Role of facet joints in spine pain and image-guided treatment: a review

Outcomes of transforaminal epidural injection of amniotic membrane/umbilical cord particulate for lumbar radiculopathy: a case series

Background

Radiculopathy can be a debilitating condition. Amniotic membrane/umbilical cord (AM/UC) particulate is a relatively new injectable treatment modality. Herein we report the outcomes of epidural injection of AM/UC particulate in managing lumbar radiculopathy.

Methods

Consecutive patients with lumbar radiculopathy who received epidural injection of AM/UC particulate for lumbar radiculopathy were included. Primary outcome was change in pain as measured by the 11-point numerical rating scale. Safety was assessed by AM/UC- and procedure-related complications. Paired t-tests were used to determine statistical significance.

Results

A total of 12 patients with a mean age of 56.7 ± 21.0 years were included in the analysis. The patients were previously treated with physical therapy (91.7%), chiropractic corrective measures (16.7%), epidural steroid injection (83.3%), and radiofrequency ablation (8.3%). Two patients (16.7%) were taking opioids for chronic pain syndrome. After AM/UC injection, the average pain score decreased from 6.6 ± 1.5 to 5.2 ± 1.9 at 1-3 months, 2.0 ± 1.4 at 6 months, and 2.9 ± 1.4 at last mean follow-up of 21.3 ± 11.1 months (p < 0.001). No patients required subsequent treatment or surgery. There were also no complications.

Conclusion

This case series supports the preliminary safety and shows potential benefit of epidural AM/UC particulate injection in this cohort of patients with lumbar radiculopathy pain.

A rare case of facet joint synovial cyst connected to the intrathecal space: a case report

Unexpected injection of local anesthetics into the intrathecal space can cause adverse effects, such as hypotension, shortness of breath, bradycardia, numbness or weakness, nausea and vomiting and serious complications, such as respiratory arrest, loss of consciousness and cardiac arrest. In this study, we report a case of a 68-year-old woman with a facet joint synovial cyst connected to the intrathecal space. The patient's clinical symptoms and radiological findings were consistent with those of a facet joint synovial cyst; however, during facet joint synovial cyst aspiration, it was found that the cyst was connected to the intrathecal space. Our experience shows that during the procedure of facet joint injection and facet joint synovial cyst aspiration, local anesthetics may be inadvertently injected intrathecally. Although this is highly uncommon, it can lead to serious side effects, such as total spinal anesthesia. Therefore, we present this case, along with a brief literature review.

The innervation of the cervical facet joints - an anatomical and histological approach

INTRODUCTION

Cervical facet joint pain syndrome accounts for a great amount of cervical pain worldwide. This study aims to provide updated knowledge of cervical facet joint innervation with new anatomical findings.

MATERIALS AND METHODS

Twenty-seven cervical facet joints and their innervating structures were dissected from five halves of three human neck specimens. Histologic staining was used to confirm that the samples were nervous tissues, and all samples were documented with photography.

RESULTS

Histology: Thirty-six assumed facet joint branch samples were obtained and stained. Twenty-two of these were confirmed to be nervous tissue. Therefore, 61% of the samples were identified as facet joint branches. Of all samples, 28% were not nerves. Dissection: At least one medial branch was clearly identified at each dissected cervical level. At some cervical levels, more than one medial branch was found. Anatomical differences, such as a plexus-like innervation in the high cervical region, were observed. Direct facet joint branches were also discovered. These branches originate directly from the dorsal root of the spinal nerve and were independent from medial branches during their direct pathway toward the facet joint.

CONCLUSION

Direct cervical facet joint branches were identified and a more diverse innervation pattern than previously described of the cervical facet joints was found. This article is protected by copyright. All rights reserved.

The effect of lumbar facet joint injection levels on spinopelvic parameters and functional outcome

BACKGROUND

Low back pain is a very common musculoskeletal complaint that impacts patients' quality of life in numerous ways. Facet joint injection is a widely used spinal intervention to relieve back pain. Effects of facet joint injection on spinopelvic parameters and the relationship between injection levels and spinopelvic parameter changes have not been evaluated before.

OBJECTIVE

To compare spinopelvic parameters before and after injections at different levels, and to evaluate the correlation between these changes and functional outcome.

METHODS

144 patients were included in the study and retrospectively grouped by injection level: Group 1 (n= 72), L4-L5 and L5-S1, and group 2 (n= 72), L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1. Pre- and post-injection Oswestry Disability Index (ODI), sacral slope, pelvic tilt, pelvic incidence, and intervertebral angles between T12 and S1 were compared. The correlation between ODI and radiographic parameter changes was evaluated.

RESULTS

The pre- to post-injection ODI change was significantly lower in group 2 (p= 0.010). There was no significant difference between the groups in terms of pre- and post-injection spinopelvic parameters before and after injection (p> 0.05) except pelvic tilt (p= 0.001 and p= 0.007, respectively). There was a significant moderate positive correlation between the change in the ODI value and the change in pelvic tilt (P= 0.012, r= 0.581).

CONCLUSIONS

Multilevel lumbar facet injections are clinically more effective than only two-level lower level lumbar injections. Pelvic tilt changes positively correlate with the ODI score changes.

The Diagnostic Value of an X-ray-based Scoring System for Degeneration of the Cervical Spine: A Reproducibility and Validation Study

Background

In interventional pain medicine, cervical facet joint (CFJ) pain is commonly treated with CFJ denervation techniques, almost automatically assuming degeneration of the CFJs as an important cause of CFJ pain. A standard cervical X‐ray is still commonly used in the clinical evaluation of patients suspected for CFJ degeneration. Although degenerative features can be visualized by different radiological imaging techniques, the relation between radiological degenerative features of the cervical spine and pain remains controversial. Paramount in order to estimate the clinical usefulness of a radiological imaging is to establish the reproducibility of the radiological scoring system. A reproducible and clinically feasible diagnostic scoring system was developed to estimate cervical degeneration on standard cervical X‐rays.

Materials and Methods

A reproducibility study for the interpretation of degenerative abnormalities on standard cervical X‐rays was performed, using a dichotomous outcome (degenerative abnormalities present Yes/No). The estimation of intervertebral disc height loss on standard cervical X‐rays was validated with computed tomography (CT) scan measurements.

Results

Five radiological degenerative features on standard cervical X‐rays (disc height loss, anterior vertebral osteophytes, posterior vertebral osteophytes, vertebral end plate sclerosis, and uncovertebral osteoarthritis) showed a substantial to excellent reproducibility (kappa value ≥ 0.60). The qualitative definition of disc height loss used in the reproducibility study showed a substantial agreement with the actual measurements of disc height loss on CT scan (kappa value = 0.69).

Conclusion

Subjective judgment of a cervical standard X‐ray is a reproducible method to demonstrate degenerative abnormalities of the cervical spine.

Anatomy and Ultrasound-Guided Injection of the Medial Branch of the Dorsal Ramus of the Cervical Spinal Nerves in the Horse: A Cadaveric Study

OBJECTIVE

 The aim of this study was to describe the anatomy of the nerves supplying the cervical articular process joint and to identify relevant anatomical landmarks that could aid in the ultrasound-guided location and injection of these nerves for diagnostic and therapeutic purposes.

STUDY DESIGN

 Twelve cadaveric equine necks were used. Five necks were dissected to study the anatomy of the medial branch of the dorsal ramus of the cervical spinal nerves 3 to 7. Relevant anatomical findings detected during dissections were combined with ultrasonographic images obtained in one other neck. Six additional necks were used to assess the accuracy of ultrasound-guided injections of the medial branch with blue dye.

RESULTS

 Each examined cervical articular process joint, except for C2 to C3, presented a dual nerve supply. The articular process joints were found to be in close anatomical relationship with the medial branch of the dorsal ramus of the cervical spinal nerve exiting from the intervertebral foramen at the same level, and with the medial branch of the dorsal ramus of the cervical spinal nerve exiting from the intervertebral foramen one level cranial to the articular process joint of interest. A total of 55 nerves were injected under ultrasonographic guidance, 51 of which were successfully stained.

CONCLUSION

 The current study provided new detailed information regarding the innervation of the cervical articular process joint. The medial branches of the dorsal rami of the cervical spinal nerves were injected with an accuracy that would be of clinical value. Our study offers the foundations to develop new diagnostic and therapeutic techniques for pain management in cervical articular process joint arthropathy in horses.

Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

BACKGROUND

Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS.

METHODS

To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements.

RESULTS

During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS.

CONCLUSIONS

A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.

The Variability of Lumbar Facet Joint Synovial Cyst Recurrence Requiring Revision Surgery After Decompression-only and Decompression/Fusion

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to evaluate lumbar spine synovial cyst recurrence rates of decompression-alone versus decompression/fusion procedures.

BACKGROUND

Improvements in imaging modalities allow for increased diagnosis and surgical treatment of symptomatic spinal juxtafacet synovial cysts. Conservative management may be used as a first-line management strategy, however rarely provides durable, effective relief of symptoms. Surgical treatment of spinal synovial cysts ranges from decompression and cyst excision to decompression with fusion procedures. Decompression procedures alone have a higher risk of recurrence of spinal synovial cysts.

METHODS

We retrospectively reviewed 87 patients undergoing surgical treatment of lumbar spinal juxtafacet synovial cysts as a single institution over 20 years. Surgical treatment consisted of either decompression versus decompression/fusion procedures. Preoperative symptoms included back pain, radiculopathy, motor deficits, or sensory deficits. The incidence of recurrence of spinal synovial cysts at the same-site or differing sites was compared between 2 categories of surgical treatment. Revision surgical procedure rates were also evaluated.

RESULTS

A total of 55 (63%) patients were treated with an index decompression-only procedure for the lumbar spinal synovial cyst compared with 32 (37%) patients treated with an index decompression and fusion procedure. Fifty-eight (68%) of the lumbar spinal cysts occurred at the L4-L5 level. There were 10 (11.5%) spinal synovial cyst recurrences in the decompression-only group, and 0 recurrences in the decompression/fusion group. Revision decompression procedures were performed in 4 of the 10 (4.6%) recurrences, and 6 of 10 (6.9%) recurrences had subsequent decompression and fusion surgery. The mean time to recurrence was 23.9±17.3 months. The mean length of follow-up was 65.1±48.6 months. Both recurrence and nonrecurrence cohorts had significant symptomatic improvement using Odom criteria.

CONCLUSIONS

Decompression and cyst excision was the more common surgical treatment of lumbar spinal synovial cysts compared with decompression/fusion procedure in our study. The rate of synovial cyst recurrence and revision surgery in patients undergoing index decompression was relatively low and comparable to current literature. Symptomatic improvement of patients undergoing decompression versus decompression/fusion was similar in our study. Although the fusion may be required for the extent of pathology or coexisting instability, decompression and excision of spinal synovial cysts provide durable, effective treatment with a known, appropriate risk of recurrence and subsequent revision surgery.

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

BACKGROUND

Neck pain is one of the most common causes of chronic pain and the fourth leading cause of disability worldwide; it is estimated that between 36% and 67% of this pain is due to facet arthropathy. For patients who have pain refractory to conservative treatments literature supports management with diagnostic cervical medial branch blocks (MBBs) to identify the associated facet innervation as the source of pain followed by therapeutic radiofrequency ablation (RFA) of the identified nerves. Cervical RFA has good published outcomes; however, the procedure is dependent upon the specificity of the diagnostic block to achieve maximal success. Currently, this prerequisite test has false positive rates between 27% and 63% and recent studies have shown that this may, in part, be a consequence of currently accepted injection volumes of 0.50 mL or more, which may decrease the sensitivity of MBBs.

OBJECTIVE

To evaluate the possible differences in volume dispersion between 0.25 and 0.50 mL of injectate during cervical MBBs.

STUDY DESIGN

Cadaveric study.

SETTING

An academic medical center in the United States.

PATIENTS

Not applicable.

METHODS

This was a cadaveric study in which six subjects were chosen with intact cervical spines. Cervical MBB were performed bilaterally at the midcervical spine, using a posterior approach under fluoroscopic guidance. 0.25 or 0.50 mL of a 9:1 solution of Omnipaque 180 mg iodine/mL and 1% medical grade methylene blue were administered on the left and right sides, respectively. Postinjection computed tomography (CT) imaging and gross dissection were performed to assess injectate spread.

MAIN OUTCOME MEASURES

Outcome measures after using commonly injected volumes for cervical MBB, included visualized and measured spread (by CT and gross dissection) of cervical medial branch blocks, coating adjacent structures not targeted by RFA.

RESULTS

Postinjection CT imaging and cadaveric dissection demonstrated that, although both volumes adequately coated the medial branches, the 0.50 mL cohort reliably spread dorsally to superficial muscles (splenius) and nerves distant from the targeted nerves (dorsal motor branches to splenius), whereas the 0.25 mL injectate cohort was contained in the deep and intermediate muscular cervical layers directly juxtaposed to the targeted cMBBs.

CONCLUSION

Results suggest that 0.50 mL injections of local anesthetic during cervical MBBs contacts many nonintended targets, thus decreasing the specificity of a targeted diagnostic cervical MBB. Furthermore, we demonstrated that 0.25 mL of injectate reliably bathed the cervical medial branches without extensive extravasation. This indicates that there would potentially be fewer local anesthetic effects on distant tissues, increasing the specificity of cervical MBBs and likely improving RFA planning.

Fluoroscopically Guided Facet Injections: Comparison of Intra-Articular and Periarticular Steroid and Anesthetic Injection on Immediate and Short-Term Pain Relief

BACKGROUND AND PURPOSE

The effectiveness of facet injections is unclear in the literature. Our objective was to determine the immediate and short-term efficacy of intra-articular and periarticular steroid/anesthetic injections for facet-mediated lumbar pain.

MATERIALS AND METHODS

All outpatient fluoroscopically guided facet injections at a single institution during a 54-month period were retrospectively and independently reviewed by 2 musculoskeletal (MSK) trained radiologists. All intra-articular, all periarticular, and partial intra-/periarticular injection locations were determined. Periarticular and partial peri-/intra-articular injections were combined for analysis. Preinjection, immediate, and 1-week postinjection numeric pain scores, patient age, sex, anesthetic/steroid mixture, fluoroscopic time, and physician performing the procedure were recorded.

RESULTS

Seventy-seven patients (mean age, 51.1 years) had 100 procedures with 205 total facet joints injected. All intra-articular, all periarticular, and partial peri-/intra-articular injections constituted 54%, 20%, and 26% of the cases, respectively. The immediate and 1-week postprocedural change in pain was -3.7 (95% CI, -4.5 to -2.8; P < .001) and -1.4 (95% CI, -2.2 to -0.6; P = .001) for the all intra-articular and -3.6 (95% CI, -4.4 to -2.9; P < .001) and -1.2 (95% CI, -1.9 to -0.4; P = .002) for the combined group. Changes in immediate pain were significantly associated with the prepain level (P < .001) and patient age (P = .024) but not with the anesthetic used. Analyses revealed no significant difference in pain reduction between the groups either immediately or 1 week postinjection. Intra-articular injections required less fluoroscopic time (geometric mean, 39 versus 52 seconds) (P = .005).

CONCLUSIONS

Intra-articular and periarticular fluoroscopically guided facet injections provide statistically significant and similar pain relief both immediately and 1 week postinjection.

Optimal area of lateral mass mini-screws implanted in plated cervical laminoplasty: a radiography anatomy study

PURPOSE

Lateral mass mini-screws used in plated cervical laminoplasty might penetrate into facet joints. The objective is to observe this complication incidence and to identify the optimal areas for 5- and 7-mm-long mini-screws to implant on lateral mass.

METHODS

47 patients who underwent plated cervical laminoplasty were included. The optimal area for mini-screws implanting was set according to pre-operative 3D CT reconstruction data. Then, each posterior-lateral mass surface was divided into three regions: 7-mm region, 5-mm region, and dangerous area. The mini-screw implanted region was recorded. Post-operative CT images were used to identify whether the mini-screws penetrated into facet joints.

RESULTS

235 mini-plates and 470 lateral mass mini-screws were used in the study. 117 (24.9%) mini-screws penetrated 88 (37.4%) facet joints. The 5-mm-long mini-screw optimal area occupied the upper 72, 65, 65, 64, and 65 % area of the posterior-lateral mass surface for C3-7, while the 7-mm-long mini-screw optimal area encompassed the upper 54, 39, 40, 33, and 32 %. Only 7-mm-long mini-screws were used to fix the plate to the lateral mass. 4 of 240 mini-screws in 7-mm region, 67 of the 179 mini-screws in 5-mm region, and 46 of the 51 mini-screws in dangerous region penetrated into the facet joint. The differences in the rate of facet joint penetration related to region were statistically significant (P < 0.001).

CONCLUSIONS

The facet joint destruction by mini-screws was not a rare complication in plated cervical laminoplasty. The optimal areas we proposed may help guide the mini-screw implantation positions.

Facet joint disturbance induced by miniscrews in plated cervical laminoplasty: Dose it influence the clinical and radiologic outcomes?

A retrospective cohort study. Plated cervical laminoplasty is an increasingly common technique. A unique facet joint disturbance induced by lateral mass miniscrews penetrating articular surface was noticed. Facet joints are important to maintain cervical spine stability and kinetic balance. Whether this facet joint disturbance could affect clinical and radiologic results is still unknown. The objective of this study is to investigate the clinical and radiologic outcomes of patients with facet joints disturbance induced by miniscrews in plated cervical laminoplasty.A total of 105 patients who underwent cervical laminoplasty with miniplate fixation between May 2010 and February 2014 were comprised. Postoperative CT images were used to identify whether facet joints destroyed by miniscrews. According to facet joints destroyed number, all the patients were divided into: group A (none facet joint destroyed), group B (1-2 facet joints destroyed), and group C (≥3 facet joints destroyed). Clinical data (JOA, VAS, and NDI scores), radiologic data (anteroposterior diameter and Palov ratio), and complications (axial symptoms and C5 palsy) were evaluated and compared among the groups.There were 38, 40, and 27 patients in group A, B, and C, respectively. The overall facet joints destroyed rate was 30.7%. All groups gained significant JOA and NDI scores improvement postoperatively. The preoperative JOA, VAS, NDI scores, and postoperative JOA scores did not differ significantly among the groups. The group C recorded significant higher postoperative VAS scores than group A (P = 0.002) and B (P = 0.014) and had significant higher postoperative NDI scores than group A (P = 0.002). The pre- and postoperative radiologic data were not significant different among the groups. The group C had a significant higher axial symptoms incidence than group A (12/27 vs 8/38, P = 0.041).Facet joints disturbance caused by miniscrews in plated cervical laminoplasty may not influence neurological recovery and spinal canal expansion, but may negatively affect postoperative axial symptoms.

Cervical Facet Joint Imaging-Guided Injections: A Comparison of Outcomes in Patients Referred Based on Imaging Findings Vs Palpation for Pain

OBJECTIVES

The purpose of this study was to compare outcomes of patients referred for cervical facet joint injections by either a medical doctor (MD) primarily basing the selection of facet levels on structural changes found on imaging vs a doctor of chiropractic (DC) selecting the levels for injection based on palpation for pain.

METHODS

This was a prospective cohort outcome study including 121 consecutive patients receiving cervical facet injections with completed outcomes questionnaires. Medical doctors referred 91 patients and DCs referred 30 patients. Baseline pain numerical rating scale (NRS) data were collected. Outcomes collected at 1 day, 1 week, and 1 month after injection included NRS pain levels and overall "improvement" using the Patient Global Impression of Change scale (primary outcome). The responses "much better" and "better" were considered "improved." The proportion improved was compared between the 2 groups using the χ(2) test. NRS change scores for the 2 groups were compared using the unpaired t test.

RESULTS

At 1 day, "improvement" was reported in 44.8% of DC-and 29.7% of MD-referred patients (P = .17). At 1 week, 37.9% of DC-and 21.3% of MD-referred patients reported improvement (P = .03). At 1 month, 50.0% of DC-and 31.0% of MD-referred patients reported improvement (P = .1).

CONCLUSIONS

A greater proportion of DC-referred patients (injection level based on palpation for pain) reported "improvement" at all follow-up time points. This finding reached statistical significance at 1 week. These findings may be because DCs use palpation for pain to determine injection level whereas MDs rely more on imaging findings. The results suggest that the reported moderate results of facet injections partially may be due to the inaccurate selection of the spinal level treated.

Factors affecting results of fluoroscopy-guided facet joint injection: Probable differences in the outcome of treatment between pure facet joint hypertrophy and concomitant diseases

Study Design:

Retrospective cohort study.

Purpose:

Facet joints are considered a common source of chronic low-back pain. To determine whether pathogens related to the facet joint arthritis have any effect on treatment failure.

Materials and Methods:

Facet joint injection was applied to 94 patients treated at our hospital between 2011 and 2012 (mean age 59.5 years; 80 women and 14 men). For the purpose of analysis, the patients were divided into two groups. Patients who only had facet hypertrophy were placed in group A (47 patients, 41 women and 6 men, mean age 55.3 years) and patients who had any additional major pathology to facet hypertrophy were placed in group B (47 patients, 39 women and 8 men, mean age 58.9 years). Injections were applied around the facet joint under surgical conditions utilizing fluoroscopy device guidance. A mixture of methylprednisolone and lidocaine was used as the injection ingredient.

Results:

In terms of Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, no significant difference was found between preinjection and immediate postinjection values in both groups, and the scores of group A patients were significantly lower (P < 0.005) compared with that of group B patients at the end of the third, sixth, and twelfth month.

Conclusion:

For low-back pain caused by facet hypertrophy, steroid injection around the facet joint is an effective treatment, but if there is an existing major pathology, it is not as effective.

Multivariate Analysis of Factors Associated With Axial Symptoms in Unilateral Expansive Open-Door Cervical Laminoplasty With Miniplate Fixation

Retrospective case-control study.Unilateral expansive open-door cervical laminoplasty with miniplate fixation is an efficient and increasing popular surgery for multilevel cervical spondylotic myelopathy. Axial symptoms are the most frequent complaints after cervical laminoplasty. But the mechanisms have not been fully clarified yet.The objective of this study is to compare the clinical and radiologic data between patients with or without axial symptoms and to investigate the factors associated with axial symptoms by multivariate analysis in cervical laminoplasty with miniplate fixation.A total of 129 patients who underwent cervical laminoplasty with miniplate fixation were comprised from August 2009 to March 2014. Patients were grouped according to whether they suffered from postoperative axial symptoms (PA) or not (NA). The clinical data including gender, age, duration of symptoms, diagnosis type, medical comorbidity, operative level, blood loss, operative time, pre- and post-Japanese Orthopedic Association (JOA) score, JOA recovery rates, and other complications were recorded. The radiologic data including cervical canal diameter, C2-7 Cobb angle, cervical range of motion (ROM), cross-sectional area, open angle, hinge union, and facet joint destroyed would be measured according to X-ray plain and CT scan images. The univariate analysis and multivariate logistic regression analysis were performed.There were 39 patients in PA group and 90 patients in NA group. Both groups gained significant JOA improvement postoperatively (P < 0.05). The preoperative neck pain (P = 0.048), negative change of cervical ROM (P = 0.018), and facet joints destroyed (P = 0.022) were significant different between the 2 groups. There were no significant differences for other clinical and radiography parameters between the groups (P > 0.05). The multivariate analysis showed that the negative change of cervical ROM (OR = 1.062, P = 0.047) and facet joints destroyed (OR = 0.661, P = 0.024) were related to axial symptoms.The change of cervical ROM and facet joints destroyed by miniscrews might be associated with axial symptoms after cervical laminoplasty with miniplate fixation. Cervical spine surgeons should carefully operate to decrease the injury of posterior musculature structure and protect the facet joints.

Radiological and Radionuclide Imaging of Degenerative Disease of the Facet Joints

The facet joint has been increasingly implicated as a potential source of lower back pain. Diagnosis can be challenging as there is not a direct correlation between facet joint disease and clinical or radiological features. The purpose of this article is to review the diagnosis, treatment, and current imaging modality options in the context of degenerative facet joint disease. We describe each modality in turn with a pictorial review using current evidence. Newer hybrid imaging techniques such as single photon emission computed tomography/computed tomography (SPECT/CT) provide additional information relative to the historic gold standard magnetic resonance imaging. The diagnostic benefits of SPECT/CT include precise localization and characterization of spinal lesions and improved diagnosis for lower back pain. It may have a role in selecting patients for local therapeutic injections, as well as guiding their location with increased precision.

Epidural steroid injections for radicular lumbosacral pain: a systematic review

Most clinical guidelines do not recommend routine use of epidural steroid injections for the management of chronic low back pain. However, many clinicians do not adhere to these guidelines. This comprehensive evidence overview concluded that off-label epidural steroid injections provide small short-term but not long- term leg-pain relief and improvement in function; injection of steroids is no more effective than injection of local anesthetics alone; post-procedural complications are uncommon, but the risk of contamination and serious infections is very high. The evidence does not support routine use of off-label epidural steroid injections in adults with benign radicular lumbosacral pain.

Efficacy of combined treatment with medial branch radiofrequency neurotomy and steroid block in lumbar facet joint arthropathy

PURPOSE

To evaluate the long-term efficacy of combined radiofrequency (RF) neurotomy and steroid nerve block in patients with lumbar facet joint arthropathy.

MATERIALS AND METHODS

Combined RF neurotomy and steroid nerve block was performed in 34 patients with chronic paravertebral low back pain. The diagnosis was confirmed by comparative double diagnostic block of the medial branch with bupivacaine and lidocaine. Under fluoroscopy, RF thermal ablation of the medial branch was performed (at RF needle tip temperature 85°C for 90 seconds), three times for each target nerve. At the end of the procedure, 20 mg of methylprednisolone acetate (sustained-release preparation) was infiltrated on each ablated nerve. Outcome variable was the degree of improvement in pain using visual analog scale (VAS) and numerical rating scale (NRS). Improvement in the quality of life was assessed using the Roland-Morris (RM) questionnaire. The procedure was repeated in cases of unbearable pain (>5 VAS score).

RESULTS

Patients had a mean VAS score of 8.6 before the procedure. Thereafter, VAS score was 0.91 immediately after the procedure and 3.0, 2.8, 3.7, and 3.6 at 1 month, 2 months, 6 months, and 1 year. NRS showed pain relief after the procedure of 85%, 65%, 78%, 62%, and 59.5% at the same time points. RM score was 18 before the procedure, 7.6 at 6 months after the procedure, and 8.5 at 1 year after the procedure. No major complication was noted except local pain in all patients and numbness of the back in six patients after the procedure.

CONCLUSIONS

Combined RF neurotomy and steroid nerve block produced substantial improvement in terms of long-term pain relief and quality of life.