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Acosta Julbe JI, Gottreich JR, Ermann J, Isaac Z, DeFilipp M, Andrew MN, Chang Y, Zampini JM, Katz JN, Mandell JC. Reporting of Facet Joint Inflammation in Lumbar Spine MRI Studies in Patients With Low Back Pain. Spine (Phila Pa 1976) 2024; 49:733-740. [PMID: 38229507 DOI: 10.1097/brs.0000000000004923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE We aimed to assess the frequency of facet joint inflammatory features noted in routine radiology reports of lumbar spine magnetic resonance imaging (MRI) studies among patients with chronic low back pain. SUMMARY OF BACKGROUND DATA Facet joint arthropathy is one of the most common causes of chronic low back pain. It may encompass various inflammatory imaging characteristics, such as facet joint effusion, bone marrow edema, and soft tissue edema. The extent to which radiology reports mention inflammatory features of the lumbar facet joints and the accuracy of these reports have not been investigated. MATERIALS AND METHODS The authors performed a chart review on 49 subjects with previous facet-related interventions ( i.e . medial branch blocks or intra-articular facet joint injection) and MRI available in the medical record. One senior musculoskeletal radiologist and a musculoskeletal radiology fellow graded the inflammatory features using a published facet joint inflammation grading system [Gold Standard (GS)]. The authors identified the inflammatory markers mentioned in the radiology reports and calculated the sensitivity and positive predictive value of the radiology reports compared with GS readings. RESULTS Compared with the GS, the sensitivity of radiology reports for facet joint effusion, bone marrow, and soft tissue edema ranged from 6% to 22%, and the positive predictive value ranged from 25% to 100%. L4/5 had the highest number of cases with inflammatory features noted on the reports. CONCLUSION Inflammatory findings, such as facet joint effusion, bone marrow edema, and soft tissue edema, are not commonly identified in radiology reports. Further investigations are needed to determine the clinical importance of MRI-detected lumbar facet joint inflammatory features as a potential mechanism of nociception and as a predictor of outcomes following injections or other therapies.
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Affiliation(s)
- José I Acosta Julbe
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Julia R Gottreich
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Joerg Ermann
- Harvard Medical School, Boston, MA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA
| | - Zacharia Isaac
- Harvard Medical School, Boston, MA
- Department of Physical Medicine and Rehabilitation, Brigham and Women's Hospital, Boston, MA
| | - Miriam DeFilipp
- Harvard Medical School, Boston, MA
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Michael N Andrew
- Harvard Medical School, Boston, MA
- Department of Physical Medicine and Rehabilitation, Brigham and Women's Hospital, Boston, MA
| | - Yuchiao Chang
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Jay M Zampini
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA
| | - Jacob C Mandell
- Harvard Medical School, Boston, MA
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
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Acosta Julbe JI, Mandell JC, Ermann J, Isaac Z, Gottreich JR, Zampini JM, DeFilipp M, Andrew MN, Katz JN. Predictors of Outcomes After Lumbar Intra-Articular Facet Joint Injections and Medial Branch Blocks: A Scoping Review. Spine (Phila Pa 1976) 2023; 48:1455-1463. [PMID: 37470372 PMCID: PMC10528906 DOI: 10.1097/brs.0000000000004776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/26/2023] [Indexed: 07/21/2023]
Abstract
STUDY DESIGN A scoping review. OBJECTIVE We aimed to identify and describe the factors associated with the patient-reported response after lumbar intra-articular facet joint (FJ) injections or medial branch blocks (MBBs). SUMMARY OF BACKGROUND DATA FJ osteoarthritis is among the most common causes of chronic low back pain. Management often includes FJ intra-articular injection and MBBs (which may be followed by radiofrequency ablation of the nerves innervating these joints). However, the success of these approaches is variable, prompting interest in identifying patient characteristics (imaging features, clinical signs, and among others) associated with response to these types of facet injections. MATERIALS AND METHODS We performed a literature search on factors associated with patient-reported outcomes after lumbar FJ intra-articular injections or MBBs for patients with low back pain published in English or Spanish between 2000 and 2023. We excluded duplicate papers that did not describe factors associated with outcomes or those describing other interventions. We collected data on the association of these factors with patient-reported outcomes. RESULTS Thirty-seven studies met the inclusion criteria and were analyzed. These studies evaluated factors, such as age, depression, and single photon emission computed tomography (SPECT), and among variables. Age and imaging findings of facet arthropathy were the most frequently described factors. Imaging findings of FJ arthropathy and positive SPECT were often associated with positive results after intra-articular FJ injections or MBBs. In contrast, younger age and smoking were frequently associated with less favorable clinical outcomes. CONCLUSION Numerous factors were considered in the 37 studies included in this review. Imaging findings of facet arthropathy, duration of pain, and positive SPECT were consistently associated with favorable results after facet interventions.
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Affiliation(s)
- José I. Acosta Julbe
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jacob C. Mandell
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Joerg Ermann
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Zacharia Isaac
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julia R. Gottreich
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jay M. Zampini
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Miriam DeFilipp
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Michael N. Andrew
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jeffrey N. Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Acosta JI, Mandell JC, Ermann J, Isaac Z, Zampini JM, DeFilipp M, Gottreich JR, Andrew M, Katz JN. Grading Systems of Lumbar Facet Joint Inflammatory Changes on Magnetic Resonance Imaging: A Scoping Review. Spine (Phila Pa 1976) 2023; 48:636-644. [PMID: 36856452 PMCID: PMC10101880 DOI: 10.1097/brs.0000000000004609] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
STUDY DESIGN A scoping review. OBJECTIVE We aimed to identify and characterize grading systems of the inflammatory features of the lumbar facet joints (FJs) noted on magnetic resonance imaging and summarize their reliability. SUMMARY OF BACKGROUND DATA Chronic low back pain is one of the most common causes of disability worldwide and is frequently accompanied by FJ osteoarthritis. Inflammatory changes in the lumbar FJs are commonly noted in imaging studies of patients with FJ osteoarthritis and low back pain. Several grading systems for these inflammatory changes have been developed. However, these grading system's features and reliability have yet to be reviewed. MATERIALS AND METHODS We performed a literature search of studies reporting grading systems for FJ inflammatory changes published in English or Spanish between 1985 and 2022. We collected data on reported interreader reliability measures of each grading system. Finally, we compared the features of inflammation described by each system. RESULTS Six studies met the inclusion criteria and were used in our analysis. Features commonly graded in these systems are the hyperintensity signal noted within the FJ, bone marrow edema, and the extent of the soft-tissue edema surrounding the FJs. We found that the interreader reliability measures ranged from 0.56 to 0.96. CONCLUSIONS Only 6 studies have reported methods for documenting inflammation in the FJs. Studies varied in the precise tissues and phenomena included in the grading systems. However, the systems were generally reliable. Future studies should document the reliability of these methods when independent investigators are not involved in developing the classification schemes. Further work might combine one or more of these measures to establish a standard and reliable grading system for inflammatory changes in the FJs, including signal intensity within the joint, bone marrow edema, and soft-tissue inflammation.
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Affiliation(s)
- José I. Acosta
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jacob C. Mandell
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Joerg Ermann
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Zacharia Isaac
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jay M. Zampini
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Miriam DeFilipp
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julia R. Gottreich
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Michael Andrew
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jeffrey N. Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Abstract
OBJECTIVE In this narrative review, the current literature on therapeutic interventions for low back pain of facet joint etiology is assessed from an economic value perspective. SUMMARY OF BACKGROUND DATA The efficacy and economics of facet joint interventions in the treatment of lumbar back pain is a controversial topic. Trends show that facet joint interventions are becoming increasingly used, perhaps as physicians become more averse to treating chronic low back pain with opioids. With the emphasis on value-based spine care and changing reimbursement models, the perspective of rigorously evaluating the outcomes these interventions provide and the costs they incur is particularly relevant. DISCUSSION Although the evidence is noted to be limited, most systematic reviews fail to demonstrate the therapeutic utility of intra-articular facet joint injections in low back pain because of high study heterogeneity. A few good quality studies and systematic reviews describe moderate evidence for the utilization of therapeutic medial branch blocks and radiofrequency neurotomies in alleviating facet joint pain. CONCLUSION Consequently, there is a need for high-quality cost-effectiveness studies for facet joint interventions so that evidence-based and economically viable solutions can be used to optimize patient care at a societally affordable price.
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