scholarly journals Systematic Review Of Diagnostic Utility Of Facet (Zygapophysial) Joint Injections In Chronic Spinal Pain: An Update

2007 ◽  
Vol 1;10 (1;1) ◽  
pp. 213-228
Author(s):  
Nalini Sehgal
Keyword(s):  
Low Back Pain ◽  
Joint Pain ◽  
Facet Joint ◽  
Spinal Pain ◽  
Medial Branch ◽  
Low Back ◽  
Facet Joints ◽  
Facet Joint Pain ◽  
Joint Injections ◽  
Chronic Spinal Pain

Background: A 2-year review of literature from October 2004 to December 2006 was completed to update current scientific evidence on diagnostic utility of facet joint injections. Diagnostic injections are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. There is no physical examination technique, laboratory test, or imaging modality that can precisely identify the spinal structure causing pain, distinguish the culprit from a variety of potential targets, and predict response to a therapeutic intervention. Zygapophysial joint injections, commonly called facet injections (intra-articular joint injections and medial branch blocks) are local anesthetic injections of the facet joint or its nerve supply. These are diagnostic procedures used to determine if pain is arising from facet joints, distinguish painful from nonpainful joints and prognosticate response to therapeutic facet joint interventions. Diagnostic injections must meet the cardinal features of a diagnostic test i.e., accuracy, safety, and reproducibility. Accuracy is based on comparison with a “gold standard” to confirm presence or absence of a disease. There is, however, no available gold standard to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. Objectives: Evaluate and update available evidence (2004 to 2006) relating to clinical utility of facet joint injections (intraarticular and medial branch blocks) in diagnosing chronic spinal pain of facet joint origin. Study Design: Review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing facet joint pain according to Agency for Healthcare Research and Quality (AHRQ) and Quality Assessment Studies of Diagnostic Accuracy (QUADAS) criteria. The level of evidence was classified as conclusive (Level I), strong (Level II), moderate (Level III), or limited (Level IV). Methods: Computerized database search (2004 to 2006) of PUBMED, EMBASE, CINAHL, and Web of Knowledge was conducted to identify studies on facet joint pain and diagnostic interventions. Abstracts, reviews, book chapters, case reports, studies based on single blocks or blocks without radiologic control, and studies describing techniques were excluded. Prospective studies were given priority over retrospective studies. Results: There is no change in the strength of evidence for facet joint diagnostic injections. There is strong evidence for controlled comparative local anesthetic facet joint injections or medial branch blocks in the diagnosis of neck and low back pain and moderate evidence in the diagnosis of pain arising from thoracic facet joints. Conclusion: The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies. Key words: Chronic spinal pain, neck pain, low back pain, cervical facet joint, thoracic facet joint, lumbar facet joint, zygapophyseal joint, medial branch block, intraarticular injection

scholarly journals Intraarticular Facet Injections for Low Back Pain: Design Considerations, Consensus Methodology to Develop the Protocol for a Randomized Controlled Trial

2015 ◽  
Vol 5;18 (5;9) ◽  
pp. 473-493
Author(s):  
David R Ellard
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Usual Care ◽  
Joint Pain ◽  
Facet Joint ◽  
Low Back ◽  
Design Considerations ◽  
Facet Joint Pain ◽  
The Uk ◽  
Joint Injections

Background: Since the publication of guidelines by the UK National Institute for Health and Care Excellence (NICE) and the American Pain Society guidelines for low back pain in 2009 there have been deep divisions in the pain treatment community about the use of therapeutic intraarticular facet joint injections. While evidence for the effectiveness or not of intraarticular facet joint injections remains sparse, uncertainty will remain. The Warwick feasibility study, along with a concurrent study with a different design led by another group, aims to provide a stable platform from which the effectiveness and cost effectiveness of intraarticular facet joint injections added to normal care could be evaluated in randomized controlled trials (RCTs). Objectives: To reach consensus on key design considerations for the Warwick facet feasibility study from which the study protocol and working manuals will be developed. Study Design: A consensus conference involving expert professionals and lay members. Methods: Preliminary work identified 5 key design considerations for deliberation at our consensus conference. Three concerned patient assessment and treatment: diagnosis of possible facet joint pain, interaarticular facet joint injection technique, and best usual care. Two concerned trial analysis: a priori sub-groups and minimally important difference and are reported elsewhere. We did systematic evidence reviews of the design considerations and summarized the evidence. Our design questions and evidence summaries were distributed to all delegates. This formed the basis for discussions on the day. Clinical experts in all aspects of facet joint injection from across the UK along with lay people were invited via relevant organizations. Nominal group technique was used in 15 facilitated initial small group discussions. Further discussion and ranking was undertaken in plenary. All small group and plenary results were recorded and checked and verified post conference. Where necessary participants were contacted via email to resolve outstanding issues. Results: Fifty-two delegates attended the conference with lay people and all relevant professions represented. Consensus was reached on the details of how to assess patients for facet joint pain, undertake the injections, and deliver usual care. Where post conference checking of results revealed errors in calculating ranking results on the day, consensus was reached by email consultation. All but 3 delegates agreed to be associated with the outcome. Limitations: Allocating one day for discussing a wide range of topics imposed time pressure on discussion and calculation of the numerous rankings. Conclusions: Through the use of an evidence-based, systematic, inclusive, and transparent process we have established consensus from expert health professionals in the UK, with lay input, on the clinical assessment of suspected facet joint pain, interaarticular injection for facet joint pain, and best usual care for use in a feasibility study for a proposed pragmatic clinical trial of interaarticular facet joint injections. This provides a strong basis for a clinical trial that will be acceptable to the pain treatment community. Key words: Low back pain, interaarticular facet joint injections, best usual care, consensus, nominal group technique

Lumbar Facet–Mediated Pain

2016 ◽  
Author(s):  
Vikram B Patel
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Lower Back Pain ◽  
Joint Pain ◽  
Facet Joint ◽  
Low Back ◽  
Lower Back ◽  
Facet Joint Pain ◽  
And Function ◽  
Lumbar Facet

Lumbar or lower back pain is a very debilitating condition that affects  almost one fifth of the adult population during a given year. Almost everyone walking on two feet is bound to suffer from some back pain during their lifetime. The health care burden for treating low back pain is enormous, especially if the lost work hours are combined with the amount used in diagnosing and treating low back pain. Lumbar facet (zygapophysial) joints are one of the major components involved in causing lower back pain. Diagnosing the pain generator is more of an art than a science. Combining various parameters in the patient’s history, physical examination, and diagnostic studies is not much different from solving a murder mystery. Although facet joint pain may be accompanied by other pain generators, that is, lumbar intervertebral disks, nerve roots, and vertebral bodies, once treated, the relief in pain is more helpful in performing proper rehabilitation and improving further deterioration in low back pain. Muscles are almost always painful due to myofascial pain syndrome that accompanies the facet joint–related pain. Treating one without addressing the other leads to failure in management and optimization of patient’s pain and function. Several treatments are available for treatment of facet joint–mediated pain, including steroid injections using a miniscule amount and radiofrequency ablation of the nerves supplying the facet joints (medial branches of the dorsal primary ramus of the lumbar nerve root). With proper diagnosis and treatment, a patient’s pain and function can be optimized to a level where it may not impact the day-to-day activities or even resumption of the patient’s routine job function. The following review describes the anatomy, pathophysiology, diagnosis, and treatment of lumbar facet joint–mediated pain.   Key words: facet joint pain, facet joint syndrome, low back pain, medial branch radiofrequency, spondylolisthesis

Prevalence of Facet Joint Pain in Chronic Low Back Pain in Postsurgical Patients by Controlled Comparative Local Anesthetic Blocks

2007 ◽  
Vol 88 (4) ◽  
pp. 449-455 ◽  
Author(s):  
Laxmaiah Manchikanti ◽  
Rajeev Manchukonda ◽  
Vidyasagar Pampati ◽  
Kim S. Damron ◽  
Carla D. McManus
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Joint Pain ◽  
Facet Joint ◽  
Low Back ◽  
Facet Joint Pain

Facet Joint Pain in Chronic Spinal Pain: An Evaluation of Prevalence and False-positive Rate of Diagnostic Blocks

2007 ◽  
Vol 20 (7) ◽  
pp. 539-545 ◽  
Author(s):  
Rajeev Manchukonda ◽  
Kavita N. Manchikanti ◽  
Kimberly A. Cash ◽  
Vidyasagar Pampati ◽  
Laxmaiah Manchikanti
Keyword(s):  
False Positive ◽  
Joint Pain ◽  
Facet Joint ◽  
False Positive Rate ◽  
Spinal Pain ◽  
Positive Rate ◽  
Facet Joint Pain ◽  
Chronic Spinal Pain

scholarly journals Accuracy of Diagnostic Lumbar Facet Joint Nerve Blocks: A 2-Year Follow-Up of 152 Patients Diagnosed with Controlled Diagnostic Blocks

2009 ◽  
Vol 5;12 (5;9) ◽  
pp. 855-866 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Low Back Pain ◽  
Joint Pain ◽  
Facet Joint ◽  
Low Back ◽  
Lumbar Facet Joint ◽  
Nerve Blocks ◽  
Facet Joint Pain ◽  
One Year ◽  
Lumbar Facet

Background: Lumbar facet joint pain is diagnosed by controlled diagnostic blocks. The accuracy of controlled diagnostic blocks has been demonstrated in multiple studies and confirmed in systematic reviews. Controlled diagnostic studies have shown an overall prevalence of lumbar facet joint pain in 31% of the patients with chronic low back pain without disc displacement or radiculitis, with an overall false-positive rate of 30% using a single diagnostic block. Study Design: An observational report of outcomes assessment. Setting: An interventional pain management practice setting in the United States. Objective: To determine the accuracy of controlled diagnostic blocks in managing lumbar facet joint pain at the end of 2 years. Methods: This study included 152 patients diagnosed with lumbar facet joint pain using controlled diagnostic blocks. The inclusion criteria was based on a positive response to diagnostic controlled comparative local anesthetic lumbar facet joint blocks. The treatment included therapeutic lumbar facet joint nerve blocks. Outcome Measures: The sustained diagnosis of lumbar facet joint pain at the end of one year and 2 years based on pain relief and functional status improvement. Results: At the end of one year 93% of the patients and at the end of 2 years 89.5% of the patients were considered to have lumbar facet joint pain. Limitations: The study is limited by its observational nature. Conclusion: Controlled diagnostic lumbar facet joint nerve blocks are valid utilizing the criteria of 80% pain relief and the ability to perform previously painful movements, with sustained diagnosis of lumbar facet joint pain in at least 89.5% of the patients at the end of a 2-year follow-up period. Key words: Chronic low back pain, lumbar facet or zygapophysial joint pain, facet joint nerve or medial branch blocks, controlled local anesthetic blocks, construct validity, diagnostic studies, diagnostic accuracy

scholarly journals Is the History of a Surgical Discectomy Related to the Source of Chronic Low Back Pain?

2012 ◽  
Vol 1;15 (1;1) ◽  
pp. E53-E58
Author(s):  
Michael J. DePalma
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Sacroiliac Joint ◽  
Joint Pain ◽  
Facet Joint ◽  
Small Sample ◽  
Medial Branch ◽  
Low Back ◽  
Discogenic Pain ◽  
History Of

Background: Recurrent or persistent low back pain (LBP) after surgical discectomy (SD) for intervertebral disc herniation has been well documented. The source of low back pain in these patients has not been examined. Objective: To compare the distribution of the source of chronic LBP between patients with and without a history of SD. Study Design: Retrospective chart review. Setting: Academic spine center. Patients: Charts from 358 consecutive patients were reviewed. Charts noting the absence/ presence of SD in patients who subsequently underwent diagnostic injections to determine the source of chronic LBP were included resulting in 158 unique cases for analysis. Methods: Patients underwent either dual diagnostic facet joint blocks, intra-articular diagnostic sacroiliac joint injections, provocation lumbar discography, or anesthetic injection into putatively painful interspinous ligaments/opposing spinous processes/posterior fusion hardware. If the initial diagnostic procedure was negative, the next most likely structure in the diagnostic algorithm was interrogated. Subsequent diagnostic procedures were not performed after the source of chronic LBP was identified. Outcome: The source of chronic LBP was diagnosed as discogenic pain (DP), facet joint pain (FJP), sacroiliac joint pain (SIJP), or other sources of chronic LBP. Results: Based on a Fisher’s exact test, there was marginal evidence the distribution of the source of chronic LBP differed for those with and without a history of SD (P = 0.080). Posthoc comparisons suggested that patients with a history of SD have a higher probability of DP compared to those without a history of SD (82% versus 41%; P = 0.011). Differences in the probability of FJP, SIJP, or other sources between the SD history groups were not significant. Limitations: Small sample size, restrospective design, and possible false-positive results. Conclusions: This is the first published investigation of the tissue source of chronic LBP after SD. It appears that DP is the most common reason for chronic LBP after SD. If more rigorous study confirms our findings, future biologic treatments may hold value in repairing symptomatic annular fissures after SD. Key words: surgical discectomy, chornic low back pain, discogenic pain, facet joint, sacroiliac joint, low back pain, diagnostic injections, medial branch block, lumbar provcation discography

scholarly journals An Algorithmic Approach for Clinical Management of Chronic Spinal Pain

2009 ◽  
Vol 4;12 (4;7) ◽  
pp. E225-E264
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Disc Herniation ◽  
Facet Joint ◽  
Spinal Pain ◽  
Low Back ◽  
Algorithmic Approach ◽  
Interventional Techniques ◽  
Epidural Injections ◽  
Chronic Spinal Pain

Interventional pain management, and the interventional techniques which are an integral part of that specialty, are subject to widely varying definitions and practices. How interventional techniques are applied by various specialties is highly variable, even for the most common procedures and conditions. At the same time, many payors, publications, and guidelines are showing increasing interest in the performance and costs of interventional techniques. There is a lack of consensus among interventional pain management specialists with regards to how to diagnose and manage spinal pain and the type and frequency of spinal interventional techniques which should be utilized to treat spinal pain. Therefore, an algorithmic approach is proposed, providing a stepby-step procedure for managing chronic spinal pain patients based upon evidence-based guidelines. The algorithmic approach is developed based on the best available evidence regarding the epidemiology of various identifiable sources of chronic spinal pain. Such an approach to spinal pain includes an appropriate history, examination, and medical decision making in the management of low back pain, neck pain and thoracic pain. This algorithm also provides diagnostic and therapeutic approaches to clinical management utilizing case examples of cervical, lumbar, and thoracic spinal pain. An algorithm for investigating chronic low back pain without disc herniation commences with a clinical question, examination and imaging findings. If there is evidence of radiculitis, spinal stenosis, or other demonstrable causes resulting in radiculitis, one may proceed with diagnostic or therapeutic epidural injections. In the algorithmic approach, facet joints are entertained first in the algorithm because of their commonality as a source of chronic low back pain followed by sacroiliac joint blocks if indicated and provocation discography as the last step. Based on the literature, in the United States, in patients without disc herniation, lumbar facet joints account for 30% of the cases of chronic low back pain, sacroiliac joints account for less than 10% of these cases, and discogenic pain accounts for 25% of the patients. The management algorithm for lumbar spinal pain includes interventions for somatic pain and radicular pain with either facet joint interventions, sacroiliac joint interventions, or intradiscal therapy. For radicular pain, epidural injections, percutaneous adhesiolysis, percutaneous disc decompression, or spinal endoscopic adhesiolysis may be performed. For non-responsive, recalcitrant, neuropathic pain, implantable therapy may be entertained. In managing pain of cervical origin, if there is evidence of radiculitis, spinal stenosis, post-surgery syndrome, or other demonstrable causes resulting in radiculitis, an interventionalist may proceed with therapeutic epidural injections. An algorithmic approach for chronic neck pain without disc herniation or radiculitis commences with clinical question, physical and imaging findings, followed by diagnostic facet joint injections. Cervical provocation discography is rarely performed. Based on the literature available in the United States, cervical facet joints account for 40% to 50% of cases of chronic neck pain without disc herniation, while discogenic pain accounts for approximately 20% of the patients. The management algorithm includes either facet joint interventions or epidural injections with surgical referral for disc-related pain and rarely implantable therapy. In managing thoracic pain, a diagnostic and therapeutic algorithmic approach includes either facet joint interventions or epidural injections. Key words: Algorithmic approach, chronic pain, chronic spinal pain, diagnostic interventional techniques, therapeutic interventional techniques, comprehensive evaluation, documentation, medical decision making.

scholarly journals Indications for and benefits of lumbar facet joint block: analysis of 230 consecutive patients

2002 ◽  
Vol 13 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Alan Bani ◽  
Uwe Spetzger ◽  
Joachim M. Gilsbach
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Local Anesthetic ◽  
Joint Pain ◽  
Facet Joint ◽  
Leg Pain ◽  
Low Back ◽  
Lumbar Facet Joint ◽  
Facet Joint Pain ◽  
Lumbar Facet

Object The authors evaluated the effectiveness of using a facet joint block with local anesthetic agents and or steroid medication for the treatment of low-back pain in a medium-sized series of patients. Methods Over a period of 4 years, the authors performed 715 facet joint injections in 230 patients with variable-length histories of low-back pain. The main parameter for the success or failure of this treatment was the relief of the pain. For the first injection—mainly a diagnostic procedure—the authors used a local anesthetic (1 ml bupivacaine 1%). In cases of good response, betamethasone was injected in a second session to achieve a longer-lasting effect. Long-lasting relief of the low-back pain and/or leg pain was reported by 43 patients (18.7%) during a mean follow-up period of 10 months. Thirty-five patients (15.2%) noticed a general improvement in their pain. Twenty-seven patients (11.7%) reported relief of low-back pain but not leg pain. Nine patients (3.9%) suffered no back pain but still leg pain. One hundred sixteen patients (50.4%), however, experienced no improvement of pain at all. In two cases the procedure had to be interrupted because of severe pain. There were no cases of infection or hematoma. Conclusions Lumbar facet joint block is a minimally invasive procedure to differentiate between facet joint pain and other causes of lower-back pain. The procedure seems to be useful for distinguishing between facet joint pain from postoperative pain due to inappropriate neural decompression after lumbar surgery. It can be also recommended as a possible midterm intervention for chronic low-back pain.

scholarly journals Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions

2004 ◽  
Vol 5 (1) ◽  
Author(s):  
Laxmaiah Manchikanti ◽  
Mark V Boswell ◽  
Vijay Singh ◽  
Vidyasagar Pampati ◽  
Kim S Damron ◽  
...  
Keyword(s):  
Joint Pain ◽  
Facet Joint ◽  
Spinal Pain ◽  
Facet Joint Pain ◽  
Chronic Spinal Pain
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