BACKGROUND: Lumbar facet joints have been implicated as the source of chronic pain in 15% to 45% of patients with chronic low back pain. Various therapeutic techniques including intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin.
OBJECTIVE: The study was conducted to determine the clinical effectiveness of therapeutic local anesthetic lumbar facet joint nerve blocks with or without steroid in managing chronic function-limiting low back pain of facet joint origin.
DESIGN: A randomized, double-blind, controlled trial.
SETTING: An interventional pain management setting in the United States.
METHODS: This study included 60 patients in Group I with local anesthetic and 60 patients in Group II with local anesthetic and steroid. The inclusion criteria was based on the positive response to the diagnostic controlled comparative local anesthetic lumbar facet joint blocks.
OUTCOME MEASURES: Numeric pain scores, Oswestry Disability Index, opioid intake, and work status. All outcome assessments were performed at baseline, 3 months, 6 months, and 12 months.
RESULTS: Significant improvement with significant pain relief (> 50%) and functional improvement (> 40%) were observed in 82% and 85% in Group I, with significant pain relief in over 82% of the patients and improvement in functional status in 78% of the patients. Based on the results of the present study, it appears that patients may experience significant pain relief 44 to 45 weeks of 1 year, requiring approximately 3 to 4 treatments with an average relief of 15 weeks per episode of treatment.
CONCLUSION: Therapeutic lumbar facet joint nerve blocks, with or without steroid, may provide a management option for chronic function-limiting low back pain of facet joint origin.
OBJECTIVES: The goal of this study was to compare the effects of conventional radiofrequency (CRF) and pulsed RF (PRF) denervation to medial branches of dorsal rami in the treatment of facet joint pain.
METHODS: The patients greater than 17-year old, with continuous low back pain with or without radiating pain with focal tenderness over the facet joints, pain on hyperextension, absence of neurologic defect, unresponsiveness to conservative treatment, no radicular syndrome, and no indication for low back surgery were included in the study. Local anesthetic was applied in the control group (n=20), whereas 80 degrees C CRF were applied in the CRF (n=20) and 2 Hz PRF were applied in the PRF group (n=20). Pain relief was evaluated by visual analog scale (VAS) and Oswestry Disability Index (ODI) at preprocedure, at procedure, at 6 months and 1 year after the procedure. Reduction in analgesic usage, patients' satisfaction, and complications were assessed.
RESULTS: Mean preprocedural VAS and ODI scores were higher than postprocedural scores in all groups. Both VAS and ODI scores of PRF and CRF groups were lower than the score of the control group at the postprocedural evaluation. Although decrease the pain score was maintained in the CRF group at 6 months and 1-year period, this decrease discontinued in the PRF group at the follow-up periods. The number of patients not using analgesics and patient satisfaction were highest in CRF group.
DISCUSSION: PRF and CRF are effective and safe alternatives in the treatment of facet joint pain but PRF is not as long lasting as CRF.
STUDY DESIGN: A prospective, randomized, double-blind, placebo-controlled trial of intradiscal electrothermal therapy (IDET) for the treatment of chronic discogenic low back pain (CDLBP).
OBJECTIVES: To test the safety and efficacy of IDET compared with a sham treatment (placebo).
SUMMARY OF BACKGROUND DATA: In North America alone, more than 40,000 intradiscal catheters have been used to treat CDLBP. The evidence for efficacy of IDET is weak coming from retrospective and prospective cohort studies providing only Class II and Class III evidence. There is one study published with Class I evidence. This demonstrates statistically significant improvements following IDET; however, the clinical significance of these improvements is questionable.
METHODS: Patients with CDLBP who failed to improve following conservative therapy were considered for this study. Inclusion criteria included the presence of one- or two-level symptomatic disc degeneration with posterior or posterolateral anular tears as determined by provocative computed tomography (CT) discography. Patients were excluded if there was greater than 50% loss of disc height or previous spinal surgery. Fifty-seven patients were randomized with a 2:1 ratio: 38 to IDET and 19 to sham procedure (placebo). In all cases, the IDET catheter was positioned to cover at least 75% of the annular tear as defined by the CT discography. An independent technician connected the catheter to the generator and then either delivered electrothermal energy (active group) or did not (sham group). Surgeon, patient, and independent outcome assessor were all blinded to the treatment. All patients followed a standard postprocedural rehabilitation program. Independent statistical analysis was performed.
OUTCOME MEASURES: Low Back Outcome Score (LBOS), Oswestry Disability Index (ODI), Short Form 36 questionnaire (SF-36), Zung Depression Index (ZDI), and Modified Somatic Perceptions Questionnaire (MSPQ) were measured at baseline and 6 months. Successful outcome was defined as: no neurologic deficit, improvement in LBOS of greater then 7 points, and improvement in SF-36 subsets (physical function and bodily pain) of greater than 1 standard deviation.
RESULTS: Baseline demographic data, initial LBOS, ODI, SF-36, ZDI, and MSPQ were similar for both groups. No neurologic deficits occurred. No subject in either arm showed improvement of greater than 7 points in LBOS or greater than 1 standard deviation in the specified domains of the SF-36. Mean ODI was 41.42 at baseline and 39.77 at 6 months for the IDET group, compared with 40.74 at baseline and 41.58 at 6 months for the placebo group. There was no significant change in ZDI or MSPQ scores for either group.
CONCLUSIONS: The IDET procedure appeared safe with no permanent complications. No subject in either arm met criteria for successful outcome. Further detailed analyses showed no significant change in outcome measures in either group at 6 months. This study demonstrates no significant benefit from IDET over placebo.
PURPOSE: To investigate the efficacy and safety of intraarticular sodium hyaluronate (SH) compared with intraarticular glucocorticoids (triamcinolone acetonide; TA) in the treatment of chronic nonradicular lumbar pain.
MATERIALS AND METHODS: Sixty patients were included in this randomized, controlled, blind-observer clinical study and randomly assigned to two groups to receive 10 mg SH or 10 mg TA per facet joint. The facet joints on both sides at levels S1-L5, L5-L4, and L4-L3 were treated once per week under computed tomographic guidance. The study visits were timed to permit assessment of the immediate effect as well as possible carryover effects at 3 and 6 months after completion of treatment. Changes in pain were assessed with a visual analog scale (VAS) and changes in function and quality of life were assessed by the Roland Morris Questionnaire (RMQ), the Oswestry Disability Questionnaire (ODQ), the Low Back Outcome Score (LBOS), and the Short Form 36 (SF-36) questionnaire.
RESULTS: Patients reported lasting pain relief, better function, and improved quality of life with both treatments. Mann-Whitney analyses of the patient questionnaires (RMQ, ODQ, and LBOS) very consistently showed that SH is not inferior to TA. In addition, the efficacy of SH was largely comparable with that of TA on the VAS and SF-36. No adverse effects were reported after administration of the test products. The intraarticular treatment of facet joints (levels S1-L5, L5-L4, and L4-L3) with SH in patients with chronic nonradicular pain in the lumbar spine resulted in a marked reduction in pain with improved function and better quality of life, which was at least equal to the effect of a course of TA injections. SH-treated patients showed greater benefits in the long term.
CONCLUSION: Intraarticular SH is a very promising new option for the treatment of patients with chronic nonradicular lumbar symptoms.
STUDY DESIGN: A randomized single-blind clinical trial of facet injections plus exercise, versus exercise alone, in chronic disabling work-related lumbar spinal disorders (CDWRLSD), accompanied by pilot interrater reliability and facet syndrome prevalence studies.
OBJECTIVES: To systematically investigate the use of facet injections as an adjunct to supervised lumbar stretching exercises in regaining lumbar range of motion (ROM) following prolonged deconditioning after work-related lumbar injuries. To assess interrater reliability of visual assessment of segmental rigidity (SR), and to evaluate the prevalence of facet syndrome in cases of lumbar SR.
SUMMARY OF BACKGROUND DATA: Corticosteroid joint injections have often been used to reduce musculoskeletal inflammation to facilitate joint mobilization in the presence of degenerative arthritis. Lumbar segmental rigidity is a recently described entity usually associated with painful chronic spinal disorders and postoperative spine surgery. Previous work has shown that SR and lumbar ROM improves with a brief intervention consisting of facet injections followed by specific stretching exercises. No systematic study has investigated the potential benefits of a combination of facet injections and exercise over supervised exercises alone to treat lumbar SR. Similarly, no study has assessed the association between SR and the facet syndrome.
METHODS: From a group of consecutive patients (n = 421) with CDWRLSD referred for tertiary rehabilitation between November 1999 and January 2001, 70 were noted to have SR on intake physical examination. The first part of this study assessed interrater reliability for detecting SR, and intrarater reliability for 3-segment true lumbar ROM measurements. Patients randomly assigned to participate in supervised stretching exercises with the addition of fluoroscopically guided bilateral facet injections at the involved levels (Group A, n = 36) also underwent facet syndrome prevalence assessment at the time of injection. They were compared to a randomly allocated comparison group (Group B, n = 34) undergoing exercises alone in a single-blind design. Physical therapists saw patients an average of twice per week, providing supervision of a progressive home stretching program. Inclinometric joint ROM was measured at the time of group allocation, and again 5 to 7 weeks later. Validated questionnaires of pain (intensity VAS) and disability (Million VAS) related to the CDWRLSD were provided before and after the interventions.
RESULTS: Part 1 reliability and facet syndrome prevalence work revealed that interrater reliability for experienced examiners to detect rigid segments was excellent (Pearson's r = 0.97, P < 0.01). Intrarater 3-joint motion measurement reliability was also good for all sagittal/coronal ROM (Pearson's r = 0.95-0.99, P < 0.01). Only 5 of 29 subjects with SR met criteria for facet syndrome (17%), consistent with prior prevalence studies of unselected patients with low back pain. In Part 2, a large majority of patients in both groups improved from the initial to the post-treatment ROM measurements (the primary outcome criterion of the study). However, a higher proportion of Group A (injection) patients (87%-95%) showed ROM improvement, compared to Group B (exercise only) patients (64%-79%). Group A patients showed a significantly greater ROM improvement in all sagittal and coronal movements, both in absolute terms and percent of initial measurement. No significant differences in pain or disability self-report were found between groups, pre- or postintervention, but both groups showed significant improvement from pre- to postintervention in pain and disability assessments.
CONCLUSIONS: The detection of SR and measurement of 3-segment true lumbar ROM by experienced examiners is highly reliable. Only 17% of CDWRLSD patients with lumbar SR met criteria for the facet syndrome, a rate approximately equal to that of unselected low back pain cohorts. This indicates that lumbar SR may be found whether or not pain of facet joint origin is present. In the randomized trial, facet injections significantly increased the percentage of patients with SR showing ROM improvement, as well as the degree of improvement in lumbar mobility after treatment. There is no evidence that facet injections increase the improvements in pain/disability report noted in both groups.
OBJECTIVE: The objective of this study was to determine the efficacy of percutaneous radiofrequency (RF) thermocoagulation of the ramus communicans nerve in patients suffering from chronic discogenic low back pain.
METHODS: Forty-nine patients who suffered chronic discogenic low back pain at only 1 painful vertebral level, and whose pain continued after undergoing intradiscal electrothermal annuloplasty (IDET), were randomly assigned to 1 of 2 treatment groups. The lesion group (n = 26) received RF thermocoagulation of the ramus communicans nerve. Patients in the control group (n = 23) received an injection of lidocaine without radiofrequency. Visual analog scale (VAS) pain scores, analgesic requirements, SF-36 subscales, and the overall patient satisfaction with the procedure were tabulated.
RESULTS: The average follow-up period was 4 months. The patient-reported VAS pain scores were significantly lower (P < 0.05) in the lesion group. The scores of the RF lesion group improved by a mean increase of 11.3 points (P < 0.05) on the SF-36 bodily pain subscale, and by a mean increase of 12.4 points on the physical function subscale (P < 0.05). In a follow-up analysis within the RF lesion group, VAS pain scores improved by a mean reduction of 3.32 (P = 0.001). The scores improved by a mean increase of 14.5 points (P = 0.005) on the SF-36 bodily pain subscale and 15.2 points(P = 0.002) on the physical function subscale within the RF lesion group. One patient in the lesion group complained of mild lower limb weakness, but he completely recovered at postoperative 15 days without any serious problems.
DISCUSSION: In patients with chronic discogenic low back pain, percutaneous RF denervation of the ramus communicans nerve should be considered as a treatment option.
BACKGROUND: Intradiscal electrothermal therapy (IDET) is a treatment for discogenic low back pain the efficacy of which has not been rigorously tested.
PURPOSE: To compare the efficacy of IDET with that of a placebo treatment.
STUDY DESIGN/SETTING: Randomized, placebo-controlled, prospective trial.
PATIENT SAMPLE: Patients were recruited by referral and the media. No inducements were provided to any patient in order to have them participate. Of 1,360 individuals who were prepared to submit to randomization, 260 were found potentially eligible after clinical examination and 64 became eligible after discography. All had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-seven were allocated to IDET and 27 to sham treatment. Both groups were satisfactorily matched for demographic and clinical features.
METHODS: IDET was performed using a standard protocol, in which the posterior annulus of the painful disc was heated to 90 C. Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure. Thirty-two (85%) of the patients randomized to the IDET group and 24 (89%) of those assigned to the sham group complied fully with the protocol of the study, and complete follow-up data are available for all of these patients.
OUTCOME MEASURES: The principal outcome measures were pain and disability, assessed using a visual analog scale for pain, the Short Form (SF)-36, and the Oswestry disability scale.
RESULTS: Patients in both groups exhibited improvements, but mean improvements in pain, disability and depression were significantly greater in the group treated with IDET. More patients deteriorated when subjected to sham treatment, whereas a greater proportion showed improvements in pain when treated with IDET. The number needed to treat, to achieve 75% relief of pain, was five. Whereas approximately 40% of the patients achieved greater than 50% relief of their pain, approximately 50% of the patients experienced no appreciable benefit.
CONCLUSIONS: Nonspecific factors associated with the procedure account for a proportion of the apparent efficacy of IDET, but its efficacy cannot be attributed wholly to a placebo effect. The results of this trial cannot be generalized to patients who do not fit the strict inclusion criteria of this study, but IDET appears to provide worthwhile relief in a small proportion of strictly defined patients undergoing this treatment for intractable low back pain.
BACKGROUND AND OBJECTIVE: Epidural blocks should provide good analgesia for the treatment of chronic low back pain without any motor block to allow active physiotherapy. Epidural ropivacaine is known to produce less motor block compared to bupivacaine at anaesthetic concentrations. This prospective, randomized double blind study compares the analgesic, motor block, and haemodynamic effects of single shot epidural injections of ropivacaine 0.2% 10 mL with bupivacaine 0.125% in outpatients suffering from chronic low back pain.
METHODS: Forty patients were assigned to receive either ropivacaine 0.2% (n = 20) or bupivacaine 0.125% (n = 20) within a series of eight single shot epidural blocks.
RESULTS: Thirty-six patients received either ropivacaine 0.2% (n = 18) or bupivacaine 0.125% (n = 18) within a series of eight single shot epidural blocks. Both groups showed no significant differences either in analgesia, or in motor blockade or haemodynamic changes. Thus ropivacaine 0.2% did not reduce the incidence of motor block (9.0% of patients with motor block Bromage scores 1, 2 or 3 in ropivacaine or bupivacaine). The combination of repeated epidural analgesia and physiotherapy reduced the median pain-scores (visual analogu scale, 0-10) from 7 (SD +/- 1.6) at the beginning of the study to 4.1 (SD +/- 1.7) at the end of the series.
CONCLUSIONS: Both bupivacaine 0.125% and ropivacaine 0.29% appear suitable for epidural administration to outpatients with chronic low back pain attending for epidural analgesia associated with physiotherapy (physical therapy).
