Lumbar Facet Syndrome: Intraarticular Injections, Medial Branch Blocks, and Neurotomies

Posterior branches of the lumbar spinal nerves are the anatomic substrate of pain in the lower back, sacrum and the gluteal area. Such pain may be associated with various pathologies which cause pain in the posterior branches of the lumbar spinal nerves due to entrapment, mechanical irritation or inflammatory reaction and/or degeneration. The posterior branches are of significant functional importance, which is related to the function of the structures they supply, including facet joints, which are the basic biomechanical units of the spine. Low back pain caused by facet joint pathology may be triggered e.g. by simple activities, such as body rotations, unnatural positions, lifting heavy weights or excessive bending as well as chronic overloading with spinal hyperextension. Pain usually presents at the level of the lumbosacral junction (L 5 -S 1 ) and in the lower lumbar spine (L 4-5 , L 3-4 ). In the absence of specific diagnostic criteria, it is only possible to conclude that patients display tenderness at the level of the affected facet joint and that the pain is triggered by extension. Differential diagnosis for low back pain is difficult, since the pain may originate from various structures. The most reliable method of identifying Lumbar Facet Syndrome has been found to be a positive response to an analgesic procedure in the form of a block of the medial branch or intraarticular injection. There appear to be good grounds for conducting further studies and developing unequivocal diagnostic tests.

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The Efficacy of Repeated Radiofrequency Medial Branch Neurotomy for Lumbar Facet Syndrome

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2010.48.3.240 ◽

2010 ◽

Vol 48 (3) ◽

pp. 240 ◽

Cited By ~ 11

Author(s):

Jung Hee Son ◽

Sang Dae Kim ◽

Se Hoon Kim ◽

Dong Jun Lim ◽

Jung Yul Park

Keyword(s):

Medial Branch ◽

Facet Syndrome ◽

Lumbar Facet

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Kryorhizotomy: an alternative technique for lumbar medial branch rhizotomy in lumbar facet syndrome

Journal of Neurosurgery Spine ◽

10.3171/spi.2003.98.1.0014 ◽

2003 ◽

Vol 98 (1) ◽

pp. 14-20 ◽

Cited By ~ 10

Author(s):

Christian B. Bärlocher ◽

Joachim K. Krauss ◽

Rolf W. Seiler

Keyword(s):

Pain Relief ◽

Spinal Surgery ◽

Work Capacity ◽

Medial Branch ◽

Alternative Technique ◽

Beneficial Result ◽

Content Type ◽

Facet Syndrome ◽

Lumbar Facet ◽

Fine Print

Object. The authors conducted a prospective study to investigate the efficacy of kryorhizotomy, an alternative procedure for lumbar medial branch neurotomy, in the treatment of lumbar facet syndrome (LFS). Methods. Fifty patients with chronic low-back pain, in whom pain was relieved by controlled diagnostic medial branch blocks of the lumbar zygapophyseal (facet) joints, underwent lumbar medial branch kryorhizotomy. Outcome was evaluated using the Visual Analog Pain Scales and assessment of work capacity. All outcome measures were repeated at 6 weeks, 6 months, and 1 year after surgery. At 1-year follow-up examination, 31 (62%) of 50 patients experienced a good response to lumbar facet kryorhizotomy. Good results with pain relief of 50% or more were obtained in 85% of patients without previous spinal surgery but only in 46% who had undergone previous spinal surgery. This difference was statistically significant. In five patients (16%) in whom a good initial benefit was observed but who experienced increased pain within 6 weeks after kryorhizotomy, the beneficial result was regained after an early repeated procedure. There were no side effects. Overall, 19 (38%) of 50 procedures were not considered successful. In six of these 19 cases a rigid stabilization of the involved segment provided permanent pain relief. Conclusions. Based on this study, patients with LFS who have not undergone previous spinal surgery benefit significantly from percutaneous lumbar kryorhizotomy. Kryorhizotomy, which has virtually no risk, seems to be a valuable alternative technique to lumbar medial branch neurotomy.

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Regression of Enlarged Lumbar Zygapophyseal Inclusions after Manipulative Therapy

Rivista di Neuroradiologia ◽

10.1177/197140099801100115 ◽

1998 ◽

Vol 11 (1) ◽

pp. 113-116

Author(s):

V. Rucco ◽

P.-T. Basadonna ◽

D. Gasparini

Keyword(s):

Magnetic Resonance ◽

Magnetic Resonance Image ◽

Pain Syndrome ◽

Spontaneous Pain ◽

Low Back ◽

Facet Joints ◽

Manipulative Therapy ◽

Facet Syndrome ◽

Lumbar Facet

We describe a case of low back pain (LBP) secondary to a facet syndrome, with a magnetic resonance image of enlarged zygapophyseal inclusions, which both regressed with manipulative therapy. The role of the lumbar zygapophyseal inclusion in the pain syndrome remains uncertain, because there are no studies on these inclusions in the lumbar facet syndrome. The explanation of the role of manual therapy is also uncertain (adjusting joint subluxations, restoring bony alignment, reducing nuclear protrusion, reducing meniscoid entrapment or extrapment, decompressing facet joints, etc). The diagnosis of classical facet syndrome LBP was made by history-taking and physical examination. The diagnosis of intra-articular enlargements was made by magnetic resonance imaging. The manipulative therapy consisted of manipulations in rotation with the spine placed in kyphosis. Before every manipulation session, spontaneous pain, pain with pressure on the zygapophyseal joint and the range of thoracic and lumbar spine motions were evaluated. After the fourth manipulation session, the patient's pain was alleviated and the enlarged zygapophyseal inclusions were no longer visible. The clinical improvement continued at the controls one and two months after the end of the manipulative therapy. This is the first report of facet syndrome LBP with a magnetic resonance image of enlarged zygapophyseal inclusions which both regressed with manipulative therapy. It is interesting to speculate on the possible mechanisms to explain this outcome, but further studies are needed.

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T722 CHANGES OF CEREBRAL BETA-ENDORPHIN IN LUMBAR FACET SYNDROME TREATED WITH RADIOFREQUENCY LUMBAR FACET DENERVATION

European Journal of Pain Supplements ◽

10.1016/s1754-3207(11)70345-5 ◽

2011 ◽

Vol 5 (S1) ◽

pp. 101-101

Author(s):

H.-K. Tsou ◽

T.-H. Kao ◽

H.-T. Chen ◽

C.-C. Shen ◽

J.C.-C. Wei

Keyword(s):

Beta Endorphin ◽

Facet Syndrome ◽

Facet Denervation ◽

Lumbar Facet

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Lumbar Facet Syndrome

Pain Management ◽

10.1016/b978-0-7216-0334-6.50088-1 ◽

2007 ◽

pp. 769-776 ◽

Cited By ~ 2

Author(s):

Nikolai Bogduk

Keyword(s):

Facet Syndrome ◽

Lumbar Facet

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Randomized prospective trial of cooled versus traditional radiofrequency ablation of the medial branch nerves for the treatment of lumbar facet joint pain

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2018-000035 ◽

2019 ◽

Vol 44 (3) ◽

pp. 389-397 ◽

Cited By ~ 9

Author(s):

Zachary L McCormick ◽

Heejung Choi ◽

Rajiv Reddy ◽

Raafay H Syed ◽

Meghan Bhave ◽

...

Keyword(s):

Radiofrequency Ablation ◽

Success Rate ◽

Joint Pain ◽

Rating Scale ◽

Facet Joint ◽

Prospective Trial ◽

Medial Branch ◽

Lumbar Facet Joint ◽

Facet Joint Pain ◽

Lumbar Facet

Background and objectivesNo previous study has assessed the outcomes of cooled radiofrequency ablation (C-RFA) of the medial branch nerves (MBN) for the treatment of lumbar facet joint pain nor compared its effectiveness with traditional RFA (T-RFA). This study evaluated 6-month outcomes for pain, function, psychometrics, and medication usage in patients who underwent MBN C-RFA versus T-RFA for lumbar Z-joint pain.MethodsIn this blinded, prospective trial, patients with positive diagnostic MBN blocks (>75% relief) were randomized to MBN C-RFA or T-RFA. The primary outcome was the proportion of ‘responders’ (≥50% Numeric Rating Scale (NRS) reduction) at 6 months. Secondary outcomes included NRS, Oswestry Disability Index (ODI), and Patient Global Impression of Change.ResultsForty-three participants were randomized to MBN C-RFA (n=21) or T-RFA (n=22). There were no significant differences in demographic variables (p>0.05). A ≥50% NRS reduction was observed in 52% (95% CI 31% to 74%) and 44% (95% CI 22% to 69%) of participants in the C-RFA and T-RFA groups, respectively (p=0.75). A ≥15-point or ≥30% reduction in ODI score was observed in 62% (95% CI 38% to 82%) and 44% (95% CI 22% to 69%) of participants in the C-RFA and T-RFA groups, respectively (p=0.21).ConclusionsWhen using a single diagnostic block paradigm with a threshold of >75% pain reduction, both treatment with both C-RFA and T-RFA resulted in a success rate of approximately 50% when defined by both improvement in pain and physical function at 6-month follow-up. While the success rate was higher in the C-RFA group, this difference was not statistically significant.Trial registration numberNCT02478437.

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Predicting Treatment Success with Facet Syndrome: An Algorithm to Predict Lumbar Radiofrequency Ablation Responders in a Military Population

Pain Medicine ◽

10.1093/pm/pnaa381 ◽

2020 ◽

Author(s):

Scott Hughey ◽

Jacob Cole ◽

Gregory Booth ◽

Jeffrey Moore ◽

Benjamin McDowell ◽

...

Keyword(s):

Radiofrequency Ablation ◽

Functional Status ◽

Scoring System ◽

Smoking History ◽

Secondary Outcome ◽

Medial Branch ◽

Pain Scores ◽

C Statistic ◽

Medial Branch Block ◽

Facet Syndrome

Abstract Objective Radiofrequency ablation (RFA) of the medial branch nerve is a commonly performed procedure for patients with facet syndrome. RFA has previously been demonstrated to provide long-term functional improvement in approximately 50% of patients, including those who had significant pain relief after diagnostic medial branch block. We sought to identify factors associated with success of RFA for facet pain. Design Active-duty military patients who underwent lumbar RFA (L3, L4, and L5 levels) over a 3-year period were analyzed. Defense and Veterans Pain Rating Scale (DVPRS) and Oswestry Disability Index (ODI) scores were assessed the day of procedure and at the 2-month and 6-month follow-up. These data were analyzed to identify associations between patient demographics, pain, and functional status and patients’ improvement after RFA, with a primary outcome of ODI improvement and a secondary outcome of pain reduction. Results Higher levels of starting functional impairment (starting ODI scores of 42.9 vs. 37.5; P = 0.0304) were associated with a greater likelihood of improvement in functional status 6 months after RFA, and higher starting pain scores (DVPRS pain scores of 6.1 vs. 5.1; P < 0.0001) were associated with a higher likelihood that pain scores would improve 6 months after RFA. A multivariate logistic regression was then used to develop a scoring system to predict improvement after RFA. The scoring system generated a C-statistic of 0.764, with starting ODI, pain scores, and both gender and smoking history as independent variables. Conclusions This algorithm compares favorably to that of diagnostic medial branch block in terms of prediction accuracy (C-statistic of 0.764 vs. 0.57), suggesting that its use may improve patient selection in patients who undergo RFA for facet syndrome.

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Lumbar Facet Nerve Block: Ultrasound

10.1093/med/9780199908004.003.0020 ◽

2016 ◽

Author(s):

David A. Provenzano

Keyword(s):

Nerve Block ◽

Iliac Crest ◽

Medial Branch ◽

Ultrasound Guided ◽

Detailed Understanding ◽

Medial Branch Block ◽

Body Mass Indexes ◽

Lumbar Facet ◽

Correct Level ◽

The Ideal

This chapter describes the relevant anatomy and sonoanatomy and the ultrasound-guided technique for lumbar medial branch blocks. The ultrasound-guided lumbar medial branch block is an intermediate level block. Prior to performing this block, it is important to have a detailed understanding of lumbar sonoanatomy in order to be able to target the correct level, the lumbar medial branch and the L5 dorsal ramus zones. In those individuals with body mass indexes in the ideal range, current studies suggest the L3 and L4 medial branches can be successfully targeted. The L5 dorsal ramus may be challenging secondary to the iliac crest, which may limit the ultrasound views needed for the target zone. Further technical and equipment advancements are needed to improve and reduce the existing limitations associated with the ultrasound-guided lumbar medial branch block technique.

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