Evaluation of endoscopic dorsal ramus rhizotomy in managing facetogenic chronic low back pain

Clinical Outcome after Endoscopic Facet Denervation in Patients with Chronic Low Back Pain

Several studies have reported that low back pain has a high prevalence among the population, with up to 85%. Percutaneous radiofrequency facet denervation (PRFD) is the gold standard of today's rhizotomy for chronic low back pain (CLBP). However, previously published studies present controversial results for the efficacy of PRFD. Therefore, this study aimed to analyse the use of endoscopic facet joint denervation (EFJD) to treat chronic low back pain and to identify potential risk factors that could limit indications for surgery.We retrospectively included 31 eligible patients into the study with at least 24 months of CLBP. All patients underwent EFJD and had to complete ODI, COMI, EQ-5D and VRS scores postoperatively, with a minimum follow up of 12 months. Basic patient data was recorded to analyse correlations.We found a significant improvement in all clinical scores measured, such as ODI, COMI, EQ-5D and VRS scores. While the best result was found at the 3 months follow-up, a slight deterioration was found at 12 months follow-up. However, significant benefit was observed when compared to preoperative scores. 28/31 patients (93.3%) reported reduced pain at 12 months follow-up and were satisfied with the procedure. Older age and psychiatric precondition were identified as potential risk factors associated with poorer outcome. Postoperative complications such as haematoma, a sensibility disorder and temporary low extremity muscular weakness were rarely observed.EFJD showed significant improvement of the clinical outcome scores and VRS when compared to preoperative results of patients, with a minimum of 12 months of CLBP prior to surgery. Older patients and patients with a psychiatric precondition seem to benefit less from the procedure.

Anatomical Observation and Clinical Significance of the Medial Branch of the Lumbar Dorsal Rami

STUDY DESIGN

Anatomical study.

OBJECTIVE

This study aimed to elaborate on the anatomical characteristics of the medial branch of the lumbar dorsal rami and to discuss its possible clinical significance.

SUMMARY OF BACKGROUND DATA

Radiofrequency ablation targeting the medial branch of the lumbar dorsal rami has been increasingly used in the clinical management of facetogenic low back pain (FLBP). Nonetheless, attention is also being given to complications such as atrophy of the lumbar soft tissues and muscles. Therefore, a more detailed understanding of the innervation pattern on the facet joint may improve the precision of nerve ablation therapy for FLBP.

METHODS

An anatomical study of eight human specimens was carried out. The anatomic characteristics of the medial branch were observed and recorded.

RESULTS

The medial branch originates from the lumbar dorsal rami, running close to the root of the posterolateral side of the superior articular process of the inferior cone. When passed through the mamillo-accessory ligament, it turns direction to the medial and caudal side, running in the multifidus muscle. In our study, each medial branch sent out two to five branches along the way. All the medial branches in L1-L4 gave off one to two small branches when crossing the facet joint and innervated the joint of the lower segment. Nineteen medial branches (23.75%) gave off recurrent branches to innervate the joint at the upper segment.

CONCLUSION

The anatomical features of the medial branch remain similar in each lumbar segment. There are two types of joint branches, including the articular fibers that emanate from the medial branch as it runs along the medial border of the facet joint and the recurrent branch from the medial branch that innervates the upper facet joint. Moreover, an anastomotic branch was found in the medial branches between different segments.

Comparative Efficacy of Clinical Interventions for Sacroiliac Joint Pain: Systematic Review and Network Meta-analysis With Preliminary Design of Treatment Algorithm

OBJECTIVE

We aimed to identify the most effective clinical treatment method for sacroiliac joint (SIJ)-related pain based on the systematic review and network meta-analysis (NMA) to evaluate the comparative efficacy of clinical interventions for sacroiliac joint pain by pooling the randomized controlled trials (RCTs).

METHODS

Our team conducted a systematic review and NMA of RCTs to determine the most effective clinical treatment for SIJ-related pain. We searched the PubMed (MEDLINE), Web of Science, Cochrane Library, and Scopus databases for RCTs until February 2023. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed. Pairwise and network meta-analyses were conducted using a random effects model.

RESULTS

Based on the search strategy and inclusion criteria, our systematic review and NMA included 9 randomized studies with 652 participants. Research has mainly focused on various radiofrequency sources, but their number is still low. In the network analysis, according to the NMA and mean ranking probabilities for the improvement of pain intensity (PI) and quality of life (QoL), sacroiliac joint fusion and cooled radiofrequency were associated with high treatment rank for improving PI and QoL in patients with sacroiliac joint pain.

CONCLUSION

This NMA suggest that SIJ fusion and cooled radiofrequency could be potential options for improving the QoL and relieving pain in patients with SIJ-related pain. Comparison studies of outcomes between these 2 procedures with solid methodology and a low risk of bias would be very beneficial to identify the optimal treatment option for this challenging disease.

Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis

Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.

Endoscopic Rhizotomy for Facetogenic Back Pain: A Review of the History, Financial Considerations, Patient Selection Criteria, and Clinical Outcomes

BACKGROUND

Chronic back pain (CBP) is a condition that places a considerable burden on society, with several million people affected in the United States alone. Treatment options to address this problem and relieve CBP are constantly evolving, and one of the most promising treatment modalities for CBP that is refractory to conservative treatment options is endoscopic rhizotomy (ER).

METHODS

A thorough search of the PubMed (MEDLINE) database was conducted to assess the full progression of ER from its earliest uses to present day in a historical narrative review of ER, with treatment of facetogenic pain as a model pathology.

RESULTS

ER allows for direct visualization and ablation of sensory branches of the dorsal ramus to provide pain relief in up to 80% of patients faced with refractory CBP. This technique has been built upon since the early 20th century, and the novel endoscopic approach continues to gain popularity among physicians. Benefits of ER include superior postoperative median pain-free duration compared with traditional percutaneous radiofrequency ablation, as well as direct visualization of regional anatomy. Patient selection criteria for the procedure and a modest list of contraindications allow the use of ER as a viable treatment option for a significant population of patients suffering from CBP. Potential barriers to ER include high cost of the procedure, longer intraoperative time, and expensive proprietary equipment.

CONCLUSIONS

ER is an effective treatment for refractory CBP with notable advantages. As the technology and popularity of this procedure progress, improvements in the cost, training, and intraoperative time may make it a favorable alternative to the current standard of care.

Comparison of Endoscopic Facet Joint Denervation to the Percutaneous Technique Regarding Efficacy in Patients With Low Back Pain: A Randomized Controlled Trial

STUDY DESIGN

This was a single-center prospective randomized controlled study.

OBJECTIVE

The aim was to compare the efficacy of endoscopic facet joint denervation (FJD) with that of the percutaneous technique in terms of pain, functional disability, and quality of life in patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Different controlled studies in patients with LBP have shown short-term benefits from percutaneous FJD. Observational studies have demonstrated that endoscopic FJD may be more effective. As the superiority of the endoscopic technique has not been clearly demonstrated in previous studies, a prospective randomized controlled study was conducted.

MATERIALS AND METHODS

For this study, 40 patients with LBP lasting more than 6 months duration and at least 50% pain reduction on the visual analog scale after medial branch block under fluoroscopy, were assigned randomly to receive percutaneous or endoscopic FJD. The primary outcome was pain, as indicated by visual analog scale. Secondary outcomes were functional disability, as assessed by the Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RDQ), and quality of life, as assessed by the Short Form Health Survey (SF-36).

RESULTS

After the intervention, the pain level decreased significantly in both groups ( P <0.001); however, the effect was still significant in the endoscopic group (EG) and diminished to lower than the statistical significance in the percutaneous group (PG) after 12 months. The ODI and RDQ scores also improved significantly in both groups ( P <0.001). However, the ODI and RDQ were significantly better ( P <0.001) in the EG after 12 months. In the SF-36, we observed significant improvement in both groups three months after the intervention. The effect decreased after six months in the PG and was predominantly not demonstrable after 12 months, whereas in the EG there was still a strong significant improvement on all scales ( P <0.001) after 12 months.

CONCLUSION

Percutaneous and endoscopic FJD reduced pain and improved functionality and quality of life. However, the effects decreased or disappeared in the PG after 12 months, whereas there was still a strong significant improvement in the EG.

Development and Description of a New Multifidus-Sparing Radiofrequency Neurotomy Technique for Facet Joint Pain

INTRODUCTION

The technique of radiofrequency neurotomy (RFN) of the facet joints has been used for decades to treat persistent low back pain to good effect in carefully selected patients. Traditionally, the target is the medial branches of the dorsal root supplying the facet joint. An alternative denervation target is the facet joint capsule. Capsule-targeting techniques may spare the multifidus muscle, a possible unintended target of traditional RFN that is thought to be important in recovering from low back pain, and have shown promising results.

METHODS

A modified RFN technique that targets the capsule and spares the multifidus (multifidus-sparing RFN) is described here, along with a brief report of its application in patients with symptomatic facet joint low back pain as compared to traditional medial branch RFN (MBRF).

RESULTS

Over a 2-year period, a total of 401 initial multifidus-sparing RFN and 94 initial MBRF procedures were performed on patients attending a multidisciplinary pain clinic. The proportion of repeat procedures was similar: 28.4% of multifidus-sparing procedures and 23.4% of MBRF procedures. The median repeat interval was 12 months for both groups and interquartile range was 10 months (8-18 months) for multifidus-sparing RFN and 4 months (11-15 months) for MBRF. Effectiveness and safety profiles appear to be similar, although limited, retrospective outcome information prevented robust analysis.

CONCLUSION

Multifidus-sparing RFN represents an intriguing technique to denervate the facet joint pain generator while maintaining normal multifidus function. Further study is warranted, particularly in order to identify the appropriate patient criteria and long-term outcomes.

Endoscopic radiofrequency facet joint treatment in patients with low back pain: technique and long-term results. A prospective cohort study

Aims:

The aim of the study was to evaluate the efficacy of endoscopic rhizotomy (ER) for denervation of lumbar facet joints in patients with chronic low back pain (LBP) due to facet joint syndrome (FJS).

Methods:

A total of 50 consecutive patients suffering from chronic LBP due to facet joints were screened to be treated with ER. The patients participating in the study had a 2-year follow up. Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) were assessed in the preoperative and postoperative period. To evaluate secondary endpoints, patients were divided into groups. One group included the patients previously treated with percutaneous radiofrequency (RF). The other group comprised patients at their first interventional treatment. We also compared patients dividing them by age and by number of joints treated, trying to elucidate if these parameters could be predictive of effectiveness of the procedure.

Results:

All patients had a reduction in NRS and an improvement in ODI. NRS was reduced significantly after 1 month and remained the same until the end of the study. ODI was significantly improved from T1 (1 month after surgery) up to T7 (end of the study). The improvements did not differ whether already treated with percutaneous rhizotomy or not. Patients less than 60 years or with 1–2 joints treated had better improvement compared with the others.

Conclusion:

The results obtained demonstrate that ER for denervation of the facet joint is an effective treatment in patients with chronic LBP, with consistent and stable results at 2-year follow up. The technique has a rapid learning curve and no major complications occurred. Moreover, the previous percutaneous RF treatment had no influence on the results obtained with endoscopic technique. There is evidence that best results are obtained in younger patients and/or in patients with 1–2 joints treated.

Lay summary

Low-back pain has facet joints inflammation or degeneration as pain generator in 20–40% of cases. Nervous lesion of the dorsal ramus innervating the facet joints has been shown as an efficacious treatment to obtain good analgesia. Percutaneous techniques have provided short term results for several reasons. This research aimed to see whether endoscopic denervation, which guarantees a more precise approach to anatomical structure, would result in more durable results. The study conducted on 40 patients has made it clear that this approach gives significant analgesia for at least 2 years, which was the time of patient follow up.

Endoscopic facet joint denervation for treatment of chronic lower back pain

OBJECTIVES

Percutaneous radiofrequency is an established method for treatment of chronic low back pain of intervertebral facet etiology. Endoscopic techniques have the advantage of visualization of the facet joint and the dorsal medial ramus and thus allow for more accurate denervation. It was thus hypothesized that pain reduction is vaster and longer enduring.

PATIENTS AND METHODS

A total of 98 consecutive patients that underwent endoscopic facet joint denervation (EFJD) were included in this study. Prior to intervention and for follow-up, patients were asked to complete VAS_pain, ODI, COMI and EQ5D questionnaires.

RESULTS

VAS_pain was reduced significantly (EFJD: p < 0.001) at last follow-up. Values for ODI, COMI and EQ5D showed significant improvements towards subjective well-being at last follow-up.

CONCLUSION

EFJD is a promising technique for the treatment of facet joint syndrome caused CLBP as it contributes to sustaining significant pain reduction and improvement of subjective quality of life parameters.

Endoscopic rhizotomy for chronic lumbar zygapophysial joint pain

BACKGROUND

Chronic lumbar zygapophysial joint pain is a common cause of chronic low back pain. Percutaneous radiofrequency ablation (RFA) is one of the effective management options; however, the results from the traditional RFA need to be improved in certain cases. The aim of this study is to investigate the effect of percutaneous radiofrequency ablation under endoscopic guidance (ERFA) for chronic low back pain secondary to facet joint arthritis.

METHODS

This is a prospective study enrolled 60 patients. The cases were randomized into two groups: 30 patients in the control group underwent traditional percutaneous radiofrequency ablation, others underwent ERFA. The lumbar visual analog scale (VAS), MacNab score, and postoperative complications were used to evaluate the outcomes. All outcome assessments were performed at postoperative 1 day, 1 month, 3 months, 6 months, and 12 months.

RESULTS

There was no difference between the two groups in preoperative VAS (P > 0.05). VAS scores, except the postoperative first day, in all other postoperative time points were significantly lower than preoperative values each in both groups (P < 0.05). There was no significant difference between the two groups in VAS at 1 day, 1 month, and 3 months after surgery (P > 0.05). However, the EFRA demonstrated significant benefits at the time points of 3 months and 6 months (P > 0.05). The MacNab scores of 1-year follow-up in the ERFA group were higher than that in the control group (P < 0.05). The incidence of complications in the ERFA group was significantly less than that in the control group (P < 0.05).

CONCLUSIONS

ERFA may achieve more accurate and definite denervation on the nerves, which leads to longer lasting pain relief.

Comparison of the Effectiveness of Radiofrequency Neurotomy and Endoscopic Neurotomy of Lumbar Medial Branch for Facetogenic Chronic Low Back Pain: A Randomized Controlled Trial

OBJECTIVE

To compare the effectiveness of radiofrequency neurotomy (RN) and endoscopic neurotomy (EN) of lumbar medial branch (MB) for facetogenic chronic low back pain (FCLBP).

METHODS

Forty patients with FCLBP were included and randomly assigned to the control group and the experimental group. The control group (20 cases) underwent X-ray-assisted RN and the experimental group (20 cases) underwent EN of the lumbar MB. The patients' Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI) score were evaluated and compared preoperatively, and at 3 weeks, 6 months, 1 year, and 2 years postoperatively.

RESULTS

First, the RN group demonstrated successful treatment results (P < 0.05) at 3 weeks, 6 months, and 1 year after surgery. At 2 years, patients reported no significant effectiveness (P > 0.05). Second, the EN group demonstrated more prolonged successful treatment outcomes compared with the RN group. At 2 years, although the efficacy declined further, the VAS and ODI scores showed significant improvements compared with the preoperative data (P < 0.05). Third, there was no difference in VAS and ODI scores between the 2 groups at 3 weeks after surgery (P > 0.05). At 6 months and later, the EN group demonstrated better outcomes (P < 0.05).

CONCLUSIONS

For FCLBP, EN and X-ray-assisted RN of lumbar MB are both effective treatments. However, endoscopic lumbar MB neurotomy has the better and longer effectiveness.

Endoscopic Radiofrequency Ablation of the Sacroiliac Joint Complex in the Treatment of Chronic Low Back Pain: A Preliminary Study of Feasibility and Efficacy of a Novel Technique

Background. Radiofrequency ablation (RFA) is a less invasive technique for treatment of sacroiliac joint (SIJ) pain. Objective. To evaluate the feasibility and efficacy of endoscope-guided RFA for the treatment of CLBP from the SIJ complex. Methods. In this retrospective study, the medical records of 17 patients who underwent endoscope-guided RFA of the SIJ complex were reviewed. A bipolar radiofrequency probe was used to lesion the posterior capsule of the SIJ as well as the lateral branches of S1, S2, S3, and the L5 dorsal ramus in multiple locations. We visualized the ablation area using endoscope. We assessed visual analogue scale (VAS) and the Oswestry disability index (ODI) preoperatively, immediately postop, and at 1-, 3-, and 6-month postop outpatient clinic visits. Patient satisfaction of the procedure was assessed in percentages. Results. The mean duration of operation was 20 to 50 minutes. The mean VAS and the ODI scores decreased significantly immediately after the procedure and were kept significantly lower than baseline levels during the follow-up periods. No complications occurred perioperatively and during the follow-up periods. 88.6% of patients were satisfied with the procedure. Conclusions. Our preliminary results suggest that endoscope-guided RFA may be alternative option to treat CLBP secondary to SIJ complex.