Lumbar facet joint syndrome. A randomised clinical trial

A group of 109 patients with unilateral low back pain for over three months were randomised to receive one of three types of injection treatment: cortisone and local anaesthetic injected into two facet joints (28), the same mixture around two facet joints (39), or physiological saline into two facet joints (42). The effect of the treatment was evaluated in relation to work attendance, pain, disability and movements of the lumbar spine. Patients were examined one hour and two and six weeks after treatment and also completed a questionnaire after three months. A significant improvement was observed in work attendance, pain and disability scores, but this was independent of the treatment given and movements of the lumbar spine were not improved. Of the 70 patients with initial pain relief after injection, 36% reported persisting benefit at the three month follow-up, independent of the mode of treatment given. We conclude that facet joint injection is a non-specific method of treatment and the good results depend on a tendency to spontaneous regression and to the psychosocial aspects of back pain.     

Prevalence of facet joint degeneration in association with intervertebral joint degeneration in a sample of organ donors

Among the most common causes of low back pain are strain on the muscles and ligaments associated with the spine, degeneration of the intervertebral discs (IVDs), and osteoarthritis of the facet joints. It is not clear, however, how these latter two conditions are related to each other in terms of their development during a patient's lifetime. The facet joint is the sole synovial joint of the spine but because it is difficult to image its degenerative history as well as its relationship to other degenerative factors within the spine remain elusive. We compared the gross and histologic characteristics of the lumbar spine from a sample of organ donors to the integrity of their associated IVDs as assessed through magnetic resonance imaging. In our study sample, we found that facet joint degeneration was common, occurring as early as 15 years of age, while the IVD could still remain intact. Facet degeneration was more severe at the L4/5 level and progressed along with IVD degeneration with age. Because such early degenerative changes in the facet joint are somewhat surprising, degeneration of this joint should not be overlooked when assessing OA of the spine and causes of lower back pain. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1267–1274, 2011     

椎间盘源性腰痛人工椎间盘置换术的中期随访研究

 目的 探讨椎间盘源性腰痛人工椎间盘置换术(artificial disc replacement,ADR)的中期疗效。方法 2004年7月至2007年7月采用ADR治疗椎间盘源性腰痛21例(24个椎间盘),男9例,女12例;年龄26~67岁,平均46岁。均经椎间盘造影明确诊断。手术节段：L4-5 5例,L5S1 13例,L4-5+L5S1 3例。SB Charité Ⅲ型椎间盘假体22个,Activ L型椎间盘假体2个。集中随访时行X线、CT和MR检查,评估疼痛视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(Oswestry disability index,ODI)。结果 随访时间4~7年,平均5.1年。(1)腰腿痛较术前明显缓解,腰痛、腿痛VAS及ODI与术前比较差异均有统计学意义。(2)未出现椎间盘假体脱出、断裂、塌陷及手术节段自发性融合。1例双间隙手术者术后出现腰椎轻度侧凸,1例单间隙手术者出现相邻节段骨质增生加重。(3)手术节段椎间隙前缘高度较术前平均增加6.3 mm,后缘高度平均增加1.9 mm,节段性前凸角平均增加2.9°,椎间活动度平均为4.6°。近侧相邻节段椎间活动度平均减少2.5°。腰椎前凸角平均增加7.8°,腰椎屈伸活动范围平均增加2.4°。(4)近侧相邻节段椎间盘退变MR分级及关节突关节退变CT分级无明显变化,手术节段关节突关节退变CT分级增加。结论 椎间盘源性腰痛ADR术后5年手术节段仍保留一定的活动度,近侧相邻节段椎间盘和关节突关节退变缓慢,但手术节段关节突关节存在退变加速现象。     

盐酸氨基葡萄糖联合低剂量NSAIDS类药物与单纯用药治疗小关节骨关节炎伴下腰痛的随机对照研究

背景：腰背痛是一个常见的临床问题。盐酸氨基葡萄糖对膝关节骨关节炎的治疗作用已得到证实,在治疗腰背痛中的有效性仍有待进一步研究。目的：探讨盐酸氨基葡萄糖与低剂量非甾体类抗炎药（non-steroid anti-inflammator ydrug,NSAID）联用与常规剂量NSAID、相同剂量盐酸氨基葡萄糖、小剂量NSAID相比治疗腰椎小关节骨关节炎伴下腰痛的临床效果。方法：160例小关节骨关节炎伴下腰痛患者,男93例,女67例,年龄29-65岁,平均（46．4±10．9）岁。随机分为A、B、C、D组。A组口服盐酸氨基葡萄糖750mg,1日2次,加用双氯酚酸钠片25mg,1日1次;B组口服双氯酚酸钠缓释片75mg,1日1次;C组口服盐酸氨基葡萄糖750mg,1日2次;D组口服双氯酚酸钠片25mg,1日1次。治疗前（0周）、8周和16周使用Oswestry残疾指数（Oswestry disability index,ODI）、视觉模拟疼痛评分（vis．ual analog score,VAS）和SF-36量表进行评估。结果：147例获得随访,失访率为8．13％。各组患者的腰痛VAS评分、ODI评分和SF-36评分在治疗前后比较均有显著性改善（P〈0．05）。A、B两组间的各个评价参数在各随访点比较均无显著性差异（P〉0．05）,但A、B两组的疗效明显优于C、D两组。无一例出现药物不良反应。结论：联合盐酸氨基葡萄糖可减少治疗小关节骨关节炎伴下腰痛中NSAID类药物的用量,可成为降低NSAID药物相关风险的替代治疗选择。     

Total hip arthroplasty outcomes correlate with spine disability

Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness. Although previous studies have evaluated the potential benefit of THA on back pain, none have reported the effects of spine disability on functional outcomes and patient satisfaction with THA. A total of 244 primary THAs (233 patients) with minimum 2-year follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Out of 244, 151 (62%) patients reported a history of back problems: 35 patients (14%)—history of lumbar surgery, 91 (37%)—daily low back pain, and 97 (40%)—back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without back pain, p = 0.0001. Patients with daily low back pain or low back pain that limited activity had lower OHS scores, p < 0.0001. Increasing spine disability, as determined by ODI, correlated with poor OHS, p < 0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R = 0.41, p < 0.0001), return to activity (R = 0.34, p < 0.0001), and overall surgical results (ODI, R = 0.38, p < 0.0001) at 2 years after THA. ODI correlated strongly with poor THA outcomes. In conclusion, lumbar spine disability correlated directly with poor Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrates that poor functional results in THA patients correlate directly with spine disability.     

Patient characteristics and patterns of use for lumbar spine radiographs: results from the Veterans Health Study

STUDY DESIGN: Longitudinal data from the Veterans Health Study, an observational study of male patients receiving Veterans Administration ambulatory care, were analyzed. OBJECTIVE: To identify patient characteristics that predict different patterns in the use of lumbar spine radiographs. SUMMARY AND BACKGROUND DATA: In this study, 401 patients with low back pain receiving ambulatory care services in four Veterans Administration outpatient clinics in the greater Boston area were followed for 12 months. METHODS: Participants were mailed the Medical Outcome Study Short Form Health Survey and participated in scheduled interviews that included the completion of a low back questionnaire, a comorbidity index, and a straight leg raising test. Four groups of patients were defined according to the patterns of use for lumbar spine radiographs: prior use, repeat use, no use, and new use of lumbar spine radiographs. These groups were compared in terms of sociodemographics, comorbid conditions, low back pain intensity, radiating leg pain, straight leg raising, Medical Outcome Study Short Form Health Survey scores, and low back disability days. RESULTS: The patients with new lumbar spine radiographs showed worse physical and psychological distress than the participants in the other three groups. In contrast, the patients with no lumbar spine radiographs reported minor physical impairment. Compared with patients who had no repeat radiographs, patients with repeat lumbar spine radiographs had similar scores on physical health, but they showed worse scores of mental health. CONCLUSIONS: Both physical and psychological factors contribute to having new radiographic examinations, whereas psychological factors have increased importance in the repeat use of roentgenographic examinations. Repeat radiographs appear to be overused, judging by the severity of physical impairment as measured by low back pain intensity, the Medical OutcomeStudy Short Form Health Survey, and disability days.     

A comparison of fear-avoidance beliefs in patients with lumbar spine pain and cervical spine pain.

STUDY DESIGN: A prospective consecutive cohort study of patients with cervical spine pain and patients with lumbar spine pain referred to an academic medical center. OBJECTIVES: To investigate the presence of fear-avoidance beliefs in a sample of patients with cervical spine pain and to compare the association of pain intensity, disability, and fear-avoidance beliefs in patients with cervical spine pain with that in patients with lumbar spine pain. SUMMARY OF BACKGROUND DATA: Fear-avoidance beliefs are a specific psychosocial variable involved in the development of disability from low back pain. Psychosocial variables are believed to play a role in cervical disability, but specific variables have not been investigated. METHODS: Consecutive patients referred to a multidisciplinary center completed self-reports of disability, pain intensity, and fear-avoidance beliefs during an initial evaluation session. Gender, type of symptom onset, acuity, and payer source were also recorded. Associations between disability, pain intensity, and fear-avoidance beliefs were investigated in patients with cervical spine pain and patients with lumbar spine pain. RESULTS: In all, 163 patients completed the self-reports and were included in this study. Weaker relations between fear-avoidance beliefs and disability were found in patients with cervical pain than in those with lumbar pain. Significant differences in fear-avoidance beliefs were found for gender, type of symptom onset, and payer source (workers' compensation, auto insurance, and traditional insurance). CONCLUSION: The associations among fear-avoidance beliefs, pain intensity, and disability differed between patients with cervical spine pain and patients with lumbar spine pain. Fear-avoidance beliefs were significantly different in subgroups of patients.     

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.     

腰椎退行性疾患接受腰椎融合术后发生下腰痛和腰椎矢状位序列的相关性研究

目的探讨分析腰椎退行性疾患接受腰椎融合术后发生下腰痛和腰椎矢状位序列的相关性。方法回顾性分析我院于2010年2月~2011年6月收治的38例接受腰椎融合术的腰椎退行性疾病且术后发生下腰痛患者的临床资料,于所有患者出院后进行为期24个月的随访。在手术前及随访期间收集所有患者站立位X线片腰椎前凸的Cobb角,并分析其与患者下腰痛程度之间的相关性。结果术后12个月及24个月与手术前的腰椎矢状位Cobb角比较,均无统计学意义(分别为t=0.042,P=0.967及t=0.268,P=0.789);术后12个月及24个月的腰椎矢状位Cobb角与正常角度的差值与手术前比较均无统计学意义(分别为t=0.450,P=0.900及t=0.174,P=0.862)。术后12个月及24个月的VAS评分与手术前相比,有明显改善(分别为t=2.838,P=0.006及t=3.251,P=0.002),而术后12个月及24个月的ODI评分与手术前相比也有明显改善(分别为t=2.300,P=0.024及t=3.320,P=0.001)。术后12个月及24个月所有患者的腰椎前凸丢失与VAS评分及ODI评分均呈正相关(P0.05)。结论腰椎前凸角度的丢失与腰椎退行性疾患腰椎融合术后的腰痛关系密切,手术过程中腰椎前凸的重建十分重要。     

Correlation of end plate shape on MRI and disc degeneration in surgically treated patients with degenerative disc disease and herniated nucleus pulposus.

BACKGROUND CONTEXT: The sagittal profile of the lumbar end plates on magnetic resonance imaging (MRI) has not been investigated in patients with degenerative disc disease (DDD) or herniated nucleus pulposus (HNP). PURPOSE: To examine the shape of the end plates in patients treated surgically for a) low back pain or b) radiculopathy with HNP. Furthermore, to investigate the correlation between end plate shape and disc degeneration on the one, and end plate shape and symptoms on the other. STUDY DESIGN/SETTING: Retrospective review of charts and radiographs. METHODS: The charts, operative reports, preoperative lateral plain radiographs, and MRI scans of 178 patients (85 with low back pain and 93 with HNP) were reviewed. End plate shape was determined on midsagittal MRI cuts, disc degeneration was graded on T2 sequences, and disc height was measured on lateral plain radiographs from L1 to S1 in all patients. Student t-test and chi(2) test were used to detect significant differences and associations. RESULTS: Flat and irregular levels were most common in the lower lumbar spine. The L5/S1 segment was flat in most cases, due to a flat sacral end plate. In DDD patients, disc degeneration on MRI and plain radiographs worsened from concave to flat, to irregular levels. In HNP patients, MRI demonstrated concave levels to be less degenerated, whereas no difference was detected between flat and irregular levels. Disc height of irregular levels was well preserved in HNP patients. Comparing the two groups, flat levels were more degenerated on MRI in HNP patients. Despite similar degrees of degeneration on MRI, concave and irregular levels in DDD patients had lower disc heights. A higher frequency of symptoms was found in flat and irregular levels for both patient groups. CONCLUSIONS: The sagittal profile of end plates in the lumbar spine was described for patients with DDD on the one and HNP on the other. A higher association with symptoms was observed for flat and irregular levels in both patient groups. In DDD patients, disck degeneration on both MRI and plain radiographs increased from concave to flat, to irregular levels. In HNP patients, MRI demonstrated concave levels to be less degenerated, whereas no difference was detected between flat and irregular levels. Disc height of irregular levels was well preserved in HNP patients. Comparing the two groups of patients, flat levels were more degenerated on MRI in HNP patients. Despite similar degrees of degeneration on MRI, concave and irregular levels in DDD patients had lower disc heights. The correlation of symptoms and disc degeneration with the end plate shapes is not definitive evidence of end plate remodeling around degenerated discs. It may simply represent the higher rate of disc degeneration in the lower lumbar levels. This analysis did not provide any hints as to which degenerated discs are more likely to herniated and cause leg symptoms or cause predominantly low back pain.     

Quantitative ultrasound measurements of the calcaneus in the prediction of lumbar spine degeneration

A cross-sectional study was conducted to evaluate the possible use of a low-cost radiation-free technique in the prediction of degenerative changes in the lumbar spine. Although an inverse correlation between osteoporosis and degenerative changes in the lumbar spine has been reported, no previous studies have asked whether there is a correlation between calcaneal quantitative ultrasound results and degenerative findings in the lumbar spine. In 117 patients with low back pain or pain in the lower limb, ultrasonographic parameters (speed of sound, broadband ultrasound attenuation, stiffness) of the calcaneus were correlated with evidence of degenerative changes and stenosis on magnetic resonance scans of the lumbar spine. Linear and logistic regression, as well as receiver operator characteristic curve analyses, were used to evaluate the correlation. Lumbar spine stenosis was associated with elevated calcaneal ultrasonographic parameters, particularly speed of sound. For the identification of a narrowing of the lumbar spinal canal below 100 mm² of dural sac cross-sectional area, speed of sound showed 89% sensitivity and 75% specificity in males older than 60 years. In male patients, we also found a significant positive correlation between ultrasonographic parameters and scores on a degenerative scale that primarily reflects intervertebral disc degeneration (P=0.019 for speed of sound; P=0.039 for stiffness). In conclusion, calcaneal quantitative ultrasound is frequently used in elderly patients with low back pain as a diagnostic test for osteoporosis. The incidental finding of high values on ultrasonographic parameters in these subjects, particularly in males, is highly correlated with lumbar spine degeneration and stenosis, and can help to identify those symptomatic patients needing more extensive diagnostic testing.     

基于腰椎间盘退变的脊柱稳定性改变的MRI研究进展

腰椎间盘是位于两个相邻椎体之间的圆盘状纤维软骨,是维持脊柱稳定性的重要解剖结构。目前,维持脊柱稳定性的解剖结构分为被动亚系、主动亚系和神经控制亚系,称为"三亚系模型",腰椎间盘退变(intervertebral disc degeneration,IVDD)会引起该模型其它组织的病理学改变,且彼此相互作用导致脊柱稳定性下降,是下腰痛最常见的原因。IVDD患者常伴有椎小关节及韧带的退变、邻近椎体Modic改变、椎体血流量减少、椎旁肌肉脂肪浸润增加、神经轴向牵拉损伤的代偿性减少等。磁共振成像(magnetic resonance imaging,MRI)是评估脊柱稳定性首选的影像学方法,常规MRI能完整显示IVDD患者三亚系模型相关组织形态学变化,MRI功能成像能定量分析其病理生理学变化的程度。本文综述IVDD患者腰椎间盘、椎小关节、韧带、椎体、肌肉、神经的MRI形态学及定量值变化,阐述IVDD引起脊柱稳定性改变的相关机制,旨在为下腰痛患者的精准诊疗提供更全面的信息。     

Relationship between alterations of the lumbar spine,visualized with magnetic resonance imaging,and occupational variables

Although the effect of physical workload on the occurrence of low back pain (LBP) has been extensively investigated, few quantitative studies have examined the morphological changes visualized via magnetic resonance imaging (MRI) in relation to occupational variables. The relationship between the severity of some abnormalities such as lumbar spinal stenosis or spondylolisthesis and physical or psychosocial occupational risk factors has not been investigated previously. In this cross-sectional study patients fulfilled the following inclusion criteria: (1) long-standing (minimum 1-year) LBP radiating down the leg (or not); (2) age more than 40 years; (3) willingness to undergo an MRI of the lumbar spine; and (4) ability to speak Italian. Primary objective of the study was to investigate the association between occupational exposure and morphological MRI findings, while controlling for the individual risk factors for LBP. Secondarily, we looked at the influence of this exposure and the degenerative changes in the lumbar spine on clinical symptoms and the related disability. Lumbar MRI scans from 120 symptomatic patients were supplemented by the results of structured interviews, which provided personal, medical, and occupational histories. All occupational factors were arranged on scales of increasing exposure, whereas pain and disability were assessed using ad hoc validated questionnaires. Evidence of intervertebral disc narrowing or herniation and the occurrence and severity of spinal stenosis and spondylolisthesis was obtained from the MRI scans and a summative degenerative score was then calculated. We detected a direct association between increasing age and the global amount of degenerative change, the severity of intervertebral disc height loss, the number of narrowed discs, stenosis, the number of stenotic levels, and spondylolisthesis. Physical occupational exposure was not associated with the presence of lumbar disc degeneration and narrowing per se, but a higher degree of such an exposure was directly associated with a higher degree of degeneration (P=0.017). Spondylolistesis and stenosis were positively related to heavy workload (P=0.014) and the manual handling of materials (P=0.023), respectively. Psychosocial occupational discomfort was directly associated to stenosis (P=0.041) and number of stenotic levels (P=0.019). A heavier job workload was the only occupational factor positively related to the degree of disability at the multivariate analysis (P=0.002). Total amount of degeneration in the lumbar spine directly influenced pain duration (P=0.011) and degree of disability (P=0.050). These results suggest that caution should be exercised when symptomatic subjects with evidence of degenerative changes on MRI scans engage in strenuous physical labor.     

Lumbar spine mobility in Marfan syndrome

Summary Low back pain symptoms and lumbar spine mobility were assessed by questionnaires and by clinical and radiological measurements in 32 patients with Marfan syndrome. Frequently occurring low back pain was reported by 19% of the patients, but the disability was slight in all of them. Flexion and extension mobility of the lumbar spine (L1-S1) assessed from radiographs was 59.9° and 13.2°, respectively. Mean lumbar angular mobility between flexion and extension radiographs was 7.4° at L1-2, 13.2° at L2-3, 16.0° at L3-4, 19.3° at L4-5 and 18.3° at L5-S1. No correlation was found between the manual assessment of lumbar segmental instability and radiological translatory motion, except at L2-3, where the correlation was negative (r=-0.41, P>0.05). In conclusion, the prevalence of low back pain does not seem to differ substantially between Marfan syndrome patients and the normal population, and it seems that there is at most a slight hypermobility of the lumbar spine in Marfan syndrome. Several validity problems are encountered in the manual assessment of lumbar instability.     

Do MRI findings correlate with mobility tests? An explorative analysis of the test validity with regard to structure

To find out whether segmental magnetic resonance imaging (MRI) findings such as intervertebral disc degeneration (DD) and facet joint osteoarthritis (FJO) are associated with motion deficiencies as seen in common mobility tests and observed range of motion (ROM). A total of 112 female subjects, nurses and office workers, with and without low back pain, were examined by clinical experts, and lumbar mobility was measured including modified Schober, fingertip-to-floor distance (FTFD) and ZEBRIS motion analysis. An MRI of the lumbar spine was made. Mobility findings were correlated with segmental morphologic changes as seen on MRI at the levels of L1-2 through L5-S1. Only a few statistically significant correlations between MRI findings and the results of the mobility tests could be found. Lateral bending was weakly and negatively correlated to DD and FJO but only on the level of L5-S1. The FTFD showed a weak positive correlation to endplate changes on the level of L4-5. When ROM is observed by clinical experts, there are several significant relationships between MRI findings and the observed motion. There is a highly significant segmental correlation between DD and disc form alteration as seen on MRI on the level of single motion segments. Pain history and current pain level did not moderate any association between MRI and mobility. There is no clear relationship between the structural changes represented by MRI and the measured mobility tests used in this study. Our findings suggest that close observation of spinal motion may provide at least equal information about the influence of spinal structures on motion than the commonly used measured mobility tests do.     

Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

Background contextLumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option.PurposeTo profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts.Study design/settingRetrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts.Patient sampleOne hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture.Outcome measuresOswestry Disability Index and numeric rating scale score for back and leg pain.MethodsA retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling.ResultsSuccessful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery.ConclusionsThis study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint steroid injection with attempted cyst rupture is correlated with avoiding subsequent surgery in half of treated patients. Successful cyst rupture does not appear to have added benefit, and it was associated with worse disability 3 years postinjection. Long-term outcomes are similar, regardless of subsequent surgery.     

腰椎关节突关节骨性关节炎的CT分级及其临床意义

目的:探讨腰椎关节突关节骨性关节炎的CT分级及其临床意义。方法:回顾性分析2008年1月～2010年12月在我院就诊的100例腰痛或腰痛伴下肢麻木疼痛患者的腰椎CT。男43例,女57例;年龄23～81岁,平均52.5岁。采用CT骨窗轴位像关节突关节的关节间隙宽度、骨赘形成及骨质变化情况作为分级依据征象,将每个征象按照其严重程度分为4个等级,相应赋予0～3分,按3个征象总分分为4级:0级,0分;Ⅰ级,1～3分;Ⅱ级,4～6分;Ⅲ级,7～9分。由初、中、高级职称3位医师在PACS系统对100例患者从L1/2至L5/S1节段的双侧关节突关节分别进行2次独立分级,Kappa分析评价3位医师分级结果的一致性。同时对患者腰痛VAS评分、Oswestry功能障碍指数(ODI)和年龄与分级结果进行Spearman相关分析。结果:3位医师分别2次对100例患者的1000个腰椎关节突关节进行分级,0级200～211个(20.0%～21.1%),Ⅰ级384～403个(38.4%～40.3%),Ⅱ级301～310个(30.1%～31.0%),Ⅲ级85～106个(8.5%～10.6%)。同一医师前后分级一致的关节突关节数为84.1%～88.4%,Kappa值为0.773～0.833;不同级别医师分级一致的关节突关节数为82.9%～87.9%,Kappa值为0.756～0.827。患者VAS评分和ODI与分级结果的相关系数分别为0.186、0.192,无显著相关性(P>0.05);年龄与分级结果的相关系数为0.558,呈显著性正相关(P<0.05)。结论:腰椎关节突关节骨性关节炎CT分级具有良好的一致性,对关节突关节退变程度的评估和研究有指导意义;腰椎关节突关节骨性关节炎CT分级与年龄呈正性相关,而与腰痛程度及腰椎ODI无显著相关性。     

Defect in the articular process of the lumbar facet

Bone defect in the lumbar articular facet is rarely noted, and only a few reports on its clinical course have been presented. We report on seven cases with lumbar inferior facet defect whose symptoms were mimicking spondylolysis. We have found three types of the defect shape on radiographs: linear, blunt, and irregular. There were five cases with linear type, one with blunt, and one with irregular. All patients had persistent low back pain, especially when doing physical activity or sports, but no one had history of major trauma or accident. Injection of a small amount of anesthetic temporarily alleviated the low back pain. The low back pain in six patients was controlled with conservative treatments, such as bracing or medication; bone union was especially gained in one case. However, a volleyball player's pain could not be controlled conservatively, and removal of the bone fragment was performed. It is considered that facet defect is not as rare as presumed, and more attention should be paid to it as a source of low back pain.     

Difference in evaluation of patients with low back pain using the Japanese Orthopaedic Association Score for Back Pain and the Japanese Version of the Roland-Morris Disability Questionnaire

Background  The number of patients suffering from degenerative diseases in the lumbar spine is increasing in Japan. Although various scales to measure disability or quality of life in patients with low back pain and/or lumbar diseases are currently available, it has been shown that one questionnaire is not always compatible with another. Our purpose is to evaluate the association and differences between the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score for low back pain. Methods  These two scales were examined and compared using data from 602 patients with low back pain and/or lumbar disease. The associations between the Japanese version of the Roland-Morris Disability Questionnaire and each subscale in the Japanese Orthopaedic Association score in back pain dominant group and leg pain dominant group, and with respect to six pathological conditions (i.e., sciatica, spondylosis, spondylolisthesis, lumbar spinal canal stenosis, muscular pain, traumatic pain) were analyzed. Results  While the Japanese version of the Roland-Morris Disability Questionnaire and the Subjective and Activities of daily living (ADL) subscale of the Japanese Orthopaedic Association score showed a good correlation (r > 0.60), the Japanese version of the Roland-Morris Disability Questionnaire and the Clinical subscale showed a weak correlation (r = 0.35). Among the six pathological conditions, the correlation between the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score was the lowest (r = 0.66) in the lumbar spinal canal stenosis category. Conclusions  The clinical signs in patients with low back pain and/or lumbar diseases are not associated closely with the Japanese version of the Roland-Morris Disability Questionnaire. Therefore, a combination of the Japanese version of the Roland-Morris Disability Questionnaire and the Japanese Orthopaedic Association score can provide wide-ranging assessment of the level of impairment in patients with low back pain and/or lumbar diseases. M. Nakamura and K. Miyamoto made equal contributions to this study     

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.