Multimodal treatment including lumbar facet joint denervation for severe low back pain in patients with neuromuscular disorders

Evaluation of long-term clinical outcomes and the incidence of adjacent proximal segment degenerative disease with algorithmic transforaminal interbody fusion: A multicenter prospective study

Study Design

This was a prospective multicenter study.

Background

Adjacent segment degenerative disease (ASDd) is a common complication of open transforaminal lumbar interbody fusion (O-TLIF), the leading cause of which is initial adjacent segment degeneration (ASD). To date, various surgical techniques for the prevention of ASDd have been developed, such as, simultaneous use of interspinous stabilization (IS) and preventive rigid stabilization of the adjacent segment. The use of these technologies is often based on the subjective opinion of the operating surgeon, or on the assessment of one of the predictors of ASDd. Only sporadic studies are devoted to a comprehensive study of risk factors of ASDd development and personalized performance of O-TLIF.

Purpose

The purpose of this study was to evaluate long-term clinical outcomes and the incidence of degenerative disease of the adjacent proximal segment using clinical-instrumental algorithm for preoperative planning to O-TLIF.

Materials and Methods

The prospective, nonrandomized, multicenter cohort study included 351 patients who underwent primary O-TLIF, and the adjacent proximal segment had initial ASD. Two cohorts were identified. The prospective cohort included 186 patients who were operated by using the algorithm of personalized O-TLIF performance. The control retrospective cohort consisted of patients (n = 165), from our own database who had been operated on previously without the algorithmized approach. Treatment outcomes were analyzed by Visual Analog Scale (VAS) assessment of pain syndrome, Oswestry Disability Index (ODI) scores, physical component score (PCS) and mental component score (MCS) scores of the Short Form 36 questionnaire, frequency of ASDd was compared between studied cohorts.

Results

Thirty-six months after follow-up, the prospective cohort had better SF36 MCS/PCS outcomes, less disability according to ODI, and lower pain level according to VAS (P < 0.05). The incidence of ASDd in the prospective cohort was 4.9%, which was significantly lower than in the retrospective cohort (9%).

Conclusions

The prospective use of a clinical-instrumental algorithm for preoperative planning of rigid stabilization, depending on the biometric parameters of the proximal adjacent segment, significantly reduced the incidence of ASDd and improved long-term clinical outcomes compared with the retrospective group.

3D kinematic characteristics of lumbar facet joints in sitting position

BACKGROUND

Recognizing the kinematic characteristics of lumbar facet joints is important for the prevention and treatment of lumbar degenerative diseases. Previous studies have been conducted in either the supine or standing position, and there are no measurements regarding the kinematic characteristics of the lumbar facet joints while sitting. The aim of this study was to measure and analyze lumbar facet joint motion characteristics while sitting.

METHODS

Ten subjects (5 males and 5 females) performed the movements of flexion-extension, left bending-right bending, and left rotation-right rotation in a sitting position. Dual Fluoroscopic Image System and computed tomography technique were used to measure the displacement and rotation angle of the lumbar facet joints of the subjects for analysis. The movement characteristics of L3-S1 were measured.

RESULTS

When the subjects were in sitting position, the lumbar vertebra mainly changed in Z-axis and α, β angle when they performed flexion-extension activities. The displacement of the left facet joint was 4.65 ± 1.99 mm at L3-4, 1.89 ± 2.99 mm at L4-5, and 0.80 ± 2.27 mm at L5-S1 in the Z-axis, and the displacement of the right facet joint was 3.20 ± 2.61 mm at L3-4, 1.71 ± 3.00 mm at L4-5, and 0.31 ± 1.69 mm at L5-S1 in the Z-axis. The rotation in the α angle was 6.00 ± 4.49° at L3-4, 3.51 ± 5.24° at L4-5, and 0.97 ± 4.13° at L5-S1, which was significant different. The rotation in the β angle was 2.30 ± 2.94°at L3-4, 0.16 ± 2.06° at L4-5, and 0.35 ± 1.74°at L5-S1, which was significant different. When the lumbar spine performed the activity of left bending-right bending, there were changes in rotation mainly in the Z-axis and β angle. The displacement of left facet joint in the Z-axis was 1.34 ± 2.84 mm at L3-4, 2.11 ± 0.88 mm at L4-5, and 0.72 ± 0.81 mm at L5-S1; the rotation in the β angle was 5.66 ± 2.70°at L3-4, 7.89 ± 2.59° at L4-5, and 1.28 ± 2.07° at L5-S1; when the lumbar spine performed the activity of left rotation-right rotation, there were changes in the β angle. The rotation of β angle was 4.09 ± 2.86° at L3-4, 2.14 ± 3.38° at L4-5, and 0.63 ± 1.85° at L5-S1.

CONCLUSION

The lumbar facet joint motion in sitting position is different in each mode of motion. The horizontal displacement and rotation are predominant during flexion and extension activities, while there are different rotation in bending and rotation. The study shows the coupled motion of the lumbar facet joints while sitting, providing a new perspective on the kinematics of the lumbar spine and the etiology of lumbar degenerative diseases.

Radiofrequency Ablation as an Effective Long-Term Treatment for Chronic Sacroiliac Joint Pain: A Systematic Review of Randomized Controlled Trials

Radiofrequency ablation (RFA) has emerged as a popular intervention for chronic pain management, including pain originating in the sacroiliac joint. It offers a less invasive option than surgery but with better results than the previous standard treatment with steroid and anesthetic injections. Procedure volumes have enjoyed significant growth in the market in recent years. The evidence supporting this intervention, in the form of randomized controlled trials, however, is both thin and mixed. The purpose of this systematic review is to evaluate the body of randomized controlled trials (RCTs) to determine the quality of support for and against the use of radiofrequency ablation to treat sacroiliac joint (SIJ) pain. Several important new papers have emerged since previous systematic reviews with similar objectives were published. The review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and three databases were used: PubMed, Google Scholar, and Scopus. Only RCTs were sought, and no other filters, such as a historical timeline cut-off, were used. Among 95 publications that returned in response to the query, 16 were ultimately accepted as meeting the inclusion/exclusion criteria. The Cochrane risk-of-bias tool was utilized as a quality assessment measure, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was used to assess the certainty of the evidence. Among the included publications, 15 out of 16 publications featured positive results and conclusions that supported the use of RFA in treating chronic sacroiliac joint pain. The single negative study was also the largest trial (n=681), but it was identified as “High Risk” using the Cochrane risk-of-bias tool. It included several design flaws including neither operator nor patient blinding, missing information, use of inconsistent treatment modalities across groups, and disproportionate drop-out rates. Despite its flaws, we have included this study in the present review because of its sheer size. Taken in aggregate, the total body of research included in this review supports this intervention. Questions continue to exist around whether there are clinically significant benefits associated with different RFA modalities (for example, unipolar vs. bipolar), with convincing evidence supporting each of them. Finally, it can be concluded that while the benefits are reasonably and justifiably supported in this patient population for up to one year, there is a dearth of evidence beyond a 12-month post-intervention follow-up.