5. Cervical facet pain.

Pain Pract. 2010 Mar-Apr;10(2):113-23

Authors: van Eerd M, Patijn J, Lataster A, Rosenquist RW, van Kleef M, Mekhail N, Van Zundert J

More than 50% of patients presenting to a pain clinic with neck pain may suffer from facet-related pain. The most common symptom is unilateral pain without radiation to the arm. Rotation and retroflexion are frequently painful or limited. The history should exclude risk factors for serious underlying pathology (red flags). Radiculopathy may be excluded with neurologic testing. Direct correlation between degenerative changes observed with plain radiography, computerized tomography, and magnetic resonance imaging and pain has not been proven. Conservative treatment options for cervical facet pain such as physiotherapy, manipulation, and mobilization, although supported by little evidence, are frequently applied before considering interventional treatments. Interventional pain management techniques, including intra-articular steroid injections, medial branch blocks, and radiofrequency treatment, may be considered (0). At present, there is no evidence to support cervical intra-articular corticosteroid injection. When applied, this should be done in the context of a study. Therapeutic repetitive medial branch blocks, with or without corticosteroid added to the local anesthetic, result in a comparable short-term pain relief (2 B+). Radiofrequency treatment of the ramus medialis of the cervical ramus dorsalis (facet) may be considered. The evidence to support its use in the management of degenerative cervical facet joint pain is derived from observational studies (2 C+).

PMID: 20415728 [PubMed – indexed for MEDLINE]

Comprehensive review of therapeutic interventions in managing chronic spinal pain.

Pain Physician. 2009 Jul-Aug;12(4):E123-98

Authors: Manchikanti L, Boswell MV, Datta S, Fellows B, Abdi S, Singh V, Benyamin RM, Falco FJ, Helm S, Hayek SM, Smith HS,

Available evidence documents a wide degree of variance in the definition and practice of interventional pain management.

PMID: 19668281 [PubMed – indexed for MEDLINE]

Local corticosteroid injections for low back pain and sciatica.

Joint Bone Spine. 2008 Jul;75(4):403-7

Authors: Valat JP, Rozenberg S

In patients with symptoms caused by intervertebral disk displacement, studies of epidural corticosteroid injections have produced compelling evidence of a short-term analgesic effect (lasting about 3 weeks), despite a number of discrepancies. In contrast, no reductions were noted in the time off work or need for surgery. Strong evidence supports a short-term symptomatic effect of guided transforaminal corticosteroid injections, and there is also some evidence of a long-term effect. Further work is needed to assess the potential of this treatment modality for decreasing surgical requirements in patients who fail conventional nonsurgical treatment. Facet-joint injections may produce pain relief in some patients with common low back pain. This modality can be offered to selected patients who fail to respond to first-line treatment. Epidural injections are not appropriate in patients with acute low back pain. They may offer short-term symptom relief to patients experiencing acute exacerbations of chronic low back pain, in whom they are used as an ancillary method. Intradural injections should not be performed, as they may induce adverse effects and have not been proved effective. Interspinous injections and iliolumbar ligament injections can be considered in selected patients. Although published data have led to controversy about the effectiveness of local corticosteroid injections, a short-term analgesic effect is usually obtained, making this modality useful for the second-line treatment of patients with disk-related sciatica, as well as in selected patients with chronic low back pain.

PMID: 18486516 [PubMed – indexed for MEDLINE]

Are joint and soft tissue injections painful? Results of a national French cross-sectional study of procedural pain in rheumatological practice.

BMC Musculoskelet Disord. 2010;11:16

Authors: Perrot S, Laroche F, Poncet C, Marie P, Payen-Champenois C

Joint, spinal and soft tissue injections are commonly performed by rheumatologists in their daily practice. Contrary to other procedures, e.g. performed in pediatric care, little is known about the frequency, the intensity and the management of procedural pain observed in osteo-articular injections in daily practice.

PMID: 20100351 [PubMed – indexed for MEDLINE]

Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients.

Spine J. 2009 Nov;9(11):899-904

Authors: Martha JF, Swaim B, Wang DA, Kim DH, Hill J, Bode R, Schwartz CE

Lumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option.

PMID: 19664971 [PubMed – indexed for MEDLINE]

Viscosupplementation in lumbar facet joint arthropathy: a pilot study.

J Spinal Disord Tech. 2008 Feb;21(1):29-32

Authors: Cleary M, Keating C, Poynton AR

Degeneration of the spine is a prevalent problem that generally advances with age, although its occurrence is not restricted to the elderly. Chronic low back pain is a common problem with several treatments, but rigorous evaluation of many interventions is still lacking. One of the most common methods of treating lumbar facet arthropathy is intra-articular injection of local anesthetic and steroid. However, in large joints, such as the knee, viscosupplementation has been shown to compare favorably to steroid in terms of symptom relief and duration of benefit. It is suggested that viscosupplementation may supersede steroid in treatment of symptomatic knee osteoarthritis. Hyaluronic acid (HA) therapy is still in its infancy in joints outside the knee, although some preliminary results are promising.

PMID: 18418133 [PubMed – indexed for MEDLINE]

Prescriptive clinical prediction rules in back pain research: a systematic review.

J Man Manip Ther. 2009;17(1):36-45

Authors: May S, Rosedale R

Prescriptive clinical prediction rules (CPRs) are a way of using a small selection of clinical findings to match patients to optimal interventions. A number of CPRs have been developed for use with back pain patients, but these have not been systematically reviewed. The purpose of this review was to evaluate existing CPRs against established criteria to determine the quality of the studies and the overall development of the CPR against a set number of stages. Medline was searched up until June 2008, and 16 studies were reviewed that related to 9 different CPRs. These studies investigated and attempted to find clinical characteristics for responders to manipulation, stabilization exercise, physical therapy, chiropractic, traction, rehabilitation, usual care, and zygapophyseal joint injections. Eleven of these studies related to the derivation stage and five to the validation stage. The manipulation and stabilization CPRs had been the most studied. The derivation studies were mostly high quality, whereas none of the validation studies were. Some of the validation studies did not provide evidence that validated the CPR. Most of these CPRs need further evaluation before they can be applied clinically; most did not pass the lowest level of evidence hierarchy. As regards the manipulation CPR, evidence to date for its clinical utility is limited and contradictory. For the stabilization CPR, there was limited evidence that it may be considered but only with caution and in similar patients. Overall, there is limited evidence to support the general application of spinal CPRs.

PMID: 20046564 [PubMed]

Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.

Pain Physician. 2009 Jul-Aug;12(4):699-802

Authors: Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJ, Erhart S, Diwan S, Hayek SM, Helm S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA,

Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians.

PMID: 19644537 [PubMed – indexed for MEDLINE]

Cervical facet joint dysfunction: a review.

Arch Phys Med Rehabil. 2008 Apr;89(4):770-4

Authors: Kirpalani D, Mitra R

To review the relevant literature on cervical facet joint dysfunction and determine findings regarding its anatomy, etiology, prevalence, clinical features, diagnosis, and treatment.

PMID: 18374011 [PubMed – indexed for MEDLINE]

Lidocaine cytotoxicity to the zygapophysial joints in rabbits: changes in cell viability and proteoglycan metabolism in vitro.

Spine (Phila Pa 1976). 2009 Dec 15;34(26):E945-51

Authors: Takeno K, Kobayashi S, Miyazaki T, Shimada S, Kubota M, Meir A, Urban J, Baba H

STUDY DESIGN.: To examine whether lidocaine cytotoxicity to chondrocytes has been implicated in the development of osteoarthritis of the zygapophysial joints. OBJECTIVE.: This study was performed to determine the effects of varying concentrations and exposure times of lidocaine on the viability and proteoglycan metabolism of rabbit zygapophysial chondrocytes in vitro. SUMMARY OF BACKGROUND DATA.: Zygapophysial joint injections are commonly administered with lidocaine for chronic spinal pain in orthopedic treatment. A lot of studies on the effect of zygapophysial joint injections are clinical, but many questions on the effect of lidocaine to zygapophysial chondrocytes remain unanswered. METHODS.: Cartilage was obtained from zygapophysial joints of adult rabbits. Chondrocytes in alginate beads were cultured in medium containing 6% fetal calf serum at 370 mOsmol at cell densities of 4 million cells/mL. They were then cultured for 24 hours under 21% oxygen with 0.125%, 0.25%, 0.5%, and 1% lidocaine, and without lidocaine as control. The cell viability profile across intact beads was determined by manual counting using fluorescent probes (LIVE/DEAD assay) and transmission electron microscopy. Lactate production was measured enzymatically as a marker of energy metabolism. Glycosaminoglycan (GAG) accumulation was measured using a modified dimethylmethylene blue assay. RESULTS.: Cell viability decreased in a time- and dose-dependent manner in the concentration range of 0.125% to 1.0% lidocaine under the confocal microscope. Under the electron microscope, apoptosis increased as the concentration of lidocaine increased. GAG accumulation/tissue volume decreases as the concentration of lidocaine increased. However, GAG produced per million cells and the rate of lactate production per live cell was significantly higher for cells cultured at 0.5% and 1% lidocaine than the control group. CONCLUSION.: While these in vitro results cannot be directly extrapolated to the clinical setting, this data suggestcaution in prolonged exposure of zygapophysial cartilage to high concentration lidocaine.

PMID: 20010383 [PubMed – indexed for MEDLINE]

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