The lumbar facet joint: a review of current knowledge: Part II: diagnosis and management.

This article is the second article in a two-part review on lumbar facet joint pathology. In this review, we discuss the current concepts and controversies regarding the proper diagnosis and management of patients presenting with presumed facet-mediated lower back pain. All efforts were made to include the most relevant literature from the fields of radiology, orthopaedics, physiatry, and pain management. Our focus in this article is on presenting the evidence supporting or refuting the most commonly employed injection-based therapies for facet-mediated lower back pain.

The lumbar facet joint: a review of current knowledge: part 1: anatomy, biomechanics, and grading.

We present a two-part review article on the current state of knowledge of lumbar facet joint pathology. This first article discusses the functional anatomy, biomechanics, and radiological grading systems currently in use in clinical practice and academic medicine. Facet joint degeneration is presented within the larger context of degenerative disc disease to enable the reader to better understand the anatomical changes underlying facet-mediated lower back pain. Other less-common, but equally important etiologies of lumbar facet joint degeneration are reviewed. The existing grading systems are discussed with specific reference to the reliability of CT and MR imaging in the diagnosis of lumbar facet osteoarthritis. It is hoped that this discussion will stimulate debate on how best to improve the diagnostic reliability of these tests so as to improve both operative and non-operative treatment outcomes.

MRI Radiological Predictors of Requiring Microscopic Lumbar Discectomy After Lumbar Disc Herniation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate radiological differences in lumbar disc herniations (herniated nucleus pulposus [HNP]) between patients receiving microscopic lumbar discectomy (MLD) and nonoperative patients. METHODS: Patients with primary treatment for an HNP at a single academic institution between November 2012 to March 2017 were divided into MLD and nonoperative treatment groups. Using magnetic resonance imaging (MRI), axial HNP area; axial canal area; HNP canal compromise; HNP cephalad/caudal migration and HNP MRI signal (black, gray, or mixed) were measured. T test and chi-square analyses compared differences in the groups, binary logistic regression analysis determined odds ratios (ORs), and decision tree analysis compared the cutoff values for risk factors. RESULTS: A total of 285 patients (78 MLD, 207 nonoperative) were included. Risk factors for MLD treatment included larger axial HNP area (P < .01, OR = 1.01), caudal migration, and migration magnitude (P < .05, OR = 1.90; P < .01, OR = 1.14), and gray HNP MRI signal (P < .01, OR = 5.42). Cutoff values for risks included axial HNP area (70.52 mm2, OR = 2.66, P < .01), HNP canal compromise (20.0%, OR = 3.29, P < .01), and cephalad/caudal migration (6.8 mm, OR = 2.43, P < .01). MLD risk for those with gray HNP MRI signal (67.6% alone) increased when combined with axial HNP area >70.52 mm2 (75.5%, P = .01) and HNP canal compromise >20.0% (71.1%, P = .05) cutoffs. MLD risk in patients with cephalad/caudal migration >6.8 mm (40.5% alone) increased when combined with axial HNP area and HNP canal compromise (52.4%, 50%; P < .01). CONCLUSION: Patients who underwent MLD treatment had significantly different axial HNP area, frequency of caudal migration, magnitude of cephalad/caudal migration, and disc herniation MRI signal compared to patients with nonoperative treatment.

Rehabilitation of orthopaedic and neurologic boxing injuries.

Clinical decision making for injured boxers follows the same therapeutic principles as the treatment plan for other injured athletes. Just as surgical techniques have improved, so has the scientific basis for implementing therapeutic exercises progressed to return the athletes to their former level of competition.

Successful treatment of phantom radiculopathy with fluoroscopic epidural steroid injections.

Phantom limb pain has been well described in the literature. However, new-onset lumbar radicular pain superimposed on baseline lower extremity phantom pain is a clinical scenario that can be challenging to recognize. Furthermore, literature on recognition and treatment of phantom radiculopathy is all but lacking. We present a patient who experienced new-onset lumbar radiculopathy superimposed on her phantom pain that was successfully treated with fluoroscopic interlaminar and transforaminal epidural steroid injections.