How I do it? Full endoscopic lumbar rhizotomy for chronic facet joint pain due to failed back surgery syndrome.

BACKGROUND: Failed back surgery syndrome (FBSS) is a general term for persistent postoperative back pain with or without accompanying radicular pain. FBSS may present as chronic facet joint pain. METHODS: We introduced full endoscopic lumbar rhizotomy for patients suffering from facet joint pain due to FBSS. Facet joint block was introduced into the facet joint to determine whether pain improved after the injection. CONCLUSION: With full endoscopic lumbar rhizotomy, the surgeon can identify the regions involved more clearly and directly. Although it is an invasive procedure, it provides a more effective and safe treatment for patients with FBSS-related facet joint pain.

[Lumbar CT-guided radiofrequency ablation of the medial branch of the dorsal ramus of the spinal nerve : Anatomic study and description of a new technique]. / Lumbale CT-gezielte Radiofrequenzablationen des Ramus medialis rami dorsalis nervi spinalis : Anatomische Untersuchung und Beschreibung einer neuen Technik.

BACKGROUND: The success of radiofrequency ablation (RF) of the medial branch of the dorsal ramus in patients with facet joint pain depends on the effective coagulation distance. To date, computed tomography(CT)-guided techniques do not reach the nerve in parallel but rather than punctually. We report a new CT-guided technique to enhance parallelism and proximity of the RF needle to the nerve. MATERIALS AND METHODS: Two examiners with different experience with CT-guided procedures in corpses performed all punctures at the lumbar spine on 10 corpses. A RF needle was inserted 1 cm lateral to the spinous process of the vertebra located caudal to the target nerve. The needle was advanced under CT guidance at a flat angle between the superior articular process and the base of the costal or transverse process of the cranial vertebra. The position was verified by dissection. Needle position was judged successful provided the needle could be positioned in the first attempt with no more than one angle correction. RESULTS: In 86 out of 100 possible cases (50 per side) at the 5 lumbar segments, the RF needle could be depicted by CT in the target area with no more than one correction of the needle position. Anatomical dissections revealed that 47 out of 86 needles (54.6%) fulfilled the requirements of parallelism and proximity to the nerve. The dorsal ramus was never reached by the RF needle. Higher success rates were obtained in the middle segments compared to the border segments of L1-L2 and L5-S1. CONCLUSIONS: We could demonstrate that the principle of parallelism and proximity of the needle to the nerve could be fulfilled with this new technique; however, needle positioning requires practice due to the oblique puncture direction.

Cost Utility Analysis of Cervical Therapeutic Medial Branch Blocks in Managing Chronic Neck Pain.

Background: Controlled diagnostic studies have established the prevalence of cervical facet joint pain to range from 36% to 67% based on the criterion standard of ≥ 80% pain relief. Treatment of cervical facet joint pain has been described with Level II evidence of effectiveness for therapeutic facet joint nerve blocks and radiofrequency neurotomy and with no significant evidence for intraarticular injections. However, there have not been any cost effectiveness or cost utility analysis studies performed in managing chronic neck pain with or without headaches with cervical facet joint interventions. Study Design: Cost utility analysis based on the results of a double-blind, randomized, controlled trial of cervical therapeutic medial branch blocks in managing chronic neck pain. Objectives: To assess cost utility of therapeutic cervical medial branch blocks in managing chronic neck pain. Methods: A randomized trial was conducted in a specialty referral private practice interventional pain management center in the United States. This trial assessed the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids for an established diagnosis of cervical facet joint pain by means of controlled diagnostic blocks. Cost utility analysis was performed with direct payment data for the procedures for a total of 120 patients over a period of 2 years from this trial based on reimbursement rates of 2016. The payment data provided direct procedural costs without inclusion of drug treatments. An additional 40% was added to procedural costs with multiplication of a factor of 1.67 to provide estimated total costs including direct and indirect costs, based on highly regarded surgical literature. Outcome measures included significant improvement defined as at least a 50% improvement with reduction in pain and disability status with a combined 50% or more reduction in pain in Neck Disability Index (NDI) scores. Results: The results showed direct procedural costs per one-year improvement in quality adjusted life year (QALY) of United States Dollar (USD) of $2,552, and overall costs of USD $4,261. Overall, each patient on average received 5.7 ± 2.2 procedures over a period of 2 years. Average significant improvement per procedure was 15.6 ± 12.3 weeks and average significant improvement in 2 years per patient was 86.0 ± 24.6 weeks. Limitations: The limitations of this cost utility analysis are that data are based on a single center evaluation. Only costs of therapeutic interventional procedures and physician visits were included, with extrapolation of indirect costs. Conclusion: The cost utility analysis of therapeutic cervical medial branch blocks in the treatment of chronic neck pain non-responsive to conservative management demonstrated clinical effectiveness and cost utility at USD $4,261 per one year of QALY.

Ultrasound versus fluoroscopy-guided cervical medial branch block for the treatment of chronic cervical facet joint pain: a retrospective comparative study.

OBJECTIVE: To compare the mid-term effects and advantages of the ultrasound (US)-guided with fluoroscopy(FL)-guided cervical medial branch blocks (CMBBs) for chronic cervical facet joint pain through assessment of pain relief, functional improvement, and injection efficiency. METHODS: Patients with chronic cervical facet joint pain who received US- (n = 68) or FL-guided CMBBs (n = 58) were included in this retrospective study. All procedures were performed using a FL or US. The complication frequencies, treatment effects, functional improvement, and injection efficiency of CMBBs were compared at 1, 3, and 6 months after the last injection. RESULTS: Both the NDI and VNS scores showed improvements at 1, 3, and 6 months after the last injection in both groups, with no significant differences between groups (p < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), the number of injections, sex, analgesic use, and age were not independent predictors of treatment success. Compared with FL-guided CMBB, US-guided CMBB was associated with a shorter administration duration and fewer needle passes. CONCLUSIONS: Our results suggest that, compared with FL-guided CMBBs, US-guided CMBBs require a shorter administration duration and fewer needle passes, while providing similar pain relief and functional improvements. Therefore, US-guided CMBBs can be considered as an effective alternative for the conservative management of chronic cervical facet joint pain.

Safety of Lumbar Spine Radiofrequency Procedures in Patients Who Have Posterior Spinal Hardware.

OBJECTIVE: The purpose of this study was to determine whether the energy generated by an active radiofrequency (RF) cannula adjacent to lumbar spine hardware could result in heating of the hardware. DESIGN: Prospective study. SETTING: Tertiary care medical center. SUBJECTS: Six patients with lumbar facet joint pain at the level adjacent to lumbar spine fusion hardware were studied. METHODS: A total of 10 lumbar medial branch nerve radiofrequency lesion procedures were performed on six patients. A temperature probe was placed on the fusion hardware to continuously monitor the temperature of the hardware throughout the RF procedure. RESULTS: The temperature of the fusion hardware increased in six of the 10 RF lesion procedures. During two of the procedures, the temperature rose rapidly to 42°C, at which time the procedure was ceased at that level. CONCLUSION: This study demonstrated that radiofrequency lesioning to treat symptomatic facet joint pain in patients who have adjacent posterior lumbar fusion hardware may result in heat energy being transferred to the adjacent hardware. This may increase the risk of injury to the patient. Monitoring for a temperature increase is easily accomplished by inserting a temperature probe onto the surface of the hardware.

Interventional therapies for chronic low back pain.

OBJECTIVE: Low back pain (LBP) is a highly prevalent condition and one of the leading causes of lost productivity and health-care costs. The objective of this review is to discuss the role of interventional pain procedures and evidence of their effectiveness in treatment of chronic LBP. METHODS: This is a narrative review examining published studies on interventional procedures for LBP. The rationales, indications, technique, evidence, and complications for the interventional procedures are discussed. RESULTS: Interventional pain procedures are used extensively in diagnosis and treatment of chronic pain. LBP is multifactorial, and while significant progress has been made in understanding its pathophysiology, this has not resulted in a proportional improvement of functional outcomes. For certain procedures, such as spinal cord stimulation, medical branch blocks and radiofrequency ablations, and epidural steroid injections for radiculopathy, safety, efficacy, and cost-effectiveness in treating LBP have been well studied. For others, such as interventions for discogenic pain, treatment successes have been modest at best. CONCLUSIONS: Implementation of interventional pain procedures in the treatment framework of LBP has resulted in improvement of pain intensity in at least the short and medium terms, but equivocal results have been observed in functional improvement.

Safety of bone marrow derived mesenchymal stem cell extracellular vesicle injection for lumbar facet joint pain.

Aim: A 3-month pilot study to evaluate the safety of injecting a bone marrow-derived mesenchymal stem cell extracellular vesicle advanced investigational product (IP) into the lumbar facet joint space as a treatment for chronic low back pain. Methods: 20 healthy adults were treated with IP injections (0.5 ml/joint) and evaluated by three functional assessments 1, 3, 7, 14, 30, 60 and 90 days later. Results: No adverse effects or complications occurred across the 3-month follow-up. There were no reports of worsening pain. After 3 months group average scores improved significantly (p < 0.0001) in the Severity Index (65.04%), Interference Index (72.09%) and Oswestry Disability Index (58.43%) assessments. Conclusion: IP injections were safe and associated with significant functional improvements.

What is this article about? Bone marrow mesenchymal stem cell derived extracellular vesicles (BM-MSC EV), a novel biologic therapeutic candidate, are a safe and promising therapeutic intervention for patients with lumbar facet joint pain, a malady that manifests as persistent low back pain (LBP). 20 adult subjects with lumbar facet joint pain received a single injection of BM-MSC EV investigational product in the lumbar facet joint space. What were the results? Follow-up was conducted through in-office and virtual visits that included outcome measures to determine the safety and efficacy of this therapy. By the 3-month end point, follow-up was successful, and no complications or adverse events were noted. Significant improvements in all three assessments of pain and disability occurred throughout the study. What do the results of the study mean? The results are promising and suggest that BM-MSC EV may represent a revolutionary treatment option with durable efficacy and minimal safety risks. Randomized, controlled clinical studies into the application of BM-MSC EV in lumbar facet joint pain should be pursued to confirm the potential benefits of this novel intervention.

Acute back pain: Clinical and radiologic diagnosis: WFNS spine committee recommendations.

Objective: To formulate the most current, evidence-based recommendations for the clinical and radiologic diagnosis of acute low back pain lasting <4 weeks. Methods: A systematic literature search in PubMed and Google Scholar databases was performed from 2012 to 2022 using the search terms "acute back pain AND clinical diagnosis" and "acute back pain AND radiologic diagnosis". Screening criteria resulted in a total of 97 papers analyzed. Using the Delphi method and two rounds of voting, the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated ten final consensus statements. Results: Ten final consensus statements address the clinical diagnosis of acute LBP, including which clinical conditions cause acute LBP and how we can distinguish between the different causes of LBP, including discogenic, facet joint, sacroiliac joint, and myofascial pain. The most important step for the radiologic diagnosis of acute LBP is to evaluate the necessity of radiologic investigation, as well as its timing and the most appropriate type of imaging modality. Importantly, imaging should not be a routine diagnostic tool, unless red flag signs are present. In fact, routine imaging for acute LBP can actually have a negative effect as it may reveal incidental radiographic findings that exacerbate patient fear and anxiety. Conclusion: Overall, the quality of evidence is not high for most of our consensus statements, and further studies are needed to validate the WFNS Spine Committee recommendations on the clinical and radiographic diagnosis of acute LBP.

Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations.

Objective: To formulate the most current, evidence-based recommendations regarding the epidemiology, clinical diagnosis, and radiographic diagnosis of lumbar herniated disk (LDH). Methods: A systematic literature search in PubMed, MEDLINE, and CENTRAL was performed from 2012 to 2022 using the search terms "herniated lumbar disc", "epidemiology", "prevention" "clinical diagnosis", and "radiological diagnosis". Screening criteria resulted in 17, 16, and 90 studies respectively that were analyzed regarding epidemiology, clinical diagnosis, and radiographic diagnosis of LDH. Using the Delphi method and two rounds of voting at two separate international meetings, ten members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated eleven final consensus statements. Results: The lifetime risk for symptomatic LDH is 1-3%; of these, 60-90% resolve spontaneously. Risk factors for LDH include genetic and environmental factors, strenuous activity, and smoking. LDH is more common in males and in 30-50 year olds. A set of clinical tests, including manual muscle testing, sensory testing, Lasegue sign, and crossed Lasegue sign are recommended to diagnose LDH. Magnetic resonance imaging (MRI) is the gold standard for confirming suspected LDH. Conclusions: These eleven final consensus statements provide current, evidence-based guidelines on the epidemiology, clinical diagnosis, and radiographic diagnosis of LDH for practicing spine surgeons worldwide.

Effectiveness of Facet Joint Nerve Blocks in Managing Chronic Axial Spinal Pain of Facet Joint Origin: A Systematic Review and Meta-Analysis.

BACKGROUND: Chronic axial spinal pain is one of the major causes of disability. Literature shows that spending on low back and neck pain and musculoskeletal disorders continues to escalate, not only with disability, but also with increasing costs, accounting for the highest amount of various disease categories. Based on the current literature utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been shown as potential sources of spinal pain. Therapeutic facet joint interventional modalities of axial spinal pain include radiofrequency neurotomy, therapeutic facet joint nerve blocks, and therapeutic intraarticular injections. OBJECTIVE: The objective of this systematic review and meta-analysis is to evaluate the effectiveness of facet joint nerve blocks as a therapeutic modality in managing chronic axial spinal pain of facet joint origin. STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. METHODS: The available literature on facet joint nerve blocks in axial spinal pain was reviewed. The quality assessment criteria utilized were the Cochrane review criteria to assess risk of bias, the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized therapeutic trials, and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for nonrandomized studies. The evidence was graded according to Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment criteria. The level of evidence was based on best evidence synthesis with modified grading of qualitative evidence from Level I to Level V. A comprehensive literature search of multiple databases from 1966 to July 2023, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included studies and best evidence synthesis were incorporated into qualitative and quantitative evidence synthesis. OUTCOME MEASURES: The primary outcome measure was the proportion of patients with significant relief and functional improvement of greater than 50% of at least 3 months. Duration of relief was categorized as short-term (less than 6 months) and long-term (greater than 6 months). RESULTS: This assessment identified 8 high-quality and one moderate quality RCTs and 8 high quality and 4 moderate quality non-randomized studies with application of spinal facet joint nerve blocks as therapeutic modalities. However, based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment, only 3 of the 21 studies showed high levels of evidence and clinical applicability, with 11 studies showing moderate levels of GRADE evidence and clinical applicability. LIMITATIONS: Despite the availability of multiple studies, the paucity of literature is considered as the major drawback. Based on Grading of Recommendations, Assessment Development, and Evaluations (GRADE) assessment, only 3 of the 21 studies showed high levels of evidence and clinical applicability. CONCLUSION: Based on the present systematic review and meta-analysis with 9 RCTs and 12 non-randomized studies, the evidence is Level II with moderate to strong recommendation for therapeutic facet joint nerve blocks in managing spinal facet joint pain.

Low Back Pain and Radiofrequency Denervation of Facet Joint: Beyond Pain Control-A Video Recording.

Chronic low back pain is often due to L5S1 instability resulting in facet joint syndrome. Patients suffering from low back pain may also have a gait pattern characterized by a reduced speed and a shorter, asymmetrical step in order to reduce pain. This case is of a patient with L5S1 instability that occurred after L1 to L5 lumbar stabilization who was treated with radiofrequency (RF) denervation of the medial branch of L5S1 bilaterally. RF ablation outcome was tested by comparing its impact on pain, function, quality of life, and on gait pattern, before and 1 month after the procedure. To objectify the impact of a good pain control on gait, a video recording was performed (see Video 1).

Abnormal Paresthesias Associated With Radiofrequency Ablation of Lumbar Medial Branch Nerves: A Case Report.

Radiofrequency ablation (RFA) is an effective treatment that has occasionally been associated with transient paresthesias. This case report details an unusual presentation of paresthesias after lumbar medial branch RFA. A 48-year-old female patient reported pain, numbness, and swelling on the left buttock and posterolateral thigh. A physical exam revealed allodynia over the left posterolateral thigh without neurologic deficits two weeks after RFA of the left-sided lumbar medial branch nerves innervating the L4-L5 and L5-S1 facet joints. Shortly after the RFA of the contralateral targets, the patient complained of numbness of the right-sided lower back extending laterally from the right hip to the right knee. Imaging confirmed the appropriate placement of all needles in both procedures. Both instances of paresthesias resolved over time. This case report aims to demonstrate that RFA can be associated with unusual paresthesias and that these adverse effects do not warrant excessive workup.

A comparison of pulsed radiofrequency and radiofrequency denervation for lumbar facet joint pain.

BACKGROUND: Lumbar facet joint pain is a common disorder. The main symptom is chronic lumbar pain, which can reduce quality of life. Radiofrequency has often been used to treat lumbar facet joint pain. However, the effectiveness of this technique has been controversial. This study was conducted to compare the effectiveness of pulsed radiofrequency (PRF) and radiofrequency denervation (RD) for lumbar facet joint pain. METHODS: One hundred and forty-two patients with lumbar facet joint pain were allocated to two treatment groups: PRF group (N = 72) and RD group (N = 70). Patients enrolled in the study were assessed using a visual analogue scale (VAS), Roland-Morris questionnaire (RMQ), Oswestry disability index (ODI) and Short-Form 36 (SF-36) questionnaire before therapy, 3 months and 12 months later. RESULTS: There were no significant differences in VAS, RMQ score, ODI score and SF-36 score at 3 months (p > 0.05). Significant differences in pain control were observed in both groups at 12 months (3.09 ± 1.72 vs. 2.37 ± 1.22, p = 0.006). There was a significant difference in RMQ score (11.58 ± 3.58 vs. 8.17 ± 2.34, p < 0.001) and ODI score (43.65 ± 11.01 vs. 35.42 ± 11.32, p < 0.001) at 12 months. The total SF-36 score was higher in the RD group than in the PRF group at 12 months (58.45 ± 6.97 vs. 69.36 ± 6.43, p < 0.001). In terms of complications, skin numbness occurred in three patients. Mild pain such as burning and pinking at the puncture site in two patients. One patient experienced a decrease in back muscle strength and back muscle fatigue. These complications disappeared in 3 weeks without any treatment. There were no serious adverse events in the PRF group. CONCLUSION: Radiofrequency is an effective and safe treatment option for patients with lumbar facet joint pain. RD could provide good and lasting pain relief, with significant improvement in lumbar function and quality of life at long-term follow-up.

Efficacy of Cervical Facet Joint Radiofrequency Ablation Using a Multitined Cannula, a Technical Note, and Observational Study.

BACKGROUND: Chronic cervical facet joint pain is a leading cause of pain and disability. In patients nonresponsive to conservative treatment, cervical facet radiofrequency ablation (RFA) has shown to be efficacious. However, the conventional RFA technique can be cumbersome. A novel RFA technique with a multitined cannula allows for a lateral approach and represents an attractive alternative option for cervical facet RFA. It offers a potentially shorter, less cumbersome procedure, with consequently less x-ray exposure and patient discomfort than the conventional cervical RFA. OBJECTIVES: To describe the novel RFA technique using the lateral approach with the multitined cannula at the cervical facet joints and to assess its efficacy in chronic cervical facet joint pain. STUDY DESIGN: This is a single-center observational study. SETTING: Interventional Pain Management Center, Switzerland. METHODS: The aim of this study is to describe the RFA technique using the lateral approach with the multitined cannula at the cervical facet joints and to assess its efficacy in chronic cervical facet joint pain. Eligible adult patients with chronic (> 3 months) cervical facet joint pain refractory to conservative treatment and confirmed by dual positive medial branch blocks, received a fluoroscopic-guided cervical facet RFA treatment using the multitined cannula. The primary outcome was pain relief. Secondary outcome measures included the proportion of patients reporting a >= 30% reduction of pain intensity 2 months after RFA, patient global impression of change (PGIC), need for pain medication, sleep quality, and patient satisfaction. RESULTS: We included 26 patients. The patients showed a clinically meaningful and significant pain relief at 2 months after cervical facet RFA (mean Numeric Rating Scale of 7.5 [1.9] at baseline to 4.2 [2.4]) and 58% of the patients reported >= 30% reduction of pain. An improvement on the PGIC was reported by 88.2% of the patients. No severe side effects or complications were observed. LIMITATIONS: Key limitations of our study were the relatively small sample size, the lack of a control group, and a relatively short-term follow-up duration. CONCLUSIONS: Our results suggest that cervical facet joint RFA using the novel technique with the multitined cannula results in significant pain reduction and improvement on the PGIC. While the conventional technique requires multiple ablations at each target level, the RFA with the multitined needle requires only a singular ablation, likely sparing time, radiation dose, discomfort, and costs. Our results merit consideration of replacement of the conventional technique with the novel technique using the multitined cannula. However, larger-scale clinical trials with an adequate long-term follow-up period are needed to prove the efficacy of RFA using the multitined cannula in cervical facet joint pain.

Current Approaches to Four Challenging Pain Syndromes.

During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.

Combined Continuous Radiofrequency Ablation and Pulsed Neuromodulation to Treat Cervical Facet Joint Pain and Alleviate Postcervical Radiofrequency Side Effects.

Background: Continuous radiofrequency ablation (RFA) can effectively manage cervical facet joint pain related to neuropathic symptoms in the post-radiofrequency period. Additionally, pulse radiofrequency (PRF) provides relief of neuropathic symptoms. However, the effect of combined RFA and PRF has yet to be determined. Objectives: The study aimed to compare the effectiveness and safety of RFA (CRF group) and combined RFA and PRF (CPRF group). Methods: The study retrospectively reviewed the charts of patients with cervical facet joint pain undergoing RFA between June 1, 2014, and June 1, 2017, or combined RFA and PRF between June 1, 2017, and June 1, 2020, at a pain research center. Thirty-nine consecutive patients identified from charts meeting the inclusion criteria were included and classified in CRF (n = 22) and CPRF groups (n = 17). The results were evaluated using a Visual Analog Scale (VAS) and neck pain disability index (NDI) before procedures and 1, 3, and 6 months after the injections. Successful treatment was expressed as at least 80% pain relief from baseline and NDI score <15 points. The duration of pain relief was expressed as the period between pain relief and pain reoccurrence to 50% of the preprocedural pain level. The primary outcome was successful treatment in the groups, and the secondary outcome was the duration of pain relief and post-cervical radiofrequency side effects in the groups. Results: Fourteen (66.7%) patients in the CRF group and 12 (66.7%) in the CPRF group experienced successful treatment at three and six-month follow-ups (P > 0.05). The median time to the reoccurrence of at least 50% of preprocedural pain level was 303.8 days in the CRF group and 270 days in the CPRF group (P = 0.395). However, the CPRF group showed significantly less postoperative numbness, dysesthesia, and hypersensitivity syndrome than the CRF group (P < 0.05). Conclusions: Combined RFA and PRF can be complementary treatment for cervical facet joint pain, providing an adequate success rate and duration of pain relief as RFA alone but with significantly fewer post-radiofrequency side effects.

Personalized multitarget biologic injection in the spine: prospective case series of multitarget platelet-rich plasma for low back pain.

Aim: To evaluate the use of a multitarget platelet-rich plasma (PRP) injection approach for the treatment of chronic low back pain (LBP). Materials & Methods: Forty-six patients with more than 12 weeks of LBP who failed conservative treatments were injected with PRP into the facet joints, intervertebral discs, epidural space and/or paravertebral muscles. Visual analog pain scale and Roland-Morris Disability Questionnaire scores were measured at baseline and predefined intervals. Results: Mean visual analog pain scale was reduced from 8.48 to 5.17 and mean Roland-Morris Disability Questionnaire from 18.0 to 10.98 at 12 weeks (p < 0.001). These statistically significant improvements were sustained over 52 weeks. No adverse effects were observed. Conclusion: Our PRP approach demonstrated clinically favorable results and may be a promising treatment for chronic LBP.

Lay abstract Back pain can be caused by a variety of conditions. Most long-term (chronic) low back pain cases involve one or more parts of the spine causing the pain. This study describes 46 people who received injections of a blood-based substance called platelet-rich plasma into multiple parts of their spine to address chronic low back pain. The patients were followed up at several time points over the course of the following year. The results showed that the patients had improvement in their pain and disability. There was also a reduction in oral pain medication use. No unexpected medical problems were seen with this treatment. This study shows promising results for the treatment of chronic back pain.

Outcomes of Cervical Therapeutic Medial Branch Blocks and Radiofrequency Neurotomy: Clinical Outcomes and Cost Utility are Equivalent.

BACKGROUND: Cervical facet joint pain is often managed with either cervical radiofrequency neurotomy, cervical medial branch blocks, or cervical intraarticular injections. However, the effectiveness of each modality continues to be debated. Further, there is no agreement in reference to superiority or inferiority of facet joint nerve blocks compared to radiofrequency neurotomy, even though cervical facet joint radiofrequency neurotomy has been preferred by many and in fact, has been mandated by the Centers for Medicare and Medicaid Services (CMS), except when radiofrequency cannot be confirmed. Each procedure has advantages and disadvantages in reference to clinical utility, outcomes, cost utility, and side effect profile. However, comparative analysis has not been performed thus far in the literature in a clinical setting. STUDY DESIGN: A retrospective, case-control, comparative evaluation of outcomes and cost utility. SETTING: The study was conducted in an interventional pain management practice, a specialty referral center, a private practice setting in the United States. OBJECTIVE: To evaluate the clinical outcomes and cost utility of therapeutic medial branch blocks with radiofrequency neurotomy in managing chronic neck pain of facet joint origin. METHODS: The study was performed utilizing Strengthening the Reporting of Observational Studies in Epidemiology Analysis (STROBE) criteria. Only the patients meeting the diagnostic criteria of facet joint pain by means of comparative, controlled diagnostic local anesthetic blocks were included.The main outcome measure was pain relief measured by Numeric Rating Scale (NRS) evaluated at 3, 6, and 12 months. Significant improvement was defined as at least 50% improvement in pain relief. Cost utility was calculated with direct payment data for the procedures with addition of estimated indirect costs over a period of one year based on highly regarded surgical literature and previously published interventional pain management literature. RESULTS: Overall, 295 patients met inclusion criteria with 132 patients receiving cervical medial branch blocks and 163 patients with cervical radiofrequency neurotomy. One hundred and seven patients in the cervical medial branch group and 105 patients in the radiofrequency group completed one year follow-up. There was significant improvement in both groups from baseline to 12 months with pain relief and proportion of patients with >= 50% pain relief. Average relief of each procedure for cervical medial branch blocks was 13 to 14 weeks, whereas for radiofrequency neurotomy, it was 20 to 25 weeks. Significant pain relief was recorded in 100%, 94%, and 81% of the patients in the medial branch blocks group, whereas it was 100%, 69%, and 64% in the radiofrequency neurotomy group at 3, 6, and 12 month follow-up, with significant difference at 6 and 12 months.Cost utility analysis showed average cost for quality-adjusted life year (QALY) of $4,994 for cervical medial branch blocks compared to $5,364 for cervical radiofrequency neurotomy. Six of 132 patients (5%) in the cervical medial branch group and 53 of 163 (33%) patients in the cervical radiofrequency neurotomy group were converted to other treatments, either due to side effects (6 patients or 4%) or inadequate relief (47 patients or 29%). CONCLUSION: In this study, outcomes of cervical therapeutic medial branch blocks compared to radiofrequency neurotomy demonstrated significantly better outcomes with significant pain relief with similar costs for both treatments over a period of one year.

A Pilot Study Implementing a Machine Learning Algorithm to Use Artificial Intelligence to Diagnose Spinal Conditions.

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease, with chronic persistent spinal pain lasting longer than one-year reported in 25% to 60% of the patients. Health care expenditures have been escalating and the financial impact on the US economy is growing. Among multiple modalities of treatments available, facet joint interventions and epidural interventions are the most common ones, in addition to surgical interventions and numerous other conservative modalities of treatments. Despite these increasing costs in the diagnosis and management, disability continues to increase. Consequently, algorithmic approaches have been described as providing a disciplined approach to the use of spinal interventional techniques in managing spinal pain. This approach includes evaluative, diagnostic, and therapeutic approaches, which avoids unnecessary care, as well as poorly documented practices.  Recently, techniques involving artificial intelligence and machine learning have been demonstrated to contribute to the improved understanding, diagnosis, and management of both acute and chronic disease in line with well-designed algorithmic approach. The use of artificial intelligence and machine-learning techniques for the diagnosis of spinal pain has not been widely investigated or adopted. OBJECTIVES: To evaluate whether it is possible to use artificial intelligence via machine learning algorithms to analyze specific data points and to predict the most likely diagnosis related to spinal pain. STUDY DESIGN: This was a prospective, observational pilot study. SETTING: A single pain management center in the United States. METHODS: A total of 246 consecutive patients with spinal pain were enrolled. Patients were given an iPad to complete a Google form with 85 specific data points, including demographic information, type of pain, pain score, pain location, pain duration, and functional status scores. The data were then input into a decision tree machine learning software program that attempted to learn which data points were most likely to correspond to the practitioner-assigned diagnosis. These outcomes were then compared with the practitioner-assigned diagnosis in the chart. RESULTS: The average age of the included patients was 57.4 years (range, 18-91 years). The majority of patients were women and the average pain history was approximately 2 years. The most common practitioner-assigned diagnoses included lumbar radiculopathy and lumbar facet disease/spondylosis. Comparison of the software-predicted diagnosis based on reported symptoms with practitioner-assigned diagnosis revealed that the software was accurate approximately 72% of the time. LIMITATIONS: Additional studies are needed to expand the data set, confirm the predictive ability of the data set, and determine whether it is broadly applicable across pain practices. CONCLUSIONS: Software-predicted diagnoses based on the data from patients with spinal pain had an accuracy rate of 72%, suggesting promise for augmented decision making using artificial intelligence in this setting.

Equivalent Outcomes of Lumbar Therapeutic Facet Joint Nerve Blocks and Radiofrequency Neurotomy: Comparative Evaluation of Clinical Outcomes and Cost Utility.

BACKGROUND: Chronic low back pain secondary to facet joint pathology is prevalent in 27% to 40% of selected populations using controlled comparative local anesthetic blocks. Lumbar facet joint nerve blocks and radiofrequency neurotomy are the most common interventional procedures for lower back pain. Nonetheless, questions remain regarding the effectiveness of each modality. Moreover, there is no agreement in reference to superiority or inferiority of lumbar facet joint nerve blocks when compared with radiofrequency neurotomy. Centers for Medicare and Medicaid Services (CMS) and almost all payers prefer radiofrequency ablation. Both procedures have been extensively studied with randomized controlled trials, systematic reviews, and cost utility analysis. OBJECTIVE: To assess the clinical outcomes and cost utility of therapeutic lumbar facet joint nerve blocks (lumbar facet joint nerve blocks with L5 dorsal ramus block) compared with radiofrequency neurotomy in managing chronic low back pain of facet joint origin. STUDY DESIGN: A retrospective, case-control, comparative evaluation of outcomes and cost utility. SETTING: The study was conducted in an interventional pain management practice, a specialty referral center, a private practice setting in the United States. METHODS: The study was performed utilizing the Strengthening the Reporting of Observational Studies in Epidemiology Analysis (STROBE) criteria. Only the patients meeting the diagnostic criteria of facet joint pain by means of comparative, controlled diagnostic local anesthetic blocks were included.The main outcome measure was pain relief measured by the Numeric Rating Scale (NRS) evaluated at 3, 6, and 12 months. Significant improvement was defined as at least 50% improvement in pain relief. Cost utility was calculated utilizing direct payment data for the procedures with the addition of estimated indirect costs over a period of one year based on highly regarded surgical literature and previously published interventional pain management literature. RESULTS: A total of 326 patients met the inclusion criteria with 99 patients receiving lumbar facet joint nerve blocks (lumbar facet joint nerve blocks with L5 dorsal ramus block) and 227 receiving lumbar radiofrequency neurotomy. Forty-eight patients in the facet joint nerve block group and 148 patients in the radiofrequency group completed one-year follow-up. Patients experienced significant improvement in both groups from baseline to 12 months with significant pain relief (≥ 50%) Significant pain relief was recorded in 100%, 99%, and 79% of the patients in the facet joint nerve block group, whereas, it was 100%, 74%, and 65% in the radiofrequency neurotomy group at the 3, 6, and 12 month follow-up, with a significant difference at 6 months. Cost utility analysis showed average costs for quality-adjusted life year (QALY) of $4,664 for lumbar facet joint nerve blocks and $5,446 for lumbar radiofrequency neurotomy. Twelve patients (12%) in the lumbar facet joint nerve block group and 79 patients (35%) in the lumbar radiofrequency group were converted to other treatments, either due to side effects or inadequate relief. CONCLUSION: This study shows similar outcomes of therapeutic lumbar facet joint nerve blocks when compared with radiofrequency neurotomy as indicated by significant pain relief and cost utility.