Nonsurgical treatment of zygapophyseal joint cyst-induced radicular pain

OBJECTIVE: To evaluate the role of fluoroscopically guided injection procedures in the nonsurgical treatment of zygapophyseal joint cyst-induced radicular pain. DESIGN: Retrospective study with independent clinical review. PARTICIPANTS: Fourteen patients (average age, 60.2 yrs), with an average symptom duration of 18.8 months, were included. METHODS: Medical records were reviewed; patients with a radiographically observed zygapophyseal joint cyst that may have represented a compressive lesion corresponding to the patient's symptoms of radicular pain were eligible for inclusion. The level of nerve root involvement was confirmed by physical examination or electrodiagnostic findings. Patients whose root level involvement remained undetermined were required to demonstrate a positive response to a fluoroscopically guided diagnostic selective nerve root block (SNRB). Nonsurgical treatments included therapeutic SNRB, intraarticular zygapophyseal joint corticosteroid injection, and cyst puncture. Data collection and analysis were performed by an independent clinical reviewer. OUTCOME MEASURES: Pain score, work status, medication usage, and patient satisfaction with treatment. RESULTS: The majority of the observed cysts (71.4%) were at the L4-L5 level. Follow-up data collection was done at an average of 1.4 years after termination of treatment. An excellent outcome was observed in 4 patients (28.6%). Fifty percent of patients underwent surgery. CONCLUSIONS: Preliminary findings suggest a role for fluoroscopically guided injection techniques in the nonsurgical treatment of zygapophyseal joint cyst-induced radicular pain, with up to one-third of patients experiencing lasting symptomatic relief.     

Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks

OBJECTIVE: To evaluate the prevalence of facet joint pain in patients with chronic low back pain (CLBP) after surgical intervention(s). DESIGN: A prospective, nonrandomized, consecutive study. SETTING: An ambulatory interventional pain management setting. PARTICIPANTS: The prevalence of facet joint pain was evaluated in patients with CLBP after various surgical intervention(s) referred to an interventional pain management practice. The sample was derived from 282 patients with persistent CLBP after various surgical intervention(s). Of these, 242 patients consented to undergo interventional techniques. A total of 117 consecutive patients with chronic, nonspecific low back pain, after lumbar surgical intervention(s) were evaluated with controlled, comparative local anesthetic blocks. INTERVENTIONS: Controlled, comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by .25% bupivacaine) under fluoroscopic visualization using 0.5mL to block each facet joint nerve. MAIN OUTCOME MEASURES: A positive response was defined as at least 80% reduction of pain with ability to perform previously painful movements. A positive response was considered to be pain relief from the lidocaine block lasting at least 1 hour or at least 2 hours or greater than duration of relief with lidocaine when bupivacaine was used. Controlled, comparative local anesthetic blocks were used to eliminate false-positive results. Valid information is only obtained by performing controlled blocks in the form of comparative local anesthetic blocks, in which, on 2 separate occasions, the same joint is anesthetized by using local anesthetics with different durations of action. If patients obtained appropriate response with both blocks, they were considered a positive. If they obtained appropriate response with lidocaine but not with bupivacaine, they were considered false-positive, whereas if the response was negative with lidocaine, they were considered negative. RESULTS: The prevalence of lumbar facet joint pain in patients with recurrent pain after various surgical intervention(s) was 16% (95% confidence interval, 9%-23%). The false-positive rate with a single block with lidocaine was 49%. CONCLUSIONS: Facet joints are clinically important pain generators in a small but significant proportion of patients with recurrent CLBP after various surgical intervention(s).     

Individualised manual therapy plus guideline-based advice vs advice alone for people with clinical features of lumbar zygapophyseal joint pain: a randomised controlled trial

Objectives

To determine whether individualised manual therapy plus guideline-based advice results in superior outcomes to advice alone in participants with clinical features potentially indicative of lumbar zygapophyseal joint pain.

The provocative lumbar facet joint

Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.     

The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review

Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review.

Objectives

To determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas.

Data Sources

A PubMed, Medline (EBSCO), and Cochrane library search (January 1971-December 2005), as well as additional references found from the initial search.

Study Selection

There were no studies that specifically addressed the objectives outlined. Eleven randomized controlled trials, 1 prospective controlled trial, and 2 prospective cohort studies were identified that included a protocol involving repeat epidural injections for radicular pain secondary to herniated nucleus pulposus or spinal stenosis. One qualitative survey was also identified. Five review articles were also included that discussed this topic.

Data Extraction

Data were extracted from clinical trials if they included the following: (1) protocols in clinical trials on ESIs that included repeat injections and the response required to trigger these injections, (2) any evidence given for establishing these protocols, and (3) similar studies that included only 1 injection. Specific mention of repeat ESIs and partial response that was mentioned in review articles was also included.

Data Synthesis

There is limited evidence to suggest guidelines for frequency and timing of ESIs or to help to define what constitutes the appropriate partial response to trigger a repeat injection. No study has specifically evaluated these objectives. Methodologically limited research suggests that repeat injections may improve outcomes, but the evidence is insufficient to make any conclusions.

Conclusions

There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design.     

Incidence of vocal cord dysfunction after fluoroscopically guided steroid injections in the axial skeleton

OBJECTIVE: To report on the incidence of dysphonia and/or associated throat symptoms after steroid injections in the axial skeleton. DESIGN: A prospective cohort study. SETTING: Academic spine center. PARTICIPANTS: Patients (N = 100) undergoing a diagnostic injection followed by a therapeutic injection in the axial skeleton. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Presence or absence of dysphonia and/or associated throat symptoms, as determined by completion of a predetermined 10-item questionnaire. This questionnaire was administered before participation in the study and at specific intervals after a diagnostic injection and, again, after a therapeutic spinal injection. RESULTS: There was a 12% incidence of transient dysphonia and/or associated throat symptoms in this study population after a therapeutic injection. CONCLUSIONS: Throat symptoms are a potential, albeit transient side effect, after an epidural space corticosteroid injection. The mechanism through which dysphonia or other throat symptoms develop is unknown but appears to be mediated by a systemic steroid effect.     

A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy

OBJECTIVE: To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs) to treat lumbosacral radiculopathy. DATA SOURCES: MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database. Databases were searched from inception through 2003. STUDY SELECTION: A database search was conducted by using the following key words: prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection , and periradicular and nerve root injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with fluoroscopically guided nerve root or transforaminal epidural injections. DATA EXTRACTION: Data were compiled for each of the following categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized, documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and Policy Research. DATA SYNTHESIS: We selected 6 articles for review. Our analysis identified a single article as the highest quality study addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking. CONCLUSIONS: The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.     

Complications of fluoroscopically guided interlaminar cervical epidural injections

OBJECTIVES: To assess the incidence of complications of fluoroscopically guided interlaminar cervical epidural injections. DESIGN: A retrospective cohort design study. SETTING: A multidisciplinary spine care center. PARTICIPANTS: One hundred fifty-seven consecutive patients with cervical radicular pain caused by cervical spondylosis or herniated nucleus pulposus confirmed by magnetic resonance imaging or computed tomography scanning. INTERVENTIONS: Fluoroscopically guided interlaminar cervical epidural injections were performed at the C7-T1 or C6-7 level using an 18-gauge, 9-mm Tuohy needle with 2mL of 1% lidocaine (Xylocaine) and 80-mg of triamcinolone acetonide (Kenalog). All injections were performed consecutively over a 12-month period by 1 of 5 physicians. MAIN OUTCOME MEASURES: An independent observer reviewed medical charts, which included a 24-hour postprocedure telephone call by an ambulatory surgery center nurse who asked a standardized questionnaire about complications after the injections. Also reviewed were physician notes regarding office follow-up consultations 3 weeks or less after the injections and epidurograms. RESULTS: The charts of 157 patients, who received 345 injections, were reviewed. Complications per injection included 23 increased neck pain (6.7%), 16 transient nonpositional headaches that resolved within 24 hours (4.6%), 6 episodes of insomnia the night of the injection (1.7%), 6 vasovagal reactions (1.7%), 5 facial flushing (1.5%), 1 fever the night of the procedure (0.3%), and 1 dural puncture (0.3%). The incidence of all complications per injection was 16.8%. CONCLUSIONS: Because all complications resolved without morbidity and no patient required hospitalization, fluoroscopically guided interlaminar cervical epidural injections may be a safe procedure for use in patients with cervical radicular pain.     

Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection

Weil L, Frauwirth NH, Amirdelfan K, Grant D, Rosenberg JA. Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection.

Objective

To describe and answer questions concerning the spread of contrast in patients receiving correctly placed lumbar epidural steroid injections (ESIs) under fluoroscopy.

Design

Prospective observational study.

Setting

An outpatient surgery center.

Participants

Consecutive patients (N=114) receiving ESIs under fluoroscopy who met inclusion criteria.

Interventions

Not applicable.

Main Outcome Measures

Spread of contrast in relation to variables, including unilateral versus bilateral, anterior versus posterior, and spread more than 1 level caudally versus less than 1 level. Variables were examined in relation to needle tip placement, level of injection, and male versus female patients. All data were collected with fluoroscopy images in lateral and anteroposterior views after injection of 5mL of fluid.

Results

Spread was greater than 1 segment caudally more than 75% of the time under all variables. Anterior versus posterior epidural spread on the lateral view was approximately even over all cases and anterior spread was found more often when the needle was within the width of the distal spinous process tip. Needle placement medial or lateral to the spinous process width also significantly affected whether the spread was unilateral versus bilateral. If the needle tip was lateral to the width of the spinous process, spread was unilateral 75% of the time, versus 45% of the time if the needle tip was medial.

Conclusions

Contrast spread is affected by needle placement, with other variables kept equal, in the performance of an interlaminar lumbar ESI. These data support the performance of interlaminar lumbar ESIs with fluoroscopic guidance and provide some parameters with which to guide the injectionist.     

关节突关节形态与退变性腰椎滑脱的关系

目的 探讨关节突关节形态与退变性腰椎滑脱的方法。方法 首先对41例60岁以下（平均年龄55岁）有L4－5退变性滑脱的患者和32例（平均年龄53岁）正常人进行对照检查。用CT轴向扫描关节突关节，测量L3－4，L4－5，L5－S1关节突关节的角度，关节横向，关节面的深度和观察关节面形态。第二部分研究分别测量40例40岁以下和40例60岁以肯要痛患者的关节突关节角度，观察其关节。结果 退变笥滑脱患者与对照组相比，L4－5节段关节角度方向明显偏向矢状面，关节角度不对称和关节面深度比也有显著差异。第二部分2组下腰痛患者的关节突关节角度无统计学差异。结论 60岁以下的退变性腰椎滑脱患者存在着关节突关节形态异常，L4－5节段关节或矢状排列和／或同时伴有关节角不对称是腰椎早期滑脱的危险因素。     

Electromyographic technique for lumbar multifidus examination: comparison of previous techniques used to localize the multifidus

OBJECTIVES: To verify and compare established techniques for needle localization in the multifidus muscle and to explore more practical techniques. DESIGN: Human cadaver study. SETTING: Anatomy laboratory in a university setting. CADAVERS: Six fresh human cadavers. INTERVENTION: A 22-gauge needle was inserted into the multifidus muscle fascicle of 6 cadavers using 2 different techniques described previously in the electrodiagnostic literature by Haig and Stein and colleagues. A mixture of colored latex and contrast dyes (0.1 mL) was injected bilaterally into each fascicle at levels L1 to L5. Two electromyographers performed injections into 60 targeted muscles, affording 120 total insertions. Separate investigators dissected the muscles to determine dye position. MAIN OUTCOME MEASURES: Not applicable. RESULTS: A total of 88 (73%) and 79 (66%) injections were successfully delivered to the targeted multifidus muscles using the Haig and the Stein techniques, respectively. With the Haig method, 22 injections (18%) were delivered to different superficial muscles. With the Stein method, 24 injections were delivered to a common tendon and 3 injections were delivered to the spinal canal. CONCLUSIONS: This study highlights the nonoptimizing accuracy of previous techniques for multifidus needle electromyography. A modified Haig method involving less acute needle angulation relative to the skin surface and closer insertion from the midline may increase accuracy and safety.     

Abstract 3: Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: An evaluation of long-term efficacy

Objective: To assess the efficacy of fluoroscopically guided caudal epidural steroid injections (ESIs) in the management of lumbar spinal stenosis. Design: Retrospective chart review and follow-up study. Setting: Academic-affiliated outpatient physiatry practice. Participants: Patients with low back and/or leg pain of at least 3 months in duration with clinical and radiographic evidence of moderate to severe lumbar spinal stenosis who received caudal ES’s between 1995 and 2002. Patients who had undergone prior lumbar spinal surgery were excluded. Intervention: Fluoroscopically guided caudal ESIs. Main Outcome Measures: Visual Numeric Scale (VNS), Roland-Morris Disability Questionnaire (RMDQ), North American Spine Society Patient Satisfaction Index (PSI), and subsequent surgery. Results: Of 3153 charts reviewed, 95 patients met inclusion criterion. 79 (83%) completed the follow-up questionnaire by mail or telephone interview. The mean patient age was 70 years, mean duration of symptoms was 39 months, and average follow-up time was 31 months. Patients underwent an average of 1.5 caudal ESIs. 9 patients subsequently underwent surgery; 1 had an intradiskal electrothermal therapy procedure. A VNS improvement of 50% or greater was seen in 37% of patients. With respect to patient satisfaction, 44% reported that the procedure either fully met their expectations or that they would undergo it again for the same outcome. A functional improvement of 2 points or greater was seen on the RMDQ in 40% of patients. The concurrent presence of degenerative spondylolisthesis was the only variable that had a significant positive correlation with successful outcomes (P<.003). Conclusions: Caudally placed, fluoroscopically guided ESIs offer a safe, minimally invasive option for managing pain caused by lumbar spinal stenosis. Many patients in this study derived long-term benefit from a single caudal ESI. The concurrent presence of degenerative spondylolisthesis appears to be a positive prognostic factor for successful response.     

The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery

Friedly J, Nishio I, Bishop MJ, Maynard C. The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery.

Objectives

To evaluate whether the use of epidural steroid injections (ESIs) is associated with decreased subsequent opioid use in patients in the Department of Veteran's Affairs (VA) and to determine whether treatment with multiple injections are associated with decreased opioid use and lumbar surgery after ESIs.

Design

VA patients undergoing ESIs during the study period for specific low back pain (LBP) diagnoses were identified, and lumbar surgery and opioid use were examined for 6 months before and after ESI.

Setting

National VA administrative data.

Participants

U.S. veterans (retrospective data analysis).

Interventions

Not applicable.

Main Outcome Measures

Opioid use and lumbar surgery after ESIs.

Results

During the 2-year study period, 13,741 different VA patients underwent an ESI for LBP. The majority of patients were using opioids before their ESIs (64%), as were the majority after their ESIs (67%). Of patients not on opioids before the ESIs, 38% were prescribed opioids afterward, whereas only 16% of people on opioids before the ESIs stopped using opioids afterward. Patients who received more than 3 injections were more likely than patients receiving fewer injections to start taking opioids after ESIs (19% vs 13%, P<.001) and to undergo lumbar surgery after ESIs (8.7% vs 6.3%, P=.003).

Conclusions

Opioid use did not decrease in the 6 months after ESIs. In this population, patients who received multiple injections were more likely to start taking opioids and to undergo lumbar surgery within the 6 months after treatment with ESIs. These findings are concerning because our data suggest that ESIs are not reducing opioid use in this VA population.     

Interspinous ligament steroid injections for the management of Baastrup's disease: a case report

Mitra R, Ghazi U, Kirpalani D, Cheng I. Interspinous ligament steroid injections for the management of Baastrup's disease: a case report. Baastrup's disease has been identified as a source of axial low back pain. There has been debate as to the etiology of pain in patients with Baastrup's disease. It has been theorized that the pain may originate from degenerative disk disease and spinal stenosis associated with the disease, whereas some have identified the neoarthrosis between joints and accompanying reactive eburnation as the source of pain. We present a simple case report of an 89-year-old woman with symptomatic Baastrup's disease. The patient underwent a fluoroscopically guided interspinous process injection of 20mg of triamcinolone acetate with local anesthetic. The patient remained pain free for 3 months. The neoarthrosis in Baastrup's disease may be the primary pain generator in cases of Baastrup's disease without significant central canal stenosis.     

Management of symptomatic cervical facet cyst with cervical interlaminar epidural block: A case report

BACKGROUNDSymptomatic cervical facet cysts are relatively rare compared to those in the lumbar region. These cysts are usually located in the 7^th cervical and 1^st thoracic vertebral (C7/T1) area, and surgical excision is performed in most cases. However, facet cysts are associated with degenerative conditions, and elderly patients are often ineligible for surgical procedures. Cervical interlaminar epidural block has been used in patients with cervical radiating symptoms and achieved good results. Therefore, cervical interlaminar epidural block may be the first-choice treatment for symptomatic cervical facet cysts.CASE SUMMARYA 70-year-old man complained of a tingling sensation in the left hand, focused on the 4^th and 5^th fingers, for 1 year, and posterior neck pain for over 5 mo. The patient’s numeric rating scale (NRS) score was 5/10. The patient was diagnosed with symptomatic cervical facet cyst at the left C7/T1 facet joint. Fluoroscopy-guided cervical interlaminar epidural block at the C7/T1 level with 20 mg triamcinolone and 5 mL of 0.5% lidocaine was administered. The patient''s symptoms improved immediately after the block, with an NRS score of 3 points. After 3 mo, his left posterior neck pain and tingling along the left 8^th cervical dermatome were relieved, with an NRS score of 2.CONCLUSIONA cervical interlaminar epidural block is a good alternative for managing symptomatic cervical facet cysts.     

Relationships between joint motion and facet joint capsule strain during cat and human lumbar spinal motions

Objective

The lumbar facet joint capsule (FJC) is innervated with mechanically sensitive neurons and is thought to contribute to proprioception and pain. Biomechanical investigations of the FJC have commonly used human cadaveric spines, whereas combined biomechanical and neurophysiological studies have typically used nonhuman animal models. The purpose of this study was to develop mathematical relationships describing vertebral kinematics and FJC strain in cat and human lumbar spine specimens during physiological spinal motions to facilitate future efforts at understanding the mechanosensory role of the FJC.

Methods

Cat lumbar spine specimens were tested during extension, flexion, and lateral bending. Joint kinematics and FJC principal strain were measured optically. Facet joint capsule strain–intervertebral angle (IVA) regression relationships were established for the 3 most caudal lumbar joints using cat (current study) and human (prior study) data. The FJC strain–IVA relationships were used to estimate cat and human spine kinematics that corresponded to published sensory neuron response thresholds (5% and 10% strain) for low-threshold mechanoreceptors.

Results

Significant linear relationships between IVA and strain were observed for both human and cat during motions that produced tension in the FJCs (P < .01). During motions that produced tension in the FJCs, the models predicted that FJC strain magnitudes corresponding to published sensory neuron response thresholds would be produced by IVA magnitudes within the physiological range of lumbar motion.

Conclusions

Data from the current study support the proprioceptive role of lumbar spine FJC and low-threshold mechanoreceptive afferents and can be used in interpreting combined neurophysiological and biomechanical studies of cat lumbar spines.     

Sources of sacroiliac region pain: insights gained from a study comparing standard intra-articular injection with a technique combining intra- and peri-articular injection

Borowsky CD, Fagen G. Sources of sacroiliac region pain: insights gained from a study comparing standard intra-articular injection with a technique combining intra- and peri-articular injection.

Objectives

To present evidence supporting the existence of extra-articular sources for sacroiliac region pain and to present evidence that intra-articular anesthetic blockade may underestimate the true prevalence of sacroiliac region pain.

Design

Retrospective review of 2 large case series comparing patient responses to intra-articular injection versus combined intra-articular and peri-articular injection of anesthetic and corticosteroid.

Setting

Private practice chronic pain clinic set in a hospital outpatient clinic.

Participants

Patients (N=120) sequentially enrolled from practice billing records. Inclusion criteria included pain in the low back below L4 and in the buttock, thigh, groin, or lower leg. If disk herniation, lumbar stenosis, or facet syndrome was previously treated with appropriately chosen injections, response to treatment had to be negative. Patients failed to respond to treatment with physical therapy. Exclusion criteria included records with an incomplete database, patients increasing pain medication use greater than 15% for pain not related to the sacroiliac region, severe psychiatric illness, and nonspecific anesthetic blockade. One hundred sixty-seven records were reviewed to obtain the 120 study subjects.

Interventions

Intra-articular injection was done according to the standard technique described by Fortin. Peri-articular injection was done by a slight modification of the procedure described by Yin.

Main Outcome Measures

Percentage change in visual analog scale (VAS) pain scores at 3 weeks and 3 months postinjection; patients' self reported activities of daily living (ADLs) improvement at 3 weeks and 3 months postinjection; and percentage change in VAS pain score within 1 hour of injection.

Results

For intra-articular injection alone, the rate of positive response at 3 months was 12.50% versus 31.25% for the combined injection (P=.025). Positive response was defined as greater than 50% drop in VAS pain score or patients describing ADLs as “greatly improved.” Anesthetic response rates were higher in the combined injection group (62.5% vs 42.5%; P=.037).

Conclusions

Significant extra-articular sources of sacroiliac region pain exist. Intra-articular diagnostic blocks underestimate the prevalence of sacroiliac region pain.