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 methodol...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 Pub Med from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources includingprevious 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.展开更多
The aim of this retrospective practice audit was to assess the correlation between painful zygapophysial joints and changes seen in magnetic resonance imaging (MRI). Patients with unilateral pain were tested with cont...The aim of this retrospective practice audit was to assess the correlation between painful zygapophysial joints and changes seen in magnetic resonance imaging (MRI). Patients with unilateral pain were tested with controlled medial branch blocks. The MRI scans of patients with a positive response were compared blinded with normal MRI scans. The dimensions of the joint were assessed and osteoarthritis was graded. Fifteen symptomatic patients and 15 asymptomatic patients were included and evaluated. Comparison of the joints showed that the maximum diameter of symptomatic joints was significantly larger, and the grading of osteoarthritis was significantly higher for symptomatic joints. No healthy patient was assigned a grade 3. Grades 2 and 3 were found significantly more often in symptomatic patients. Only one symptomatic joint was assigned grade 0. Grade 0 was found significantly more often in asympto-matic patients. The presented MRI technique has limited value as a diagnostic test for lumbar zygapophysial joint pain. It is not possible to detect a single symptomatic joint. However, the osteoarthritis grading for the lumbar zyg-apophysial joints might be helpful for finding predictors for negative response if the results of the rating are grade zero. Therefore, unnecessary medial branch blocks might be avoided.展开更多
The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The join...The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The joint capsule and the surrounding structures have an extensive nerve supply. The stretching of the capsule and loads being transmitted through the joint can causepain. The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain(10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks(MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks.展开更多
文摘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 Pub Med from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources includingprevious 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.
文摘The aim of this retrospective practice audit was to assess the correlation between painful zygapophysial joints and changes seen in magnetic resonance imaging (MRI). Patients with unilateral pain were tested with controlled medial branch blocks. The MRI scans of patients with a positive response were compared blinded with normal MRI scans. The dimensions of the joint were assessed and osteoarthritis was graded. Fifteen symptomatic patients and 15 asymptomatic patients were included and evaluated. Comparison of the joints showed that the maximum diameter of symptomatic joints was significantly larger, and the grading of osteoarthritis was significantly higher for symptomatic joints. No healthy patient was assigned a grade 3. Grades 2 and 3 were found significantly more often in symptomatic patients. Only one symptomatic joint was assigned grade 0. Grade 0 was found significantly more often in asympto-matic patients. The presented MRI technique has limited value as a diagnostic test for lumbar zygapophysial joint pain. It is not possible to detect a single symptomatic joint. However, the osteoarthritis grading for the lumbar zyg-apophysial joints might be helpful for finding predictors for negative response if the results of the rating are grade zero. Therefore, unnecessary medial branch blocks might be avoided.
文摘The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The joint capsule and the surrounding structures have an extensive nerve supply. The stretching of the capsule and loads being transmitted through the joint can causepain. The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain(10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks(MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks.
