Intra-articular Triamcinolone Versus Hyaluronate Injections for Low Back Pain With Symptoms Suggestive of Lumbar Zygapophyseal Joint Arthropathy: A Pragmatic, Double-Blind Randomized Controlled Trial

Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.

Effectiveness of Nonpharmacological Measures on Improving Headache Score, Strength, Pain, and Quality of Life in Cervicogenic Headaches: A Systematic Review

Cervicogenic headache (CGH) is a common condition affecting a significant portion of the population and is effectively managed through various interventions, including nonpharmacological approaches. Physical therapy plays a crucial role in CGH management, with numerous studies supporting its effectiveness. This systematic review aimed to evaluate the effectiveness of specific nonpharmacological physical therapy interventions for CGH. A comprehensive search was conducted across various databases (PubMed, Medline, PEDro, and Cochrane Library) for randomized controlled trials (RCTs) published between January 2017 and January 2023 investigating the effectiveness of specific nonpharmacological physical therapy interventions for CGH. We employed manual searches to capture potentially missed studies. Independent reviewers screened all studies based on predefined eligibility criteria. Extracted data included methodology, specific interventions, outcome measures (headache score, strength, pain, and quality of life (QOL)), and study conclusions. Eight RCTs were identified as meeting all inclusion criteria and were thus included in the data synthesis. The findings from these trials revealed a diverse range of nonpharmacological physical therapy interventions, including but not limited to manual therapy, exercise therapy, and multimodal approaches. Specifically, the interventions demonstrated significant improvements in headache scores, strength, pain levels, and overall QOL among individuals with CGH. These results underscore the multifaceted benefits of physical therapy in managing CGH and highlight its potential as a comprehensive treatment option. This review identified eight relevant RCTs investigating nonpharmacological interventions for CGH. Despite the promising findings, this review acknowledges several limitations, including the limited sample size and the heterogeneity of interventions across studies. These limitations emphasize the necessity for further research to elucidate optimal intervention strategies and refine treatment protocols. Nevertheless, the comprehensive analysis presented herein reinforces the pivotal role of physical therapy in not only alleviating pain but also enhancing function and improving the QOL for individuals suffering from CGH.

The Relationship of Radiographic Parameters and Morphological Changes at Various Stages of Degeneration of the Lumbar Facet Joints: Cadaver Study

STUDY DESIGN

Cadaveric specimens.

OBJECTIVE

To perform a pathomorphological analysis of the degree of facet joint (FJ) degeneration utilizing fresh cadaveric models and correlating these structural changes with imaging findings.

METHODS

L1-L5 FSU including all tissue between the anterior longitudinal ligament to the posterior spinal structures were obtained on 28 patients at a mean of 5.7 hours post-mortem. The samples were fixed in an agar medium and CT and MRI were performed. The level of FJ degeneration was identified based on prior classifications Osteoarthritis Research Society International (OARSI), as was the facet angle and tropism. Pathomorphological assessment including articular cartilage cell density was performed according to prior established methodology.

RESULTS

Radiographically, a direct association was identified between FJ degeneration and patient age. Facet angle and tropism did not significantly vary by patient age. Pathomorphologically, there was a decrease in the cellular density of articular cartilage with increasing patient age. Similarly, there was a significant direct correlation between radiographic degree of degenerative changes in FJs with the age of cadavers and the degree of degeneration of FJs according to the morphological classification of OARSI, as well as a significant inverse correlation with cell density.

CONCLUSION

A comprehensive assessment of various signs of FJ degeneration using cadaveric material has established that, based on radiographic imaging, it is possible to assess the microstructural state of FJ, including at an early stage of the disease. This data may be useful for surgeons in guiding therapeutic strategies based on individual biometric parameters of the FJ.

[Lumbar Facet Joint Injection: A Review of Efficacy and Safety]

Facet joint arthrosis is a progressive degenerative disease that is frequently associated with other spinal degenerative disorders such as degenerative disc disease or spinal stenosis. Lumbar facet joint arthrosis can induce pain in the proximal lower extremities. However, symptoms and imaging findings of "facet joint syndrome" are not specific as they mimic the pain from herniated discs or nerve root compression. Currently, evidence for therapeutic intra-articular lumbar facet joint injections is still considered low, with a weak recommendation strength. Nevertheless, some studies have reported therapeutic effectiveness of facet joint injections. Moreover, the use of therapeutic facet joint injections in clinical practice has increased. This review article includes opinions based on the authors' experience with facet joint injections. This review primarily aimed to investigate the efficacy of lumbar facet joint injections and consider their associated safety aspects.

Mechanical Needling With Sterile Water Versus Lidocaine Injection for Lumbar Spinal Stenosis

Study Design: This was a retrospective observational study that assessed the clinical outcome of ageing patients who received ultrasound-guided (USG) mechanical needling with sterile water injection. In addition, the clinical outcome of age-and gender matched patients randomly selected from patients who received needling with sterile water was compared to the patients injected with lidocaine in a 1:1 ratio.Objective: This present study aimed to explore the clinical effects of USG mechanical needling with sterile water injection for lumbar spinal stenosis (LSS).Methods: The data was extracted from the medical records of ageing patients with LSS who received USG injection at the lumbosacral spine by the first author. Low back pain or axial pain, and leg pain or radicular pain were assessed by the visual analogue scale, and gait ability with walking distance were obtained at six different time points.Results: A total of 4328 medical records were examined. Four thousand two hundred and twenty-eight ageing patients received mechanical needling with sterile water injection and found the efficacy lasted up to 6 months. One hundred patients were compared with 100 patients who received lidocaine injection. Those who received lidocaine had pain returned at 3 months and 6 months post-injection.Conclusions: USG mechanical needling with sterile water injection could help relieve axial and radicular pain for at least 6 months. Removal of calcification and fibrosis as well as reduction of sensitization are all possible mechanisms.

Intra-Articular Facet Joint Injection of Normal Saline for Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Objective: This systematic review and meta-analysis compared the patient-reported outcomes of intra-articular facet joint injections of normal saline and selected active substances to identify a more effective agent for treating subacute and chronic low back pain (LBP). Methods: The PubMed, Embase, Scopus, Web of Science, and CENTRAL databases were searched for randomized controlled trials and observational studies published in English. A research quality assessment was performed using ROB2 and ROBINS-I. A meta-analysis was conducted using a random-effects model, and the mean differences (MD) with 95% confidence intervals (CI) in efficacy outcomes, including pain, numbness, disability, and quality of life, were assessed. Results: Of the 2467 potential studies, 3 were included (247 patients). The active substances and normal saline had similar therapeutic effects on pain within 1 h, after 1-1.5 months, and after 3-6 months, with MD and 95% CI of 2.43 and -11.61 to 16.50, -0.63 and -7.97 to 6.72, and 1.90 and -16.03 to 19.83, respectively, as well as on the quality of life after 1 and 6 months. Conclusions: The short- and long-term clinical effects of intra-articular facet joint injections of normal saline are comparable to those of other active substances in patients with LBP.

Interventional Minimally Invasive Treatments for Chronic Low Back Pain Caused by Lumbar Facet Joint Syndrome: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To investigate the efficacy of nonsurgical interventional treatments for chronic low back pain (LBP) caused by facet joint syndrome (FJS).

METHODS

A systematic review of the literature was conducted to identify studies that compared interventional treatments for LBP due to FJS among them, with usual care or sham procedures. Studies were evaluated for pain, physical function, disability, quality of life and employment status. The RoB-2 and MINORS tools were utilized to assess the risk of bias in included studies.

RESULTS

Eighteen studies published between January 2000 and December 2021 were included (1496 patients, mean age: 54.31 years old). Intraarticular (IA) facet joint (FJ) injection of hyaluronic acid (HA) did not show significant difference compared to IA corticosteroids (CCS) in terms of pain and satisfaction. FJ denervation using radiofrequency (RF) displayed slightly superior or similar outcomes compared to IA CCS, physical therapy, or sham procedure. IA CCS showed better outcomes when combined with oral diclofenac compared to IA CCS or oral diclofenac alone but was not superior to IA local anesthetic and Sarapin. IA platelet-rich plasma (PRP) led to an improvement of pain, disability and satisfaction in the long term compared to IA CCS.

CONCLUSION

FJS is a common cause of LBP that can be managed with several different strategies, including nonsurgical minimally invasive approaches such as IA HA, CCS, PRP and FJ denervation. However, available evidence showed mixed results, with overall little short-term or no benefits on pain, disability, and other investigated outcomes.

Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment

Facet joint osteoarthritis (OA) is the most frequent form of facet joint syndrome. Medical history, referred pain patterns, physical examination, and diagnostic imaging studies (standard radiographs, magnetic resonance imaging, computed tomography and single-photon emission computed tomography) may suggest but not confirm lumbar facet joint (LFJ) syndrome as a source of low back pain (LBP). However, the diagnosis and treatment of facet joint syndrome is still controversial and needs further study. It is widely acknowledged that block with local anesthetic is perhaps the most effective method to establish a diagnosis of pain from LFJ. Particularly, there are different rates of success among different populations selected for diagnostic block with various positive criteria. Currently, in addition to conservative treatments for pain such as painkillers, functional exercises, and massage, there are many other methods, including block, denervation of the nerves that innervate the joints by radiofrequency, freezing or endoscopy, and injections. Due to the limited duration of pain relief from neurolysis of medial branch, many scholars have recently turned their targets to dorsal roots and LFJ capsules. Therefore, we reviewed the latest research progress of facet joint syndrome from diagnosis to treatment.

Management of facet joints osteoarthritis associated with chronic low back pain: A systematic review

INTRODUCTION

Facet joint injections (FJI) and medial branch blocks (MBB) can be employed for chronic low back pain (LBP) using different drugs such as corticosteroids, hyaluronic acid, sarapin and local anaesthetics. This systematic review compares the results of injections obtained with different compounds in the management LBP originating from facet joints.

METHODS

The present systematic review was conducted according to the PRISMA statement. The literature search was performed in October 2020. All the randomized clinical trials concerning injection treatments for chronic LBP. Drugs rather than steroids, hyaluronic acid, anaesthetics and sarapin were not considered, as well as those reporting outcomes from combined treatments. The Oswestry Disability Index (ODI) and the numeric rating scale (NRS) were retrieved.

RESULTS

Data from 587 patients were retrieved. The mean follow-up was 12.4 ± 10.5 months. The mean age was 51.3 ± 9.6 years old. 57% (335/587) of patients were women. Steroids promoted a reduction of NRS by 28% (P < 0.0001) and an improvement of the ODI by 13.2% (P = 0.005), and local anaesthetics produced an improvement of the ODI by 9.8% (P < 0.0001). Sarapin resulted in a reduction of NRS by 44% (P = 0.04) and an improvement the ODI by 14.9% (P = 0.004); sarapin combined with steroids promoted a reduction of NRS by 47% (P = 0.04) and an improvement of the ODI by 11.7% (P = 0.001).

CONCLUSION

Injections for chronic LBP deriving from facet joints osteoarthritis are encouraging, especially when considering MBB.

LEVEL OF EVIDENCE

I, systematic review of RCTs.