Lateral branch blocks as a treatment for sacroiliac joint pain: A pilot study

BACKGROUND AND OBJECTIVES: Pain arising from the sacroiliac (SI) joint is a common cause of low back pain for which there is no universally accepted, long-term treatment. Previous studies have shown radiofrequency (RF) procedures to be an effective treatment for other types of spinal pain. The purpose of this study was to determine the efficacy of reducing SI joint pain by percutaneous RF lesioning of the nerves innervating the SI joint. METHODS: Eighteen patients with confirmed SI joint pain underwent nerve blocks of the L4-5 primary dorsal rami and S1-3 lateral branches innervating the affected joint. Those who obtained 50% or greater pain relief from these blocks proceeded to undergo RF denervation of the nerves. RESULTS: Thirteen of 18 patients who underwent L4-5 dorsal rami and S1-3 lateral branch blocks (LBB) obtained significant pain relief, with 2 patients reporting prolonged benefit. At their next visit, 9 patients who experienced >50% pain relief underwent RF lesioning of the nerves. Eight of 9 patients (89%) obtained >/=50% pain relief from this procedure that persisted at their 9-month follow-up. CONCLUSIONS: In patients with SI joint pain who respond to L4-5 dorsal rami and S1-3 LBB, RF denervation of these nerves appears to be an effective treatment. Randomized, controlled trials are needed to further evaluate this procedure.     

Radiofrequency sacroiliac joint denervation for sacroiliac syndrome

BACKGROUND AND OBJECTIVES: Radiofrequency (RF) denervation of the sacroiliac (SI) joint has been advocated for the treatment of sacroiliac syndrome, yet no clinical studies or case series support its use. METHODS: We report the results of a consecutive series of 50 SI joint RF denervations performed in 33 patients with sacroiliac syndrome. All patients underwent diagnostic SI joint injections with local anesthetic before denervation. Changes in visual analog pain scores (VAS), pain diagrams, physical examination (palpation tenderness over the joint, myofascial trigger points overlying the joint, SI joint pain provocation tests, and range of motion of the lumbar spine), and opioid use were assessed pre- and postdenervation. RESULTS: The criteria for successful RF denervation were at least a 50% decrease in VAS for a period of at least 6 months; 36.4% of patients (12 of 33) met these criteria. Failure of denervation correlated with the presence of disability determination and pain on lateral flexion to the affected side. The average duration of pain relief was 12.0 +/- 1.2 months in responders versus 0.9 +/- 0.2 months in nonresponders (P < or = 0.0001). A positive response was associated with an atraumatic inciting event. Successful denervation was associated with a change in the pain diagram and a reduction in the pattern of referred pain, a normalization of SI joint pain provocation tests, and a reduction in the use of opioids. CONCLUSIONS: This study suggests that RF denervation of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome for a protracted time period. Moreover, certain abnormal physical findings (i.e., SI joint pain provocation tests) revert to normal for the duration of the analgesia.     

Factors predicting success and failure for cervical facet radiofrequency denervation: a multi-center analysis

BACKGROUND AND OBJECTIVES: The concept of radiofrequency denervation has recently come under question in light of several studies showing minimal to no benefit. One possibility proposed for these negative outcomes is poor selection criteria. Unlike virtually all other spine interventions, the factors associated with success and failure for cervical facet denervation have yet to be determined. The purpose of this study is to determine which demographic, clinical and treatment factors are associated with cervical facet radiofrequency denervation outcomes. METHODS: Data were garnered from 3 academic medical centers on 92 patients with chronic neck pain who underwent radiofrequency denervation after a positive response to diagnostic local anesthetic blocks. Success was defined as at least 50% pain relief lasting at least 6 months. Variables evaluated for their association with outcome included age, sex, duration of pain, opioid use, pain referral pattern, paraspinal tenderness, pain exacerbated by extension/rotation, magnetic resonance image abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery, and levels treated. RESULTS: The only clinical variable associated with success was paraspinal tenderness. Factors associated with treatment failure included radiation to the head, opioid use, and pain exacerbated by neck extension and/or rotation. CONCLUSIONS: Selecting patients based on key clinical variables may increase the chance of treatment success for cervical facet radiofrequency denervation.     

Randomized Placebo-controlled Study Evaluating Lateral Branch Radiofrequency Denervation for Sacroiliac Joint Pain

Background: Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain.

Methods: A randomized placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology after a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who did not respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology.

Results: One, 3, and 6 months after the procedure, 11 (79%), 9 (64%), and 8 (57%) radiofrequency-treated patients experienced pain relief of 50% or greater and significant functional improvement. In contrast, only 2 patients (14%) in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3 months after the procedure. In the crossover group (n = 11), 7 (64%), 6 (55%), and 4 (36%) experienced improvement 1, 3, and 6 months after the procedure. One year after treatment, only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief.     

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.     

Alternative denervation using laser irradiation in lumbar facet syndrome

BACKGROUND AND OBJECTIVE: Facet syndrome is persistent low back pain that might be treated with some surgical interventions. The target of surgical techniques is the transverse process bases where the medial nerve branches innervated the facet. However, highly variable success rates have been demonstrated in different series. STUDY DESIGN/MATERIALS AND METHODS: We carried out laser denervation to the dorsal surface of the facet capsule, where it is richly innervated with medial nerve branches. RESULTS: One year after laser denervation, 17 patients (81%) experienced complete or greater than 70% pain reduction in all 21 patients. Among the six patients who had previously undergone spinal surgery, two (33.3%) experienced successful pain relief. Overall, in four patients (19%), the response to laser denervation at 1-year follow-ups was not successful. CONCLUSION: The dorsal surface of the facet capsule might be a more preferable target for facet denervation.     

Laparoscopic adhesiolysis and relief of chronic pelvic pain.

OBJECTIVE: To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy. METHODS: Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief. RESULTS: We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically. CONCLUSION: We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.     

Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks

STUDY DESIGN: A retrospective review. OBJECTIVES: Evaluation of the prevalence of facet or zygapophysial joint pain in chronic spinal pain of cervical, thoracic, and lumbar origin by using controlled, comparative local anesthetic blocks and evaluation of false-positive rates of single blocks in the diagnosis of chronic spinal pain of facet joint origin. SUMMARY OF BACKGROUND DATA: Facet or zygapophysial joints are clinically important sources of chronic cervical, thoracic, and lumbar spine pain. The previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, with a prevalence of 15% to 67% variable in lumbar, thoracic, and cervical regions. False-positive rates of single diagnostic blocks also varied from 17% to 63%. METHODS: Five hundred consecutive patients receiving controlled, comparative local anesthetic blocks of medial branches for the diagnosis of facet or zygapophysial joint pain were included. Patients were investigated with diagnostic blocks using 0.5 mL of 1% lidocaine per nerve. Patients with lidocaine-positive results were further studied using 0.5 mL of 0.25% bupivacaine per nerve on a separate occasion. Medial branch blocks were performed with intermittent fluoroscopic visualization, at 2 levels to block a single joint. A positive response was considered as one with at least 80% pain relief from a block of at least 2 hours duration when lidocaine was used, and at least 3 hours or longer than the duration of relief with lidocaine when bupivacaine was used, and also the ability to perform prior painful movements. RESULTS: A total of 438 patients met inclusion criteria. The prevalence of facet joint pain was 39% in the cervical spine [95% confidence interval (CI), 32%-45%]; 34% (95% CI, 22%-47%) in the thoracic pain; and 27% (95% CI, 22%-33%) in the lumbar spine. The false-positive rate with a single block in the cervical region was 45%, in the thoracic region was 42%, and in the lumbar region 45%. CONCLUSIONS: This retrospective review once again confirmed the significant prevalence of facet joint pain in chronic spinal pain.     

Gamma knife surgery with a dose of 75 to 76.8 Gray for trigeminal neuralgia

OBJECT: The author presents a large series of patients with idiopathic trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS), at a maximum dose of 75 to 76.8 Gy, and followed up in a nearly uniform manner for up to 4.6 years. METHODS: Two hundred ninety-three patients were treated and followed up for at least 6 months (range 0.4-4.6 years, median 1.9 years). At the final follow-up review, there was complete (100%) pain relief without medicines in 64 patients (21.8%), 90% or greater relief with or without small doses of medicines in 86 (29.4%), between 75 and 89% relief in 31 (10.6%), between 50 and 74% relief in 19 (6.5%), and less than 50% relief in 23 patients (7.8%). Recurrent pain requiring a second procedure occurred in 70 patients (23.9%). Kaplan-Meier analysis showed that 100%, 90% or greater, and 50% or greater pain relief was obtained and maintained for 3.5 to 4.1 years in 5.6, 23.7, and 50.4% patients, respectively. Of 31 patients who described pain relief ranging from 75 to 89%, 80% of patients described it as good and 10% as excellent; of 17 patients who reported between 50 and 74% pain relief, 53% described it as good and none as excellent (p = 0.014). Dysesthesia scores greater than 5 (scale of 0-10, in which a score of 10 represents excruciating pain) occurred in four (3.2%) of 126 patients who had not undergone prior surgery; all these patients obtained either good or excellent relief from TN pain. There were 36 patients in whom the TN had atypical features; these patients were less likely to attain at least 50% or at least 90% pain relief compared with those without atypical TN features (p = 0.001). CONCLUSIONS: Gamma knife surgery is a safe and effective way to relieve TN. Patients who attain between 75 and 89% pain relief are much more likely to describe this outcome as good or excellent than those who attain between 50 and 74% pain relief.     

Utility and Prognostic Ability of a Diagnostic Injection Before Revision Total Knee Arthroplasty

BackgroundDiagnostic injections are commonly utilized in the workup of painful total knee arthroplasties (TKA), particularly when the diagnosis remains unclear. However, current literature provides limited evidence regarding the utility and prognostic capability of anesthetic injections in this scenario. This study sought to establish the role of diagnostic injections in predicting successful revision TKA.MethodsA retrospective review was conducted on 144 consecutive aseptic revision TKAs receiving diagnostic anesthetic injections. Instability (57.6%) and aseptic loosening (33.3%) comprised most revision etiologies. Patient-reported percentage pain relief after the injection was statistically correlated with KOOS JR, Knee Society Score, UCLA Activity Level, and satisfaction scores.ResultsAbout 74.3% (107/144) of revision TKAs reported >50% pain relief after injection. There were no differences in pain relief based on revision indication (P = .841). Improvement from preoperative activity level was greater in the >50% pain relief group (P = .024). Four-month patient satisfaction did not differ between patients who reported >50% and ≤50% pain relief (67% vs. 66%, P = .130). About 64% of patients who reported >50% pain relief were satisfied at minimum 1-year follow-up, compared with only 47% of those who reported ≤50% pain relief after diagnostic injection (P < .001).ConclusionStudy results show that patients reporting >50% pain relief after diagnostic injection have improvements in activity level and maintain greater satisfaction at minimum 1-year than those reporting ≤50% pain relief. Expectations for improvement after revision TKA should be tempered if diagnostic anesthetic injection yields minimal subjective pain relief.     

Combination therapy of radiofrequency lumbar facet joint denervation and epidural spinal cord stimulation for failed back surgery syndrome

An 81-year-old woman with failed back surgery syndrome (FBSS) was treated using a combination of percutaneous radiofrequency (RF) lumbar zygapophysial joint denervation and epidural spinal cord stimulation (SCS). She had undergone a staged laminectomy for narrowing of the spinal canal from L1 to S1 and degenerative spondylolisthesis at the L3-4 level. Postoperatively, in addition to low back pain (LBP) induced by dynamic motion, she began to experience intractable leg pain with a burning sensation, presumably caused by damage to the cauda equina. She initially underwent RF lumbar zygapophysial joint denervation for the LBP and subsequently underwent SCS via dual electrode leads for the leg pain. This combination therapy of RF denervation and SCS relieved the LBP almost entirely and relieved the leg pain by approximately 50%. The combination of these two minimally invasive interventions is particularly effective for severe leg pain and LBP in elderly patients or medically compromised cases with contraindications against general anesthesia, as well as in patients with FBSS.     

Cervical facet radiofrequency neurotomy

More than 50% of posttraumatic cervical pain after events such as whiplash is caused by facet joint injury. These patients present with neck pain that often radiates to the head or shoulders and is aggravated by neck movement. Imaging studies are usually negative. If diagnostic local anesthetic blocks of the facet nerves produce appropriate pain relief, then significant and long-lasting pain relief may be obtained by percutaneous cervical facet radiofrequency neurotomy. This outpatient procedure is performed by using fluoroscopy and strictly adhering to proper needle placement. Stimulation is performed before radiofrequency neurotomy to avoid sensory or motor deficits; however, temporary cutaneous dysesthesia and numbness are not uncommon. Success rates range from 60% to 70% with a duration of months to years. The procedure can be repeated if necessary. In addition to pain relief, activities of daily living can be restored, rehabilitation facilitated, and resolution of associated psychological distress can occur. Copyright © 2000 by W.B. Saunders Company     

Denervation of the proximal interphalangeal joint: a realistic and simple procedure

Pain relief in osteoarthritis of the proximal interphalangeal joint is a difficult problem. Joint denervation, a technique yielding good reproducible results in wrist and first carpometacarpal joint osteoarthritis, is, at the proximal interphalangeal joint level, a good alternative to implant arthroplasty or arthrodesis. The surgical technique is simple and may be performed under local anesthesia. Results are satisfactory with about 80% pain relief.     

Factors determining the success of radiofrequency denervation in lumbar facet joint pain: a prospective study

Background and aims  

Radiofrequency denervation (RF) of the lumbar facet joints has been shown to be effective in well-selected patients. However, long-term success varies between studies. We evaluated the influence of selected psychosocial and constitutional factors on the outcome of RF, expressed as the duration of pain relief.     

The role of radiofrequency in the treatment of mechanical pain of spinal origin

Radiofrequency (RF) ablation is a method that has been gaining popularity over the past few years among spinal surgeons. It has a role when dealing with pain of spinal origin, either mechanical or neuropathic, after conservative treatment has failed. In the present study, 122 patients with a minimal follow up of 1 year were examined at our institution after having undergone RF heat lesion of the medial branch for mechanical spinal pain (low back pain, thoracic pain or cervical pain). They were followed up 1, 3, 6 and 12 months after treatment. Twenty-two of them were additionally followed up at 18 months. After 1 month, 91 patients (75%) were satisfied with the results. After 3 months, 87 patients (71%) had significant pain relief, while in 35 patients (29%) there was no improvement. After 6 months of follow-up, 80 patients (66%) had pain relief and in 42 patients (34%) there was no effect. At 12-months follow-up, 77 patients (63%) showed good results and 45 patients (37%) had no effect. In the case of the 22 patients who were followed for 18 months, all showed significant pain relief. Minor complications occurred in 27 patients (22%), who had transient discomfort and burning pain. We concluded that RF is a safe and partially effective procedure for mechanical back pain.     

Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenervation of lumbar facet joints

BACKGROUND AND OBJECTIVES: At many institutions, it is not practically feasible to perform a series of controlled or placebo-controlled medial branch blocks on several facet joints in order to select patients for facet joint rhizotomy. As for uncontrolled blocks, there is no proof that medial branch blocks are superior to other types of blocks. This study was performed to compare medial branch blocks to simple pericapsular blocks for the selection of patients for lumbar facet joint cryodenervation. METHODS: Patient selection was based on history, imaging, and physical examination. Diagnostic blocks were either medial branch blocks or pericapsular blocks. Percutaneous medial branch cryodenervation was performed by use of a Lloyd Neurostat 2000. Outcome parameters were low back pain (visual analog scale [VAS]), limitation of activity (Macnab), and overall satisfaction. A total of 26 patients were recruited, 13 for each group. Follow-up was 6 months. RESULTS: Patients who had been selected by medial branch blocks had better pain relief than did patients who had been diagnosed by use of pericapsular blocks. At 6 weeks and at 3 months after treatment, these results reached statistical significance (VAS 2.2 v 4.2, P < .05). CONCLUSIONS: Our results suggest that uncontrolled medial branch blocks are superior to pericapsular blocks in selecting patients for facet joint cryodenervation, but both blocks work. If serial controlled blocks cannot be used, lumbar facet joint pain remains a diagnostic dilemma.     

A preliminary review of the use of deep peroneal neurectomy for the treatment of painful midtarsal and tarsometatarsal arthritis

This report describes a retrospective analysis of chart and radiographic data pertaining to 10 consecutive cases performed over a 30-month period, undertaken in an effort to evaluate the preliminary efficacy of denervation for pain relief in high-risk surgical candidates with midfoot and tarsometatarsal joint arthritis. Ten patients (13 feet) were treated, and objective and subjective assessments were obtained using an index of subjective patient satisfaction. Results revealed 9 (69.2%) feet from 7 (70%) patients had greater than 75% relief. Two (15.4%) feet from 2 (20%) patients had at least 50% improvement and 2 (15.4%) feet from 1 (10%) patient claimed no relief. Our results indicate that this method of treatment can be an effective way to relieve pain associated with arthrosis involving the midfoot and tarsometatarsal joints.     

Systemic alpha-adrenergic blockade with phentolamine: a diagnostic test for sympathetically maintained pain.

The diagnosis of sympathetically maintained pain (SMP) is typically established by assessment of pain relief during local anesthetic blockade of the sympathetic ganglia that innervate the painful body part. To determine if systemic alpha-adrenergic blockade with phentolamine can be used to diagnose SMP, we compared the effects on pain of local anesthetic sympathetic ganglion blocks (LASB) and phentolamine blocks (PhB) in 20 patients with chronic pain and hyperalgesia that were suspected to be sympathetically maintained. The blocks were done in random order on separate days. Patients rated the intensity of ongoing and stimulus-evoked pain every 5 min before, during, and after the LASB and PhB. Patients and the investigator assessing pain levels were blinded to the time of intravenous administration of phentolamine (total dose 25-35 mg). The pain relief achieved by LASB and PhB correlated closely (r = 0.84), and there was no significant difference in the maximum pain relief achieved with the two blocks (t = 0.19, P greater than 0.8). Nine patients experienced a greater than 50% relief of pain and hyperalgesia from both LASB and PhB and were considered to have a clinically significant component of SMP. We conclude that alpha-adrenergic blockade with intravenous phentolamine is a sensitive alternative test to identify patients with SMP.     

The validity of manual examination in assessing patients with neck pain.

BACKGROUND CONTEXT: Although manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination, that conviction is based on only one study. That study claimed that manual examination of the neck had 100% sensitivity and 100% specificity for diagnosing painful zygapophyseal joints. However, the study indicated that its results should be reproduced before they could be generalized. PURPOSE: The present study was undertaken to answer the call for replication studies. The objective was to determine the sensitivity, specificity, and likelihood ratio of manual examination for the diagnosis of cervical zygapophyseal joint pain. STUDY DESIGN: The study was conducted in a private practice located in a rural town. The practice specialized in musculoskeletal pain problems. PATIENT SAMPLE: The study sample was 173 patients with neck pain in whom cervical zygapophyseal joint pain was suspected on clinical examination, and who were willing to undergo controlled diagnostic blocks of the suspected joint or joints. OUTCOME MEASURES: The validity of manual diagnosis was determined by calculating its sensitivity, specificity, and positive likelihood ratio. METHODS: Patients who exhibited the putatively diagnostic physical signs of cervical zygapophyseal joint pain were referred to a radiologist who performed controlled, diagnostic blocks of the suspected joint, and other joints if indicated. The results of the blocks constituted the criterion standard, against which the clinical diagnosis was compared, by creating contingency tables. RESULTS: Manual examination had a high sensitivity for cervical zygapophyseal joint pain, at the segmental levels commonly symptomatic, but its specificity was poor. Likelihood ratios barely greater than 1.0 indicated that manual examination lacked validity. Although the results obtained were less favorable than those of the previous study, paradoxically they were statistically not different. CONCLUSIONS: The present study found manual examination of the cervical spine to lack validity for the diagnosis of cervical zygapophyseal joint pain. It refutes the conclusion of the one previous study. The paradoxical lack of statistical difference between the two studies is accounted for by the small sample size of the previous study.