CRITICAL APPRAISAL OF PUBLISHED SYSTEMATIC REVIEWS OF THERAPEUTIC LUMBAR FACET JOINT INJECTIONS

BackgroundPain of lumbar facet-joint origin is a common cause of low back pain in adults and may lead to chronic pain and disability, with associated health and socioeconomic implications. The socioeconomic burden includes an inability to return to work resulting in loss of productivity in addition to direct and indirect health-care utilisation costs. Lumbar facet-joints are paired synovial joints between the superior and inferior articular processes of consecutive lumbar vertebrae and between the fifth lumbar vertebra and the sacrum. Facet-joint pain is defined as pain that arises from any structure that is part of the facet-joints, including the fibrous capsule, synovial membrane, hyaline cartilage and bone. This pain may be treated by intra-articular injections with local anaesthetic and steroid, although this treatment is not standardised. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. Because of the lack of high-quality, robust clinical evidence, the National Institute for Health and Care Excellence (NICE) guidelines on the management of chronic low back pain [NICE.Low Back Pain in Adults: Early Management. Clinical guideline (CG88). London: NICE; 2009] did not recommend the use of spinal injections despite their perceived potential to reduce pain intensity and improve rehabilitation, with NICE calling for further research to be undertaken. The updated guidelines [NICE.Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE guideline (NG59). London: NICE; 2016] again do not recommend the use of spinal injections.ObjectivesTo assess the feasibility of carrying out a definitive study to evaluate the clinical effectiveness and cost-effectiveness of lumbar facet-joint injections compared with a sham procedure in patients with non-specific low back pain of > 3 months’ duration.DesignBlinded parallel two-arm pilot randomised controlled trial.SettingInitially planned as a multicentre study involving three NHS trusts in the UK, recruitment took place in the pain and spinal orthopaedic clinics at Barts Health NHS Trust only.ParticipantsAdult patients referred by their GP to the specialist clinics with non-specific low back pain of at least 3 months’ duration despite NICE-recommended best non-invasive care (education and one of a physical exercise programme, acupuncture or manual therapy). Patients who had already received lumbar facet-joint injections or who had had previous back surgery were excluded.InterventionsParticipants who had a positive result following a diagnostic test (single medial branch nerve blocks) were randomised and blinded to receive either intra-articular lumbar facet-joint injections with steroids (intervention group) or a sham procedure (control group). All participants were invited to attend a group-based combined physical and psychological (CPP) programme.Main outcome measuresIn addition to the primary outcome of feasibility, questionnaires were used to assess a range of pain-related (including the Brief Pain Inventory and Short-Form McGill Pain Questionnaire version 2) and disability-related (including the EuroQol-5 Dimensions five-level version and Oswestry Low Back Pain Questionnaire) issues. Health-care utilisation and cost data were also assessed. The questionnaire visits took place at baseline and at 6 weeks, 3 months and 6 months post randomisation. The outcome assessors were blinded to the allocation groups.ResultsOf 628 participants screened for eligibility, nine were randomised to receive the study intervention (intervention group,n = 5; sham group,n = 4), six completed the CPP programme and eight completed the study.LimitationsFailure to achieve our expected recruitment targets led to early closure of the study by the funder.ConclusionsBecause of the small number of participants recruited to the study, we were unable to draw any conclusions about the clinical effectiveness or cost-effectiveness of intra-articular lumbar facet-joint injections in the management of non-specific low back pain. Although we did not achieve the target recruitment rate from the pain clinics, we demonstrated our ability to develop a robust study protocol and deliver the intended interventions safely to all nine randomised participants, thus addressing many of the feasibility objectives.Future workStronger collaborations with primary care may improve the recruitment of patients earlier in their pain trajectory who are suitable for inclusion in a future trial.Trial registrationEudraCT 2014-003187-20 and Current Controlled Trials ISRCTN12191542.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 74. See the NIHR Journals Library website for further project information.

Download Full-text

Predictors of response to medial branch block, radiofrequency ablation or facet joint injections: a retrospective study

Pain Management ◽

10.2217/pmt-2020-0032 ◽

2020 ◽

Author(s):

Saba Javed ◽

Jordan Chen ◽

Billy Huh

Keyword(s):

Radiofrequency Ablation ◽

Facet Joint ◽

Demographic Data ◽

Patient Characteristics ◽

Medial Branch ◽

Lumbar Facet Joint ◽

Predictors Of Response ◽

Medial Branch Block ◽

Lumbar Facet ◽

Joint Injections

Aim: Low back pain is a leading cause of patient disability in the USA. Our goal was to determine association between patient characteristics and their response to lumbar medial branch block, radiofrequency ablation of medial nerves or lumbar facet joint injections. Materials & methods: Medical records for the first 100 patients who underwent lumbar medial branch block, radiofrequency ablation of lumbar medial nerves or lumbar facet joint injections between 1 September 2019 and 31 March 2020 were reviewed and demographic data were recorded. Results: At the 3-month post-procedure visit, positive responders were significantly more likely to be non obese patients (BMI <30) and those with pain <5-years. Conclusion: Obesity and chronicity of pain certainly are found to be predictors of response to the above mentioned procedures.

Download Full-text

Lumbar Facet Joint Injections: Is CT Guided Intra-Articular Needle Position Advantageous?

Journal of Pain & Relief ◽

10.4172/2167-0846.1000178 ◽

2015 ◽

Vol 04 (02) ◽

Cited By ~ 1

Author(s):

Lilach Goldstein Karin Ariche

Keyword(s):

Facet Joint ◽

Lumbar Facet Joint ◽

Ct Guided ◽

Needle Position ◽

Lumbar Facet ◽

Joint Injections

Download Full-text

Corticosteroid and Cortisol Serum Levels Following Intra-articular Triamcinolone Acetonide Lumbar Facet Joint Injections

Pain Practice ◽

10.1111/papr.12686 ◽

2018 ◽

Vol 18 (7) ◽

pp. 864-870 ◽

Cited By ~ 7

Author(s):

Rozalin R. Dickson ◽

Joel M. Reid ◽

Wayne T. Nicholson ◽

Tim J. Lamer ◽

W. Michael Hooten

Keyword(s):

Triamcinolone Acetonide ◽

Facet Joint ◽

Serum Levels ◽

Lumbar Facet Joint ◽

Lumbar Facet ◽

Joint Injections

Download Full-text

Do Regenerative Medicine Therapies Provide Long-Term Relief in Chronic Low Back Pain: A Systematic Review and Metaanalysis

January 2018 - Pain Physician ◽

10.36076/ppj.2018.6.515 ◽

2018 ◽

Vol 1 (21;1) ◽

pp. 515-540 ◽

Cited By ~ 2

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Systematic Review ◽

Low Back Pain ◽

Back Pain ◽

Sacroiliac Joint ◽

Facet Joint ◽

Low Back ◽

Lumbar Facet Joint ◽

Level I ◽

Lumbar Facet ◽

Joint Injections

Background: Several cell-based therapies have been proposed in recent years the management of low back pain, including the injection of medicinal signaling cells or mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). However, there is only emerging clinical evidence to support their use at this time. Purpose: To assess the effectiveness of MSCs or PRP injections in the treatment of low back and lower extremity pain. Study Design: A systematic review and metaanalysis of the effectiveness of PRP and MSCs injections in managing low back and lower extremity pain. Data Sources: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed from 1966 through June 2018. Study Selection: Randomized trials, observational studies, and case reports of injections of biologics into the disc, epidural space, facet joints, or sacroiliac joints. Data Extraction: Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data Synthesis: Twenty-one injection studies met inclusion criteria. There were 12 lumbar disc injections, 5 epidural, 3 lumbar facet joint, and 3 sacroiliac joint studies Results: Evidence synthesis based on a single-arm metaanalysis, randomized controlled trials (RCTs), and observational studies, disc injections of PRP and MSCs showed Level 3 evidence (on a scale of Level I through V). Evidence for epidural injections based on single-arm metaanalysis, a single randomized controlled trial and other available studies demonstrated Level 4 (on a scale of Level I through V) evidence. Similarly, evidence for lumbar facet joint injections and sacroiliac joint injections without metaanalysis demonstrated Level 4 evidence (on a scale of Level I through V).. Limitations: Lack of high quality RCTs. Conclusion: The findings of this systematic review and single-arm metaanalysis shows that MSCs and PRP may be effective in managing discogenic low back pain, radicular pain, facet joint pain, and sacroiliac joint pain, with variable levels of evidence in favor of these techniques. Key Words: Chronic low back pain, regenerative therapy, medicinal signaling or mesenchymal stem cells, platelet-rich plasma, disc injection, lumbar facet joint injections, sacroiliac joint injections

Download Full-text