Complications of Lumbar Facet and Medial Branch Blocks and Ablations
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Objective: The purpose of this study was to determine the distribution of referred pain from the lumbar zygapophyseal joints (L1/2 to L5/S1) and the medial branches of the lumbar dorsal rami (Th12 to L5) in a large number of patients with chronic low back pain. Setting: This study was conducted at the pain clinics of Kanto Teishin Hospital and Hannan Central Hospital from March 1994 to May 1996. Patients and Design: Chronic low back pain patients who underwent zygapophyseal joint injection or radiofrequency facet denervation were studied. Under fluoroscopic control, the joints from L1/2 to L5/S1 were stimulated by injection of contrast medium, and the lumbar medial branches of the dorsal rami from Th12 to L5 underwent electrical stimulation during radiofrequency facet denervation. Outcome Measures: If the injection or electrical stimulation reproduced the patient's usual pain, the distribution of induced pain was determined, and the sites of induced pain were divided into six areas. Results and Conclusions: A total of 71 joints and 91 medial branches were studied in 48 patients. The distribution of referred pain from the L1/2 to L5/S1 zygapophyseal joints, and the medial branches of the dorsal rami from L1 to L5 were similar for each level stimulated, and the overlap of referred pain between each level was considerable.
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Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence. Keywords: Facet joint injection; Imaging-guided injections; Interventional spinal procedures; Low back pain; Zygapophyseal joint
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Low back pain is the most common pain syndrome and a global health burden. The etiology in most cases is multifactorial and the facet joints can be a source of low back pain. The facet joint is innervated by the medial branch of the dorsal ramus of the spinal nerve. Facet joint disturbances can be responsible for 10% to 50% of all cases of chronic lumbar pain. In the absence of predictive clinical or radiologic findings, nerve blocks are considered to be the best way of diagnosing presumed facet-mediated pain. Radiofrequency ablation to induce thermal necrosis of the facet neural fibers has been reported to provide significant pain reduction in patients for 6–12 months. A radiofrequency neurotomy is a type of injection procedure used to treat facet joint pain caused by arthritis or other degenerative changes, or from an injury. In this procedure, a heat lesion is created on certain nerves with the goal of interrupting the pain signals to the brain, thus eliminating pain. Medial Branch Neurotomy could be considered an option for patients suffering persistent axial and referred non-radicular leg pain unresponsive to less invasive conservative measures.
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Chronic low back pain secondary to involvement of the facet joints is a common problem. Facet joints have been recognized as potential sources of back pain since 1911. Multiple authors have described distributions of pain patterns of facet joint pain. The facet joints are paired diarthrodial articulations between the posterior elements of the adjacent vertebrae. Lumbar facet joints are innervated by medial branches of the dorsal rami of the spinal nerves from the L1 to L4 levels. At L5, the dorsal ramus travels between the ala of the sacrum and its superior articular process and divides into medial and lateral branches at the caudal edge of the process. Each segmental medial branch of the dorsal ramus supplies at least two facet joints. The existence of lumbar facet joint pain claims has a preponderance of evidence, even though there are a few detractors. Multiple studies utilizing controlled diagnostic blocks have established the prevalence of lumbar facet joint involvement in patients with chronic low back pain, as ranging from 15% to 52%, based on type of population and setting studied. Long-term therapeutic benefit has been reported from three types of interventions in managing lumbar facet joint pain, including intraarticular injections, medial branch blocks and neurolysis of medial branches. This review will discuss chronic low back of facet joint origin and covers anatomy, pathophysiology, diagnosis, and various aspects related to treatment, including clinical effectiveness, cost effectiveness, technical aspects and complications.
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Read the full review for this Faculty Opinions recommended article: A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial.
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The effects of pulsed radiofrequency treatment in low back pain was evaluated in a routine clinical setting and compared with thermal neurotomy of nerve structures of the facet joint. The treatment of 19 patients with lumbar facet joint pain was prospectively evaluated. Follow-ups were recorded at 6 weeks and 6 months after intervention. Patients with ≥50% pain relief following controlled diagnostic local anesthetic block underwent medial branch neurotomy with thermal continuous radiofrequency (CRF, n=16) or pulsed radiofrequency (PRF, n=3). Experiences between the two radiofrequency modes in the treatment of facet joint pain were recorded. In the overall population, a facet joint pain reduction of 23% at 6 weeks, 20% at 6 months and an improvement in various clinical scores was achieved. CRF and PRF appeared to be similarly effective in the treatment of facet joint pain, providing pain relief for at least 6 months. These observations should encourage pain researcher to design meaningful studies to further address this concept.
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Object. The authors conducted a prospective study to investigate the efficacy of kryorhizotomy, an alternative procedure for lumbar medial branch neurotomy, in the treatment of lumbar facet syndrome (LFS). Methods. Fifty patients with chronic low-back pain, in whom pain was relieved by controlled diagnostic medial branch blocks of the lumbar zygapophyseal (facet) joints, underwent lumbar medial branch kryorhizotomy. Outcome was evaluated using the Visual Analog Pain Scales and assessment of work capacity. All outcome measures were repeated at 6 weeks, 6 months, and 1 year after surgery. At 1-year follow-up examination, 31 (62%) of 50 patients experienced a good response to lumbar facet kryorhizotomy. Good results with pain relief of 50% or more were obtained in 85% of patients without previous spinal surgery but only in 46% who had undergone previous spinal surgery. This difference was statistically significant. In five patients (16%) in whom a good initial benefit was observed but who experienced increased pain within 6 weeks after kryorhizotomy, the beneficial result was regained after an early repeated procedure. There were no side effects. Overall, 19 (38%) of 50 procedures were not considered successful. In six of these 19 cases a rigid stabilization of the involved segment provided permanent pain relief. Conclusions. Based on this study, patients with LFS who have not undergone previous spinal surgery benefit significantly from percutaneous lumbar kryorhizotomy. Kryorhizotomy, which has virtually no risk, seems to be a valuable alternative technique to lumbar medial branch neurotomy.
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