONS: Abnormal disc structure and rapid degeneration explain the diminished decreased mobility of the spine and may be a causative factor in the development of scoliosis. Muscular atrophy may be caused by reduced physical activity and rigid spinal deformities. The spinal canal is narrowed, but symptomatic lumbar spinal stenosis is uncommon.     

Spondylolisthesis of the thoracic spine. Case report

The thoracic spine is stabilized in the anteroposterior direction by the rib cage and the facet joints. Spondylolisthesis of the thoracic spine is less common than that of the lumbar spine. The authors describe a rare case of thoracic spondylolisthesis in which the patient suffered back pain and myelopathy. The patient was a 44-year-old woman. Plain radiography revealed Grade I T11-12 spondylolisthesis. The pedicle-facet joint angle at T-11 was 118 degrees, greater than that of T-10 or T-12. Postmyelography computerized tomography scanning revealed posterior compression of the dural sac as well as enlargement of and degenerative changes in the facet joint at T-11. Magnetic resonance imaging showed anterior and posterior compression of the spinal cord at the level of the spondylolisthesis. To achieve posterior T10-12 decompression, the surgeons performed a laminectomy and posterolateral fusion in which a pedicle screw fixation system was placed. The patient's back pain disappeared immediately after the operation. The authors conclude that the enlargement of the pedicle-facet joint angle and the degenerative changes of the facet joint caused the thoracolumbar spondylolisthesis.     

超声技术应用于脊椎小关节综合征

小关节综合征是导致颈部、腰背部慢性疼痛的病因之一.目前临床上主要通过X线辅助进行小关节内注射治疗,采用内侧支神经阻滞(mediai branch blocks,MBB)或内侧支神经松解术来诊断或治疗颈椎和腰椎小关节源性疼痛.近年来,由于超声无辐射、便捷、可实时观测等优点,其作为引导工具被应用于脊椎小关节综合征的诊断和治疗中.其研究热点集中于超声技术的临床应用、相关疗效、局限性和发展前景.     

超声技术应用于脊椎小关节综合征

小关节综合征是导致颈部、腰背部慢性疼痛的病因之一.目前临床上主要通过X线辅助进行小关节内注射治疗,采用内侧支神经阻滞(mediai branch blocks,MBB)或内侧支神经松解术来诊断或治疗颈椎和腰椎小关节源性疼痛.近年来,由于超声无辐射、便捷、可实时观测等优点,其作为引导工具被应用于脊椎小关节综合征的诊断和治疗中.其研究热点集中于超声技术的临床应用、相关疗效、局限性和发展前景.