Clinical evaluation and surgical decision making for patients with lumbar discogenic pain and facet syndrome

Comparison of the Efficacy of Different Radiofrequency Techniques for the Treatment of Lumbar Facet Joint Pain: Combined with Anatomy

PURPOSE OF REVIEW

Lumbar facet pain is generally considered to be one of the major causes of chronic low back pain. Each lumbar facet joint is innervated by the medial branch of the posterior spinal nerve from its own level and above. Radiofrequency (RF) of the medial branch of the posterior branch of the spinal nerve is an effective method for the treatment of lumbar facet pain. RF technology is diverse, including traditional radiofrequency (TRF), pulsed radiofrequency (PRF), cooled radiofrequency (CRF), low-temperature plasma radiofrequency ablation (CA), and other treatment methods. The purpose of this paper is to compare the efficacy of different radiofrequency techniques and to analyze the reasons for this in the context of anatomy.

RECENT FINDINGS

There have been studies confirming the differences in efficacy of different RF techniques. However, most of the studies only compared two RF techniques, not four techniques, TRF, CRF, PRF, and CA, and did not analyze the reasons for the differences in efficacy. This article reviews the differences in the efficacy of the above four RF techniques, clarifies that the differences are mainly due to the inability to precisely localize the medial branch of the posterior branch of the spinal nerve, analyzes the reasons for the inability to precisely localize the posterior branch of the spinal nerve in conjunction with anatomy, and proposes that the development of RF technology for lumbar facet pain requires more in-depth anatomical, imaging, and clinical studies.

Review: Discogenic Back Pain: Update on Treatment

Purpose of Review

Lower back pain (LBP) has a lifetime prevalence of 80% in the United States population. Discogenic back pain (DBP), a subcategory of LBP, occurs as a result of the interverbal disc degeneration without disc herniation. Diagnosis relies on history, physical exam, and imaging such as MRI, provocative discography, or CT discography.

Recent Findings

Treatment of DBP involves a multifaceted approach with an emphasis on conservative measures including behavioral modification, pharmacologic management, and other non-pharmacologic interventions with invasive therapy reserved for select patients. Due to the paucity of data on the treatment of DBP, treatment also relies on data derived from treatment of chronic LBP (CLBP).

Summary

Despite the scarcity of data for the treatment of DBP, treatments do exist with varying efficacy for DBP. Novel techniques such as the use of biologics may provide another avenue for treatment though further studies are needed to better evaluate the most efficacious regimen for both novel and existing treatments.

A tool to improve functional outcome assessment of a multimodal program for patients with chronic low back pain: A study on walk tests (at comfortable and fast speed)

BACKGROUND

Tools for functional assessment of chronic low back pain (LBP) are lacking.

OBJECTIVE

To determine the correlations and the responsiveness of the 400 m comfortable walk test (400 mCWT) and the 200 m fast-walk test (200 mFWT) in the functional assessment of a multimodal program.

METHODS

One hundred and twenty-seven participants (68 females) with LBP and with or without radicular pain completed a Quebec Back Pain Disability Scale, a Sorensen test, a Shirado test, a 400 mCWT and a 200 mFWT, at baseline and at the end of the program.

RESULTS

No significant side effect was reported during walk tests. Walking speed was significantly increased after the program (0.18 ± 0.15 m.s-1 for the 400 mCWT and 0.17 ± 0.17 m.s-1 for the 200 mFWT). Clinical parameters were also significantly improved (82.02 ± 83.1 seconds for the Shirado, 92.1 ± 100.1 seconds for the Sorensen, -14.0 ± 12.9 for the Quebec scale). A significant relationship was found between the increase in walking speed for the two walk tests and the improvement of the Quebec scale. The gait speed improvement was close to the minimal clinically important change (95% confidence interval: 0.14-0.22) determined from the Quebec scale threshold (minimum detectable change).

CONCLUSIONS

Both 400 mCWT and 200 mFWT are correlated with functional parameters and are responsive for the functional assessment of LBP.

Prognostic factors in low back pain individuals undergoing steroid and anaesthetic intra-articular facet joint infiltration: a protocol for a prospective, longitudinal, cohort study

INTRODUCTION

Lumbar pain of facet origin is a common problem worldwide. For those patients not responding to traditional treatment, one approach may be intra-articular infiltration of corticoid and anaesthetic. However, despite the increasing demand for this procedure, no consensus exists regarding its therapeutic value. The selection of eligible participants may be a determining factor since only those with an inflammatory process will benefit from the use of corticosteroids. This study aims to identify differences in disability, pain and quality of life scores in individuals with and without facet joint inflammation who were diagnosed using MRI.

METHOD AND ANALYSIS

This prospective cohort will include individuals older than 18 years with a clinical diagnosis of facet syndrome who underwent intra-articular infiltration. Changes in scores of pain, disability and quality of life questionnaires at 1, 3, 6 and 12 months of follow-up compared with baseline will be analysed. An MRI examination performed before infiltration will help to distinguish between exposed (with inflammation) and non-exposed (non-inflammation) groups with facet syndrome. The primary outcome will be the disability questionnaire (Roland Morris), and the secondary outcomes will be the score questionnaires for pain (Visual Analogue Scale), quality of life (EuroQol Quality of Life Questionnaire) and disability (Oswestry).

ETHICS AND DISSEMINATION

The Internal Review Board approved this study, which started only after the approval number (5291417.0.0000.0071) was received. All recruited participants will receive a verbal explanation about the purpose of the study, and their decision to participate will be free and voluntary. All participants enrolled in the study will provide a signed informed consent form including confidentiality terms. The results obtained in this study will be presented at national and international conferences and published in peer-reviewed scientific journals to disseminate the knowledge.

TRIALS REGISTRATION NUMBER

NCT03304730; Pre-results.

Discogenic Back Pain: Literature Review of Definition, Diagnosis, and Treatment

Discogenic back pain is multifactorial; hence, physicians often struggle to identify the underlying source of the pain. As a result, discogenic back pain is often hard to treat—even more so when clinical treatment strategies are of questionable efficacy. Based on a broad literature review, our aim was to define discogenic back pain into a series of more specific and interacting pathologies, and to highlight the need to develop novel approaches and treatment strategies for this challenging and unmet clinical need. Discogenic pain involves degenerative changes of the intervertebral disc, including structural defects that result in biomechanical instability and inflammation. These degenerative changes in intervertebral discs closely intersect with the peripheral and central nervous systems to cause nerve sensitization and ingrowth; eventually central sensitization results in a chronic pain condition. Existing imaging modalities are nonspecific to pain symptoms, whereas discography methods that are more specific have known comorbidities based on intervertebral disc puncture and injection. As a result, alternative noninvasive and specific diagnostic methods are needed to better diagnose and identify specific conditions and sources of pain that can be more directly treated. Currently, there are many treatments/interventions for discogenic back pain. Nevertheless, many surgical approaches for discogenic pain have limited efficacy, thus accentuating the need for the development of novel treatments. Regenerative therapies, such as biologics, cell‐based therapy, intervertebral disc repair, and gene‐based therapy, offer the most promise and have many advantages over current therapies. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research

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.

A comparison of occupational groups using different working postures in terms of their low back and neck health status

OBJECTIVE

To compare how disability, fear of movement, psychosocial status and quality of life are affected in terms of low back-neck health status in three occupational groups using different work postures.

METHOD

Three hundred thirty-nine individuals participated in this study from the following three different occupational groups: group A, where the individuals worked in a prolonged sitting position (secretaries), group B, where the individuals performed dynamic activities in a standing position (cleaning workers) and group C, where the individuals worked in a prolonged standing position (private security officers). The participants were evaluated by Million Visual Analog Scale, Neck Disability Index, Oswestry Disability Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale and Tampa Kinesiophobia Scale.

RESULTS

It was found that disability, emotional status and the quality of life were minimally affected, but kinesiophobia was increased in all of the occupational groups. In the group C, low back pain disability, quality of life and fear of movement were more affected than the other groups (p< 0.05).

CONCLUSION

For the occupational groups with long working years, the presence of kinesiophobia should be considered and cognitive-behavioural treatment methods should be recommended. In cleaning workers, low back pain is an important risk factor. Therefore, its awareness should be increased, and preventive programmes should be offered.

Mechanisms of low back pain: a guide for diagnosis and therapy

Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making. Answering the question "what is the pain generator" among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet Joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

Mechanisms of low back pain: a guide for diagnosis and therapy

Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making. Answering the question "what is the pain generator" among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet Joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

Management of lumbar zygapophysial (facet) joint pain

AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.

METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.

RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.

CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.