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Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cut off values: a letter to the editor.
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Changes in gait kinematics and lower back muscle activity post-radiofrequency denervation of the zygapophysial joint: a case study.

Spine J. 2013 Oct 10;

Authors: Stegemöller EL, Roper J, Hass CJ, Kennedy DJ

Abstract
BACKGROUND CONTEXT: Using diagnostic anesthetic blocks, the lumbar zygapophysial (facet) joint has been shown to be the primary cause of pain in approximately 15% of patients with chronic low back pain. Radiofrequency neurotomy (RFN) of the lumbar medial branch innervating the zygapophysial joint has been shown to provide a significant decrease in pain in patients selected by dual comparative anesthetic blocks, but quantitative improvements in mobility have not been fully elucidated. A theoretical concern with RFN is that the multifidus muscle, a stabilizing paraspinal muscle, is also denervated during this procedure, which may have adverse effects on mobility and spine stability.
PURPOSE: The purpose of this study was to examine gait kinematics and muscle activity of the low back during treadmill walking both before and after RFN.
STUDY DESIGN: Case study.
PATIENT SAMPLE: One 33-year-old female, with 15 years of chronic left low back pain and a diagnosis of L4/L5 lumbar zygapophysial joint pain by dual comparative anesthetic blocks was studied.
OUTCOME MEASURES: Self-reported measures of perceived pain and effort; in addition to physiologic measures of heart rate, gait kinematics and surface electromyography (EMG) activity of the multifidus and erector spinae muscles were collected before and after the procedure.
METHODS: The participant walked for 15 consecutive minutes on a treadmill. The first and last 5-minute intervals were at a self-selected pace, and the middle 5-minute interval was at a 50% increase of the self-selected pace. Gait kinematics and lumbar paraspinal surface EMG activity were recorded during the last minute of each walking interval. Heart rate, perceived effort, and perceived pain were also collected at the end of each walking interval. Data were collected both 7 and 1 days before RFN, and on the following days post-RFN: 0, 8, 14, 28, and 58.
RESULTS: Perceived effort did not change despite an increase in treadmill speed and heart rate. Pain decreased by 60% in the first two weeks and by 92% by 4 weeks post-RFN. There were also gradual positive changes in gait kinematics across all post-sessions and an immediate and sustained decrease in surface EMG activity over the left multifidus and erector spinae muscles following RFN.
CONCLUSIONS: The results of this pilot study are the first to show quantitative positive changes in gait and muscle activity post-RFN, suggesting that the relationship between this procedure and mobility warrant further investigation.

PMID: 24120824 [PubMed – as supplied by publisher]

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Establishing an optimal “cutoff” threshold for diagnostic lumbar facet blocks: a prospective correlational study.

Clin J Pain. 2013 May;29(5):382-91

Authors: Cohen SP, Strassels SA, Kurihara C, Griffith SR, Goff B, Guthmiller K, Hoang HT, Morlando B, Nguyen C

Abstract
OBJECTIVES: Diagnostic medial branch blocks (MBB) are considered the reference standard for diagnosing facetogenic pain and selecting patients for radiofrequency (RF) denervation. Great controversy exists regarding the ideal cutoff for designating a block as positive. The purpose of this study is to determine the optimal pain relief threshold for selecting patients for RF denervation after diagnostic MBB.
METHODS: In this multicenter, prospective correlational study, 61 consecutive patients undergoing lumbar facet RF denervation after experiencing significant pain relief after MBB were enrolled. A positive outcome was defined as a ≥50% reduction in back pain at rest or with activity coupled with a positive satisfaction score lasting longer than 3 months. The relationship between pain relief after the blocks and denervation outcomes was evaluated by pairwise correlation matrix, receiver’s operating characteristic curve, and stratifying outcomes based on 10- and 17-percentage point intervals for MBB.
RESULTS: There were no significant differences in RF outcomes based on any MBB pain relief cutoff over 50%. A trend was noted whereby those patients who obtained <50% pain relief reported poorer outcomes. No optimal threshold for designating a diagnostic block as positive, above 50% pain relief, could be calculated.
CONCLUSION: Employing more stringent selection criteria for lumbar facet RF is likely to result in withholding a beneficial procedure from a substantial number of patients, without improving success rates.

PMID: 23023310 [PubMed – indexed for MEDLINE]

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Cost comparisons of various diagnostic medial branch block protocols and medial branch neurotomy in a private practice setting.

Pain Med. 2013 Mar;14(3):378-91

Authors: Derby R, Melnik I, Lee JE, Lee SH

Abstract
OBJECTIVE: We calculated the average total facility and professional cost of medial branch neurotomy (MBN) procedure and diagnostic medial branch blocks (MBBs), based on increments of MBB results (50-100% cutoff values), to determine the most cost-effective protocol that correlates with positive MBN outcome.
DESIGN/METHODS: We evaluated both actual cost and the theoretical cost of procedures in three groups: 0, single and double MBB. We calculated costs assuming MBB success rates at incrementally higher levels by incrementally raising the cutoff values for a successful diagnostic MBB by 10% increments (from 50% to 100%). We analyzed each cutoff value using the preposition that all patients meeting the cutoff value would proceed to MBN. Those not meeting the cutoff value would not have the cost of MBN added to the cost calculations. A cost per successful procedure was also analyzed.
RESULTS: Cost savings were noted when ≥70% cutoff MBB values were utilized and additionally when patients declined MBN for reasons other than their MBB outcome, although these dropouts lowered the cost-effectiveness of MBB when analyzed as cost per successful procedure. Costs over 5 years per successful procedure using 0, 1 and 2 diagnostic MBB protocol (x) and MBB protocol (o) were, however, similar at all MBB cutoff values.
CONCLUSIONS: Diagnostic MBB using progressively stringent MBB cutoff values incrementally excluded patients without posterior element pain as evidenced by incremental increase in positive outcomes following MBN. The exclusion of patients from MBN due to failure to report 70% or greater pain relief following MBB resulted in cost savings in favor of performing diagnostic MBB.

PMID: 23294522 [PubMed – indexed for MEDLINE]

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