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.     

Chronic whiplash and whiplash-associated disorders: an evidence-based approach

Whiplash is neck pain experienced as a result of a motor vehicle collision or similar trauma. Following a motor vehicle collision, 15% to 40% of patients with acute neck pain develop chronic neck pain. The cervical facet joint is the most common source of chronic neck pain after whiplash injury, followed by disk pain. Some patients experience pain from both structures. Initial management recommendations need not be directed toward an exact structural cause, but treatment includes advising the patient to remain active, prescribing medications when necessary, and providing advice regarding the generally favorable outcome. When neck pain persists, the physician should recommend medial branch blocks of the dorsal rami of the spinal nerves that supply the putative painful facet joint or joints; this is done to determine whether the facet joints are the cause of pain. When significant relief occurs on two occasions, radiofrequency neurotomy typically provides substantial relief for approximately 8 to 12 months and can be repeated indefinitely as needed. Occasionally, long-term treatment with medication may be indicated. Anterior cervical diskectomy and fusion is necessary on rare occasions.     

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。     

Percutaneous radiofrequency neurotomy of lumbar medial branch (facet rhizotomy)--a report of 6 cases

We performed radiofrequency neurotomy of lumbar medial branch as a treatment of facet syndrome. Our six cases had no indication for surgical therapy, such as neuralgia, spinal canal stenosis without neurological deficit except for pain and deformed spines. Facet joint injection with regional anesthetics and steroids could not prevent their recurrent back pain. By facet rhizotomy, they could obtain relief of back pain for several months to a year. We conclude that facet rhizotomy is a more effective method for facet syndrome when a proper indication is present.     

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     

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.     

Percutaneous cryodenervation of lumbar facet joints: a prospective clinical trial

Facet joint pain is an important aspect of degenerative lumbar spine disease, and radiofrequency medial branch neurotomy remains an established therapy, while cryodenervation has still been poorly examined. This study was undertaken to examine the effects of medial branch cryodenervation in the treatment of lumbar facet joint pain. This was a prospective clinical case series. Patient selection was based on the history, physical examination and positive medial branch blocks. Percutaneous medial branch cryodenervation was performed using a Lloyd Neurostat 2000. Target parameters were low back pain (VAS), limitation of activity (McNab) and overall satisfaction. Fifty patients were recruited, and 46 completed the study. The follow-up time was 1 year. At 6 weeks, 33 patients (72%) were pain free or had major improvement of low back pain; 13 (28%) had no or little improvement. Including failures, mean low back pain decreased significantly from 7.7 preoperatively to 3.2 at 6 weeks, 3.3 at 3 months, 3.0 at 6 months and 4.2 at 12 months (P<0.0001). Limitation of the activities of daily living improved parallel to reduced pain. Our results suggest that medial branch cryodenervation is a safe and effective treatment for lumbar facet joint pain.     

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.     

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.     

Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain

Prompted by clinical failures of percutaneous radiofrequency neurotomy in the treatment of back pain and neck pain, we performed a study to determine the shape and size of lesions made by radiofrequency electrodes. Experimental lesions were made in egg white and fresh meat at temperatures recommended in clinical practice. The cardinal finding was that lesions do not extend distal to the tip of the electrode. They only extend radially around the electrode tip in the shape of an oblate spheroid, with a maximal effective radius of only 2 mm. Consequently, if electrodes are directed perpendicularly onto a nerve, the nerve may not be encompassed by the lesion generated. Some of the clinical failures of percutaneous medial branch neurotomy ("facet rhizotomy") may be due to this phenomenon. We suggest modified techniques for medial branch neurotomy in which the electrodes are introduced parallel to the target nerve whereupon it is more readily encompassed by the radial spread of the lesion.     

Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain

STUDY DESIGN: A prospective audit. OBJECTIVE: To establish the efficacy of lumbar medial branch neurotomy under optimum conditions. SUMMARY OF BACKGROUND DATA: Previous reports of the efficacy of lumbar medial branch neurotomy have been confounded by poor patient selection, inaccurate surgical technique, and inadequate assessment of outcome. METHODS: Fifteen patients with chronic low back pain whose pain was relieved by controlled, diagnostic medial branch blocks of the lumbar zygapophysial joints, underwent lumbar medial branch neurotomy. Before surgery, all were evaluated by visual analog scale and a variety of validated measures of pain, disability, and treatment satisfaction. Electromyography of the multifidus muscle was performed before and after surgery to ensure accuracy of the neurotomy. All outcome measures were repeated at 6 weeks, and 3, 6, and 12 months after surgery. RESULTS: Some 60% of the patients obtained at least 90% relief of pain at 12 months, and 87% obtained at least 60% relief. Relief was associated with denervation of the multifidus in those segments in which the medial branches had been coagulated. Prelesion electrical stimulation of the medial branch nerve with measurement of impedance was not associated with outcome. CONCLUSIONS: Lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. Adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. Electrical stimulation before lesioning is superfluous in assuring correct placement of the electrode.     

Prospective,double-blind,randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us

Background contextThe prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective.PurposeThis article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials.Study designReview article.MethodsExtensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature.ResultsFluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effiective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervial medial branch neurotomy are both effective. Intraarticular sacrociliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections.ConclusionsThe prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.     

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain

Purpose

Chemical denervation is not recommended as part of the routine care of chronic non-cancer pain. Physicians face a dilemma when it comes to repeated interventions in cases of recurrent thoracolumbar facet joint pain after successful thermal radiofrequency ablation (RFA) in medial branch neurotomy. This study was performed to compare the effects of alcohol ablation (AA) with thermal RFA in patients with recurrent thoracolumbar facet joint pain after thermal RFA treatment.

Methods

Forty patients with recurrent thoracolumbar facet joint pain after successful thermal RFA defined as a numeric rating scale (NRS) score of ≥7 or a revised Oswestry disability index (ODI) of ≥22 % were randomly allocated to two groups receiving either the same repeated RFA (n = 20) or AA (n = 20). The recurrence rate was assessed with NRS and ODI during the next 24 months, and adverse events in each group were recorded.

Results

During the 24-month follow-up after RFA and AA, one and 17 patients, respectively, were without recurring thoracolumbar facet joint pain. The median effective periods in the RFA and AA groups were 10.7 (range 5.4–24) and 24 (range 16.8–24) months, respectively (p < 0.000). No significant complications were observed with the exception of injection site pain, which occurred in both groups.

Conclusion

In our patient cohort, alcohol ablation in medial branch neurotomy provided a longer period of pain relief and better quality of life than repeated radiofrequency medial branch neurotomy in the treatment of recurrent thoracolumbar facet joint pain syndrome after successful thermal RFA without significant complications during the 24-month follow-up.     

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.     

The surgical anatomy of thoracic facet denervation

Summary Thoracic percutaneous facet denervation has been employed for the treatment of thoracic zygapophysial joint pain. But the surgical anatomy of this procedure has been assumed to be the same as for lumbar medial branch neurotomy. To establish the anatomical basis for thoracic medial branch neurotomy, an anatomical study was undertaken. Using an X40 dissecting microscope, a total of 84 medial branches from 7 sides of 4 embalmed human adult cadavers were studied.The medial branches of the thoracic dorsal rami were found to assume a reasonably constant course. Upon leaving the intertransverse space, they typically crossed the superolateral corners of the transverse processes and then passed medially and inferiorly across the posterior surfaces of the transverse processes before ramifying into the multifidus muscles. Exceptions to this pattern occurred at mid-thoracic levels (T5–T8). Although the curved course remained essentially the same, the inflection occurred at a point superior to the superolateral corner of the transverse process.At no time during the dissection were nerves encountered crossing the junctions between the superior articular processes and transverse processes which have been the target points advocated for thoracic facet denervation. Rather, the results of this study indicate that the superolateral corners of the transverse processes are more accurate target points.     

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.     

Anatomical description of the facet joint innervation and its implication in the treatment of recurrent back pain

AIM: Many techniques are used in the back pain treatment, standing out the facet denervation as a therapeutic option for pain that originates in the facet joints. It's known that the facet joint is an abundant area of nocireceptor innervation, although the distribution and the location of the involved branches have not being well demonstrated. A good comprehension about the affected innervation is very important to get an effective treatment. Purpose of study was to describe innervation of the lumbar facet joints, potentially used in the diagnosis and treatment of painful pictures of the lumbar region by facet syndrome. Study design: anatomical study of nerve roots distribution of the facet joint 3 human corpses. The determination of the neurotomy s point was carried out by direct visualization and the radiological study in human parts. METHODS: Three anatomical pieces of the human lumbar spine were dissected. In those 3 pieces, the facet joint innervation distribution was studied thoroughly using surgical microscope and microsurgical technique. In one of the pieces the needles positioning was first made to test through the radiological study the possible application of the precise denervation in low back pain treatment. RESULTS: The L1 to L4 segments, each dorsal branch of root emits a medial branch that emerges from intertransversal ligament. This branch crosses the superior margin of the medial termination of transverse process, passing through the root of the superior articulate process. Each branch innerves the anterior region of the inferior facet and the inferior portion of articulation which one spins around. The L5 dorsal branch was larger than the superior branches. It emerges dorsally and in the inferior region on top of the sacrum wing. This nerve is in the bone fissure of the junction between the wing and the posterior region of the sacrum articular process. Near the inferior portion of the articular process, the nerve ramifies itself in lateral and medial branch. The medial branch comes back around the inferior portion of the lumbar-sacrum articulation that it innervates. CONCLUSIONS: We didn't note great variations in the anatomy from L1 do L4. The L5 segment has a different distribution of the branches that should be considered when we do a percutaneous denervation procedure. The approach of the needle must touch the transverse process and feels the resistance of the articular joint . The determination of the neurotomy s point tends to become more precise denervation procedure.     

Radiofrequency lesioning of the cervical medial branches

While radiofrequency (RF) has been used in many clinical contexts, perhaps the most ubiquitous use is in treating cervical facet pain in patients who have suffered whiplash injury. The pathophysiology of these injuries has only recently become clearer.