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IntroductionThere are numerous studies appraising the variables that may influence the clinical outcomes after lumbar thermal radiofrequency ablation (RFA). Expanding the lesion size may increase the likelihood of capturing the target nerves in the lesion, thereby increasing the technical success rate of RFA. However, our literature search has failed to identify a consensus on the optimal target temperature. A retrospective study demonstrated that there seems to be significant functional improvement associated with the temperature of 90°C compared with 80°C. The authors prospectively studied the subject in a double-blinded randomized fashion.MethodsPatients undergoing RFA for lumbar facetogenic pain were randomized in two cohorts (80°C and 90°C). Physicians and patients were blinded to the temperature used. The primary outcome was self-reported pain scores up to 12 months. Secondary outcomes included: self-reported functional improvement, duration of relief as measured by the time before repeat ablation of the same medial branches nerves, opioids’ consumption, and patient satisfaction.ResultsBoth groups reported pain improvement in all follow-up time points. Overall, both groups achieved statistically significant pain reduction (p<0.05). The median time to repeat RFA in the 80°C group was 112 (49–252) days, while it was 217 (198–348) days in the 90°C group (p<0.04). The univariate analysis emphasized that the RFA temperature is a statistically significant factor for pain improvement of more than 50%, OR 2.7 (1.1 to 6.6) p value=0.031.ConclusionRFA has been demonstrated as an effective therapeutic modality for lumbar facetogenic back pain. Yet, the several factors involved in determining a favorable outcome of this procedure require further research and optimization. This prospective double-blinded randomized trial demonstrated that RFA at both temperatures (80°C, 90°C) provided significance at all the time periods examined. However, RFA at 90°C was superior to 80°C in regard to the duration of relief.

BackgroundThe past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.MethodsIn August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.ResultsTwenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.ConclusionsCervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

A number of interspinous process devices have recently been introduced to the lumbar spinal market as an alternative to conventional surgical procedures in the treatment of symptomatic lumbar stenosis. One of those “dynamic” devices is the Coflex™ device which has been already implanted worldwide more than 14,000 times. The aim of implanting this interspinous device is to unload the facet joints, restore foraminal height and provide stability in order to improve the clinical outcome of surgery. Published information is limited, and there are so far no data of comparison between the implant and traditional surgical approaches such as laminotomy. The purpose of our prospective study is to evaluate the surgical outcome of decompressive surgery in comparison to decompressive surgery and additional implantation of the Coflex™ interspinous Device. 60 patients who were all treated in the Spine Center of Klinikum Neustadt, Germany for a one or two level symptomatic LSS with decompressive surgery were included. Two groups were built. In Group one (UD) we treated 30 patients with decompression surgery alone and group two (CO) in 30 patients a Coflex™ device was additional implanted. Pre- and postoperatively disability and pain scores were measured using the Oswestry disability index (ODI), the Roland–Morris score (RMS), the visual analogue scale (VAS) and the pain-free walking distance (WD). Patients underwent postoperative assessments 3, 6 and 12 month including the above-mentioned scores as well as patient satisfaction. In both groups we could see a significant improve ( p  < 0.001) in the clinical outcome assessed in the ODI, in the RMS for evaluation of back pain, in the VAS and in the pain-free WD at all times of reinvestigation compared to base line. At 1-year follow up there were no statistically differences between both groups in all ascertained parameters including patient satisfaction and subjective operation decision. Because there is no current evidence of the efficacy of the Coflex™ device we need further data from randomized controlled studies for defining the indications for theses procedures. To the best of our knowledge this is the first prospective controlled study which compares surgical decompression of lumbar spinal stenosis with additional implanting of an interspinous Coflex™ device in the treatment of symptomatic LSS.

The zygapophyseal (facet) joint plays a critical role in load transmission and stability of the spine, and facet degeneration is a common consequence of aging and osteoarthritis. The ability to accurately measure facet space is important, as decreased facet space is associated with facet degeneration and lower back pain. Although grading systems exist for assessing facet joint space narrowing, static imaging fails to characterize changes in the facet gap under load that play a role in segmental stability. Current methods for estimating the dynamic behavior of the facet joint are either inaccurate, radiation costly, or clinically impractical. In the current study, we demonstrate the feasibility of a novel method for 3D measurement of facet joint space using digital tomosynthesis (DTS) imaging in supine and standing positions. Facet gap measurements were found to be strongly correlated with (r to 0.98) and accurate (<20 µm error for median facet gap) relative to microcomputed tomography reference values. In a pilot in vivo demonstration with seven participants, the effect of physiological loading was detectable, with median facet joint space being larger in standing as compared to supine images (p < 0.0001). The presented approach may be useful in directly characterizing changes in the facet joint relevant to segmental stability that are not readily assessed via current clinical imaging methods.

•Facet joint are important source of chronic low back pain.•RF denervation of the medial branch results in short-term pain relief.•RF lesioning of the facet capsule results in a longer pain relief. Percutaneous radiofrequency denervation of the medial dorsal branch is often used in chronic low back pain of intervertebral facet etiology, which is sometimes difficult to perform and recurrence of pain often ensues. We theorized that shifting the target of RF coagulation to the facet joint capsule would provide an easier target and a longer-lived pain relieving response. A prospective randomized controlled trial where 120 patients diagnosed with CLBP of a confirmed facet origin were randomly divided into three equal groups, the first was submitted to percutaneous radiofrequency coagulation of the facet joint capsule, the second underwent percuataneous denervation of the medial dorsal branch and the third did not receive radiofrequency lesioning. All the three groups received local injection of a mixture of local anesthetic and steroid. Cases were followed for up to 3 years. 87(72.5%) patients were females. By 3 months’ post procedure, improvement in VAS was significantly better than pretreatment levels in all groups (p<0.05). The control group lost improvement by 1-year follow-up (p=0.017). At 2 years’ follow-up, the joint capsule denervation group maintained significant improvement (p=0.033) whereas the medial branch denervation group lost its significant effect (p=0.479). By the end of follow-up period, only joint capsule denervation group kept significant improvement (p=0.026). In CLBP of facet origin, shifting the target of percutaneous radiofrequency to the facet joint capsule provides an easier technique with an extended period of pain relief compared to the medial dorsal branch of the facet joint.

ObjectiveThe objective of this study is to investigate safety and effectiveness of a fluoroscopy-guided high-intensity focused ultrasound (HIFU) system for thermal ablation of the lumbar medial branch nerves.MethodsThis dual center prospective cohort study enrolled 30 participants with lumbar zygapophyseal joint syndrome. Each participant previously had a positive response to either a single diagnostic analgesic block or radiofrequency ablation (RFA). The primary effectiveness outcome was individual responder rate, defined as a reduction of two points or more on the pain intensity numerical rating scale without an increase in opioid intake, or a reduction in opioid intake without an increase in pain at 6 months after the intervention. The primary safety outcome was procedure-related or device-related adverse events (AEs). Secondary outcome variables included MRI evidence of tissue ablation, Oswestry Disability Index, 12-Item Short Form Health Survey, Brief Pain Inventory, and Patient Global Impression of Change.ResultsThe individual responder rate was 89.7% at 2 days, 89.7% at 7 days, 72.4% at 14 days, 82.1% at 30 days, 59.3% at 90 days and 82.6% at 180 days. The average Numeric Rating Scale for pain severity decreased from 7.1 at baseline to 3.0 (N=29) after 2 days, 3.0 (N=29) after 7 days, 3.1 (N=29) after 14 days, 3.2 (N=28) after 30 days, 4.3 (N=27) after 90 days, and 3.3 (N=23) after 180 days. All participants tolerated the procedure well with no significant side effects or complications.ConclusionsFluoroscopy-guided HIFU neurotomy achieved clinical responses comparable with RFA, and there were no significant device-related or procedure-related AEs.Trial registration number NCT04129034.

Background and objectivesNo previous study has assessed the outcomes of cooled radiofrequency ablation (C-RFA) of the medial branch nerves (MBN) for the treatment of lumbar facet joint pain nor compared its effectiveness with traditional RFA (T-RFA). This study evaluated 6-month outcomes for pain, function, psychometrics, and medication usage in patients who underwent MBN C-RFA versus T-RFA for lumbar Z-joint pain.MethodsIn this blinded, prospective trial, patients with positive diagnostic MBN blocks (>75% relief) were randomized to MBN C-RFA or T-RFA. The primary outcome was the proportion of ‘responders’ (≥50% Numeric Rating Scale (NRS) reduction) at 6 months. Secondary outcomes included NRS, Oswestry Disability Index (ODI), and Patient Global Impression of Change.ResultsForty-three participants were randomized to MBN C-RFA (n=21) or T-RFA (n=22). There were no significant differences in demographic variables (p>0.05). A ≥50% NRS reduction was observed in 52% (95% CI 31% to 74%) and 44% (95% CI 22% to 69%) of participants in the C-RFA and T-RFA groups, respectively (p=0.75). A ≥15-point or ≥30% reduction in ODI score was observed in 62% (95% CI 38% to 82%) and 44% (95% CI 22% to 69%) of participants in the C-RFA and T-RFA groups, respectively (p=0.21).ConclusionsWhen using a single diagnostic block paradigm with a threshold of >75% pain reduction, both treatment with both C-RFA and T-RFA resulted in a success rate of approximately 50% when defined by both improvement in pain and physical function at 6-month follow-up. While the success rate was higher in the C-RFA group, this difference was not statistically significant.Trial registration number NCT02478437.

Purpose Reduction of cervical facet dislocation should be performed as soon as possible to depressurize neuron cells although some randomized control studies defined early reduction as over 24 h after trauma. The purpose of this study was to define the actual time limit for early reduction in patients with complete motor paralysis. Methods Cervical spine dislocation patients with complete motor paralysis admitted between April 2007 and December 2014 were analyzed as retrospective cohort study. We separated the patients into three groups according to the number of hours lapsed between the trauma and reduction, within 4 h (very early group), >4–6 h (early group), and >6 h (delayed group). We compared the neurological outcomes, patient injury patterns, the arrival time at the hospital, and the injury severity score (ISS). Results Of 30 patients who enrolled, 8 (27%) were recovered to American Spinal Injury Association Impairment Scale Grades C-E. The delayed group had poorer neurological outcomes than the very early group and early group, although no significant differences were noted in the recovery rate between the very early group and early groups. The injury pattern, arrival time, and ISS were not found to be associated with the neurological outcome. Conclusion Our data suggest that early (<6 h) reduction of cervical spine dislocation is associated with favorable neurological outcome as compared with those performed after 6 h.

Purpose To evaluate the association between facet joints cross-sectional area asymmetry (FCAA) and cervical intervertebral disc herniation (CDH). Methods Overall, we retrospectively recruited 390 consecutive patients with CDH who underwent surgical treatment at our institution and 50 normal participants. Clinical variables and radiological findings related to CDH were collected. Results Patients with CDH were more likely to have a higher absolute value of the facet asymmetry factor (FAF) ( p   < .001), in which the FAF value of the left group was significantly higher than the other groups ( p   < .001) and the right group was lower than the central group ( p   < .001). 9.62% (C3/4), 12.19% (C4/5), 8.70% (C5/6), and 8.14% (C6/7) were determined as cutoff values for each variable that maximized sensitivity and specificity. Furthermore, multivariate analysis showed that cross-sectional area asymmetry of the facet joint (FCAA) was an independent risk factor for the occurrence of CDH. Also, the Chi-square test showed a significant difference in the distribution of the degeneration classification of the disc between the facet-degenerated group and the nondegenerated group at C5/6 ( p  = 0.026) and C6/7 ( p  = 0.005) in the facet asymmetry (FA) group. Conclusions FCAA is evaluated as an independent risk factor for CDH and associated with the orientation of disc herniation. And facet joint orientation may also play a role in cervical spine degeneration rather than facet joint tropism.