Athrodesis of the lateral atlanto-axial joint for the relief of neck pain and cervicogenic headache.

BACKGROUND: Osteoarthrosis of the lateral atlanto-axial joint (LAAJ) may be a cause of upper neck pain and headache. Intra-articular injection of steroids may provide only short-lasting relief. For intractable pain, arthrodesis of the joint might be considered. OBJECTIVE: To determine the success rates of arthrodesis of the lateral atlanto-axial joint for relieving neck pain and disability. DESIGN: Practice audit. SETTING: Private practice of senior author. SUBJECTS: Prospective series of 23 consecutive patients. METHODS: Outcomes were measured using a numerical rating scale for neck pain, and the Neck Disability Index for disability. Success rates were calculated for various degrees of improvement of neck pain at long-term follow-up (8-40 months), and for achieving various combinations of improvement of both neck pain and disability. RESULTS: Complete relief of pain was achieved in 40% of patients, with a further 40% achieving at least 50% relief. At long-term follow-up, 30% of patients had no neck pain and no disability, and a further 25% had only minimal pain, minimal disability, or both. CONCLUSIONS: The present study did not corroborate earlier studies that claimed outstanding outcomes for arthrodesis of the LAAJ, but its outcomes are consonant with more recent studies that provided transparent outcome data. These studies provide Pain Physicians with empirical data on success rates and outcomes, upon which they can base their consideration of referral for arthrodesis.

Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints.

OBJECTIVES: The study sought to assess the utility of controlled diagnostic blocks in patients with probable cervicogenic headache by determining the prevalence of sources of pain among the upper and lower synovial joints of the cervical spine. METHODS: Controlled diagnostic blocks were performed in 166 consecutive patients who clinically exhibited features consistent with a diagnosis of probable cervicogenic headache. Data were collected on how often a particular source of pain could be pinpointed and how often particular diagnostic blocks provided a positive yield. RESULTS: In patients in whom headache was the dominant complaint, diagnostic blocks succeeded in establishing the source of pain in 75% of patients. The C2-3 joint was the source of pain in 62%, followed by the C1-2 (7%) and C3-4 (6%). In patients in whom headache was less severe than neck pain, blocks were successful in 67%. C2-3 was the source of pain in 42%, followed by lower cervical joints in 18% and the C3-4 joint in 7%. CONCLUSIONS: Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2-3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2-3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint.

The Prevalence of "Pure" Lumbar Zygapophysial Joint Pain in Patients with Chronic Low Back Pain.

BACKGROUND: Estimates of the prevalence of lumbar zygapophysial joint (Z joint) pain differ in the literature, as do case definitions for this condition. No studies have determined the prevalence of "pure" lumbar Z joint pain, defined as complete relief of pain following placebo-controlled diagnostic blocks. OBJECTIVE: The objective of this study was to estimate the prevalence of "pure" lumbar Z joint pain. METHODS: In a private practice setting, 206 patients with possible lumbar Z joint pain underwent controlled diagnostic blocks using one of two protocols: placebo-controlled comparative blocks and fully randomized, placebo-controlled, triple blocks. RESULTS: In the combined sample, the prevalence of "pure" lumbar Z joint pain was 15% (10-20%). CONCLUSIONS: The prevalence of "pure" lumbar Z joint pain is substantially and significantly less than most of the prevalence estimates of lumbar Z joint pain reported in the literature.

The Effectiveness of Cervical Medial Branch Thermal Radiofrequency Neurotomy Stratified by Selection Criteria: A Systematic Review of the Literature.

OBJECTIVE: To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria. DESIGN: Comprehensive systematic review. METHODS: A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. OUTCOME MEASURES: The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief. RESULTS: Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. CONCLUSIONS: Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief.

Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique.

OBJECTIVE: To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques. DESIGN: Comprehensive systematic review. METHODS: A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. OUTCOME MEASURES: The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes. RESULTS: Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique-two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement-resulted in 56% of patients experiencing 100% relief of pain at six months. CONCLUSIONS: This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.

Update of a Study of Not Ceasing Anticoagulants for Patients Undergoing Injection Procedures for Spinal Pain.

OBJECTIVES: To determine prevalence rates of hemorrhagic complications in patients who either ceased or continued anticoagulants during interventional pain procedures. METHODS: A total of 1,936 consecutive patients were prospectively monitored during a total of 12,723 injection procedures. The prevalence of hemorrhagic complications was tallied for a variety of procedures performed on patients who ceased or continued various anticoagulants. RESULTS: No hemorrhagic complications occurred in any patient who continued anticoagulants. Sufficiently large sample sizes were obtained to conclude that, in patients who continued warfarin or clopidrogel during lumbar transforaminal injections and for lumbar facet procedures, the zero prevalence of complications had 95% confidence intervals of 0% to 0.3%. This prevalence was significantly lower than the risk of medical complications in patients who ceased warfarin. CONCLUSIONS: Lumbar transforaminal injections and lumbar facet injections have a very low rate of hemorrhagic complications when patients continue to take anticoagulants.

The Costs of Confronting Osteoporosis: Cost Study of an Australian Fracture Liaison Service.

Fracture liaison services (FLS) are an accepted approach to lowering rates of osteoporotic refractures. However, resource allocations to FLS are open to challenge, as most relevant cost analyses are based on anticipated, rather than observed, benefits. To support informed decision making, we have estimated the cost of operating an FLS, from the perspective of the Australian health system, with real life costs. On the basis of hospital records, we compared total costs of two cohorts of patients presenting with minimal trauma fractures (MTFs) at two hospital emergency departments (EDs) across a 6-month period (July to December 2010). The treatment cohort (FLS Cohort, n = 515) attended an ED at a hospital offering FLS post-fracture care; the Usual Care Cohort (n = 416) attended an ED at a hospital without an FLS. Hospital records were reviewed for further attendance of both groups at their respective hospitals' EDs with refractures for the subsequent 3 years. Costs were constructed from "bottom up" with a "microcosting" approach. Total costs for both cohorts included any FLS and the costs of refractures. Cohort costs were estimated for every 1000 patients over the 3 observed years. Compared with the Usual Care Cohort, the FLS Cohort had 62 fewer fractures per 1000 patients and $617,275 lower costs over 3 years. In a sensitivity analysis, where 20% of the Usual Care Cohort received FLS preventative treatment, FLS Cohort costs were lower by $880,154. As both hospitals consistently process around 2000 patients per year, the estimated annual saving is $1.2 million to $1.8 million (Australian dollars). From the perspective of the Australian public health system, investment in FLS can be a financially effective way of reducing the cost of osteoporotic fracture management.

Cervical Discs as a Source of Neck Pain. An Analysis of the Evidence.

OBJECTIVESBACKGROUND: Objectives To determine the extent and strength of evidence that supports the belief that cervical intervertebral discs are a source of neck pain. DESIGN: Design The evidence from anatomical, laboratory, experimental, diagnostic, and treatment studies was summarized and analyzed for concept validity, face validity, content validity, and construct validity. RESULTS: Results Evidence from basic sciences shows that cervical discs have a nociceptive innervation, and experimental studies show that they are capable of producing neck pain. Disc stimulation has been developed as a diagnostic test but has rarely been used in a disciplined fashion. The prevalence of cervical disc pain has not been properly established but appears to be low. No treatment has been established that reliably achieves complete relief of neck pain in substantial proportions of patients. CONCLUSIONS: Conclusions Basic science evidence supports the concept of cervical disc pain, but epidemiologic and clinical evidence to vindicate the clinical application of the concept is poor or lacking.

Neck-Tongue syndrome: A systematic review.

Objective Neck-Tongue syndrome (NTS) is characterized by brief attacks of neck or occipital pain, or both, brought out by abrupt head turning and accompanied by ipsilateral tongue symptoms. As the disorder is rare, we undertook a systematic review of the literature to identify all reported cases in order to phenotype clinically the disorder and subsequently inform clinical diagnostic criteria. Methods Two electronic databases were searched using the search term "neck tongue syndrome". All English language references were reviewed in full. Cases were abstracted using a standardized abstraction form and the references of the retrieved articles were reviewed by hand to identify additional references and cases. Conference proceedings from recent headache meetings were searched. We also report six new cases from our centers. Results There were 39 primary cases, 56% of which were female. Mean age (SD) at onset was 16 (12) years. Twenty (53%) experienced neck pain, seven (18%) occipital pain, and 11 (29%) both. Pain was most often sharp or stabbing and severe, lasting several seconds to several minutes. Eleven experienced numbness and/or tingling in the neck/occiput following the pain. Thirty-six had an accompanying tongue sensory disturbance and three a motor/posture disturbance; five had both. Thirteen had other headaches, and four a family history of Neck-Tongue syndrome. Conclusions Neck-Tongue syndrome typically has pediatric or adolescent onset, suggesting that ligamentous laxity during growth and development may facilitate transient subluxation of the lateral atlantoaxial joint with sudden head turning. Familial cases suggest a genetic predisposition in some individuals. Neck-Tongue syndrome should be re-instated in the International Classification of Headache Disorders.

Guidelines for Composing and Assessing a Paper on Treatment of Pain.

Authors, readers, and editors share a common focus. Authors want to publish their work. Readers want to see high-quality, new information. Referees and editors serve to ensure that authors provide valid conclusions based on the quality of information that readers want.Common to each of these roles are instructions to authors. However, these are typically written in an uninspiring, legalistic style, as if they are a set of rules that authors must obey if they expect to get published. This renders the instructions boring and oppressive, if not forbidding. Yet they need not be so, if they are set in context.Instructions to authors can be cast in a way as to reflect common purpose. They can remind authors what perceptive readers want to see in a paper and, thereby, prompt authors to include all necessary information. If cast in this way, instructions to authors are not a set of rules by which to satisfy publishers; they become guidelines for the etiquette of communication between authors and their readers.Against this background, the present article has been composed to serve several purposes. Foremost, it amplifies instructions to authors beyond the conventional technicalities such as headings, layout, font size, and line spacing. It prescribes the type of information that should be communicated and explains the reasons for those recommendations. Doing so not only informs authors about what to write, but also informs readers and referees about what to look for in a good paper. Secondarily, the article publicizes examples of errors and deficiencies of manuscripts submitted to the Journal in the past that have delayed their acceptance and publication, which could have been avoided had the forthcoming recommendations been followed. The recommendations also reprise the elements taught in courses conducted by the Spine Intervention Society in their extended program on evidence-based medicine. Doing so underscores that instructions for authors are not a procedural technicality but a way to ensure that what authors write, what readers read, and what the Journal publishes comply with contemporary precepts of good evidence.Some 20 years ago, the Journal of the American Medical Association published a comprehensive series of articles with a common title: "Users' Guides to the Medical Literature" [1,2]. These articles focused on the science of statistical tests and critical appraisal, and their importance for properly understanding the literature. The present article differs in that it does not presume to teach technicalities. Instead, it describes and explains, step by step, the critical components of an article, what authors should include, and what readers should look for, so that the Journal can ensure that consistent, high-quality information is shared between its authors and readers.The present article focuses on articles concerning treatment of pain, largely because this type of article is more commonly submitted than articles on reliability or validity of diagnostic procedures. Although the present article principally focuses on papers for the Spine Section of the Journal, the same principles, appropriately adapted, serve for other sections.