Normality analysis of numeric rating scale scores in patients with chronic axial spine pain before and after medial branch blocks: a multicenter study.

OBJECTIVE: The statistical analysis typically used to compare pain before and after interventions assumes that scores are normally distributed. The present study evaluates whether numeric rating scale (NRS) scores, specifically NRS-11 scores, are indeed normally distributed in a clinically relevant cohort of adults with chronic axial spine pain before and after analgesic intervention. METHODS: Retrospective review from 4 academic medical centers of prospectively collected data from a uniform pain diary administered to consecutive patients after they had undergone medial branch blocks. The pain diary assessed NRS-11 scores immediately before injection and at 12 different time points after injection up to 48 hours. D'Agostino-Pearson tests were used to test normality at all time points. RESULTS: One hundred fifty pain diaries were reviewed, and despite normally distributed pre-injection NRS-11 scores (K2 = 0.655, P = .72), all post-injection NRS-11 data were not normally distributed (K2 = 9.70- 17.62, P = .0001-.008). CONCLUSIONS: Although the results of parametric analyses of NRS-11 scores are commonly reported in pain research, some properties of the NRS-11 do not satisfy the assumptions required for these analyses. The data demonstrate non-normal distributions in post-intervention NRS-11 scores, thereby violating a key requisite for parametric analysis. We urge pain researchers to consider appropriate statistical analysis and reporting for non-normally distributed NRS-11 scores to ensure accurate interpretation and communication of these data. Practicing pain physicians should similarly recognize that parametric post-intervention pain score statistics might not accurately describe the data and should expect articles to utilize measures of normality to justify the selected statistical methods.

[Radiofrequency denervation of the spine and the sacroiliac joint : A systematic literature search according to GRADE with new German S3 guideline]. / Radiofrequenzdenervation der Wirbelsäule und des Iliosakralgelenks : Eine systematische Literaturrecherche nach GRADE mit neuer S3-Leitlinie.

BACKGROUND: This article summarizes the results of the German guideline on radiofrequency denervation of the facet joints and the sacroiliac joint. Evidence on the indications, test blocks and technical parameters are presented. OBJECTIVE: The aim is to avoid overtreatment and undertreatment, which is also of socioeconomic importance. MATERIAL AND METHOD: A systematic evaluation of the literature was carried out according to the grading of recommendations assessment, development and evaluation (GRADE) approach. A multidisciplinary guideline group has developed recommendations and statements. RESULTS: Statements and recommendations were given for 20 key questions. There was an 87.5% consensus for 1 recommendation and 100% consensus for all other recommendations and statements. The guideline was approved by all scientific medical societies involved. Specific questions included the value of the medical history, examination and imaging, the need for conservative treatment prior to an intervention, the importance of test blocks (medial branch block and lateral branch block), choice of imaging for denervation, choice of trajectory, the possibility to influence the size of the lesion, stimulation, the possibility of revision, sedation and decision support for patients with anticoagulants, metal implants and pacemakers and advice on how to avoid complications. CONCLUSION: Selected patients can benefit from well-performed radiofrequency denervation. The guideline recommendations are based on very low to moderate quality of evidence.

Facets of facet joint interventions.

Facet joint (FJ) disease is a common cause of axial low back pain with many minimally invasive image-guided treatment options. This article discusses fluoroscopic and CT-guided intraarticular FJ injections, medial branch (MB) radiofrequency ablation (RFA), and lumbar facet synovial cyst (LFSC) aspiration, rupture, or fenestration. Additionally, the article will highlight medial branch blocks (MBBs) utilized to diagnose facet-mediated pain and to predict outcomes to RFA.

Multiple injections for low back pain: What's the future?

AIMS: To examine the strength of evidence available for multiple facet joint injections (FJIs) and medial branch blocks (MBBs), and to report on the variations in the NHS England framework using the getting it right first time (GIRFT) data. METHODS: Systematic review using patient, intervention, comparison, outcome and study strategy. The literature search using Cochrane, MEDLINE and EMBASE databases using MeSH terms: lumbar spine, spinal injection and facet joint ("Appendix A"). RESULTS: Three studies were identified that investigated the efficacy of multiple FJIs or MBBs. None of these studies reported sustained positive outcomes at long-term follow-up. CONCLUSION: There is a paucity of levels I and II evidence available for the efficacy of multiple FJIs and MBBs in treating low back pain. GIRFT data show a high degree of variation in the use of multiple FJIs, which would not be supported by the literature. These slides can be retrieved under Electronic Supplementary Material.

The Source and the Course of the Articular Branches to the T4-T8 Zygapophysial Joints.

OBJECTIVE: To define the source and the course of the articular branches to the midthoracic zygapophysial ("z") joints. DESIGN: Cadaveric dissection. SETTING: The Gross Anatomy Laboratory of the Duke University School of Medicine. SUBJECTS: Ten human cadaveric thoraces. METHODS: Gross and stereoscopic dissection of dorsal rami T4-T8 was performed bilaterally on 10 adult embalmed cadavers. The medial and lateral branches were traced to their origins from the dorsal rami, and the course of the articular nerves was documented through digital photography. Radio-opaque wire (20 gauge) was applied to the nerves. Fluoroscopic images were obtained to delineate their radiographic course with respect to osseous landmarks. RESULTS: Forty-eight inferior articular branches were identified. Three (6.3%) originated from the medial branch and 44 (91.7%) from the dorsal ramus. One was indeterminate. Fifty-one superior articular branches were identified. Eight (15.7%) originated from the medial branch and 43 (84.3%) from the dorsal ramus. In 12% of cases (6/50), there was side-to-side asymmetry in the origins of the articular branches. Nerves were commonly suspended in the intertransverse space. The articular branches contacted an osseous structure in only 39% of cases. As previously reported, a "descending branch" was not identified in any specimen. CONCLUSIONS: Articular branches to the T4-T8 z-joints have substantial inter- and intraspecimen variability of origin. They typically arise from the dorsal ramus rather than the medial branch and frequently do not contact any osseous structure to allow percutaneous needle placement.

Interventional Pain Treatments in the Management of Oncologic Patients With Thoracic Spinal Tumor-Related Pain: A Case Series.

BACKGROUND: Advanced tumors of the thoracic spine are difficult to treat and can lead to complex pain syndromes. Following conventional oncologic treatments, pharmacologic therapy may be insufficient to manage pain. Minimally invasive interventional procedures offer alternatives to treat malignant thoracic spinal pain. METHODS: Thirteen patients with metastatic disease and poorly controlled thoracic axial and/or radicular pain were identified via a retrospective chart review. Patients were either treated with radiation, surgery, chemotherapy, or a combination of these. Then, the patients were organized into groups based on their diagnoses, anatomical disease locations, symptoms, prior treatments, and interventional pain procedures offered. RESULTS: All cases of intercostal nerve, costotransverse junction, erector spinae plane, and paravertebral blocks resulted in pain relief without any reported complications. A patient who received a thoracic epidural injection had a complete resolution of pain when combined with radiation therapy 2 weeks after the injection. One patient who underwent repeat thoracic epidural injections eventually had an intrathecal pump placement, resulting in reduced opioid usage. Finally, 1 patient who received a thoracic medial branch block with a relief of thoracic axial pain reported greater pain relief with a medial branch nerve cryoablation. CONCLUSION: We propose a treatment algorithm to manage patients with thoracic spinal tumor-related pain. Interventional thoracic axial procedures may be safe and efficacious pain treatments for patients with cancer.

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.

Technique for CT Fluoroscopy-Guided Lumbar Medial Branch Blocks and Radiofrequency Ablation.

OBJECTIVE: The purpose of this study is to describe the procedure for CT fluoroscopy-guided lumbar medial branch blocks and facet radiofrequency ablation. CONCLUSION: CT fluoroscopic guidance allows more-precise needle tip positioning and is an alternative method for performing medial branch blocks and facet radiofrequency ablation.

Detection of Intravascular Injection During Lumbar Medial Branch Blocks: A Comparison of Aspiration, Live Fluoroscopy, and Digital Subtraction Technology.

BACKGROUND CONTEXT: Medial branch blocks may have unrecognized vascular uptake potentially resulting in false- negative results. PURPOSE: To determine the rate of unintended vascular injection of contrast medium during medial branch blocks (MBB) with digital subtraction (DS) technology in the context of negative vascular uptake as determined by live fluoroscopy. STUDY DESIGN/SETTING: Prospective Study in an academic medical center. PATIENT SAMPLE: 344 consecutive MBBs in 80 subjects. OUTCOME MEASURES: The presence of vascular flow as determined by live fluoroscopy and DS technology. METHODS: Unintended vascular injection of contrast medium was determined on 344 consecutive MBBs in 84 subjects, first using live fluoroscopy followed by DS. If live fluoroscopy initially detected vascular uptake, the needle was repositioned until no vascular flow was detected. Once no vascular uptake was confirmed by live fluoroscopy, a contrast medium was then injected while being visualized with DS to again assess the presence or absence of vascular flow undetected by live fluoroscopy. RESULTS: Live fluoroscopy revealed inadvertent vascular uptake in 38 of the 344 blocks [11% (95% CI 8.0-15%)]. DS uncovered an additional 27 of the 344 blocks [7.8% (95% CI 5.3-11.4%)] with evidence of vascular uptake that were not detected with conventional live fluoroscopy. CONCLUSION: DS enhances the ability to detect inadvertent vascular flow during medial branch blocks. This study demonstrates that standard live fluoroscopy can miss a small percentage of cases with unintentional vascular uptake during MBB when compared with DS and may contribute to occasional false-negative responses.

[Interventions on facet joints. Techniques of facet joint injection, medial branch block and radiofrequency ablation]. / Interventionen an Facettengelenken. Techniken der Facettengelenkinjektion, der Blockade des Ramus medianus und der Radiofrequenzablation.

Fluoroscopy-guided interventions on facet joints have been used for decades for the symptomatic management of pain in spinal disorders. A large number of imaging techniques are used to achieve a precise and safe needle placement in interventional procedures. Pulsed fluoroscopy is one of the most widely used and well-accepted tools for these procedures. This article presents a technical overview of commonly used fluoroscopy-guided interventions on the facet joints of the cervical and lumbar spine, such as facet joint injection, blockade of the medial nerve branches and radiofrequency ablation.

A Comparison of Precision and Safety using Three Recognized Ultrasound-Guided Approaches to Cervical Medial Branch Blocks: A Cadaver Study.

BACKGROUND: Ultrasound (US) guidance is widely used for needle positioning for cervical medial branch blocks (CMBB) and radiofrequency ablation, however, limited research is available comparing different approaches. OBJECTIVE: We aimed to assess the accuracy and safety of 3 different US-guided approaches for CMBB. STUDY DESIGN: A cadaveric study divided into ultrasound-guided needle placement and fluoroscopy evaluation stages. SETTING: Department of Pathology, Forensic, and Insurance Medicine, Semmelweis University. METHODS: Sonographically guided third occipital nerve (TON), C3, C4, C5 and C6 medial branch injections and radiology evaluations were performed.The 3 approaches compared were:1. ES (published by Eichenberger-Siegenthaler): US probe in the coronal plane to visualize the cervical articular pillars, needle approach out of the plane, from anterior to posterior.2. Fi (published by Finlayson): US probe in the transverse plane to visualize a cervical articular pillar and its lamina, needle approach in the plane, from posterior to anterior.3. FiM (Modified Finlayson approach): Needles are placed as in Fi, but then adjusted with a coronal view of the cervical articular pillars.Fluoroscopy images were taken and later evaluated, for "crude", "high precision" and "dangerous" placement. RESULTS: One hundred and fifty-five needle placements were assessed (10 were excluded, as no anterior-posterior fluoroscopy images were saved). Interobserver agreement on position of needle placement between the 5 observers was very high; the Fleiss' Kappa was 0.921. For crude placement, no significant differences were identified between various approaches; (77.6%, 79.5%, and 75.6% for the ES, Fi, and FiM respectively). However, for placement in predefined high-precision zones, ES resulted in significantly more success (ES: 42.9%, Fi: 22.7%, and FiM: 24.4%, P = 0.032). Fi and FiM resulted in no dangerous placements, while ES led to the potential compromise of the exiting nerve root and vertebral artery on three occasions. In 10% of the placements, the levels were identified wrongly, with no difference between the various approaches. LIMITATIONS: Feedback from a live patient, may prevent some existing nerve root injections, unlike in a cadaver. Though a higher number of needles were placed in this study than in most available publications, the number is still low at each individual medial branch level. CONCLUSION: Fi proved safer than ES. Fi was equally successful in targeting the articular pillar, however, ES proved the most successful in placing the needle in the center of the articular pillar. Adding another, (coronal) US view to check needle position in FiM did not improve safety or precision. Identifying CMB levels with the US is challenging with all approaches, therefore we still recommend using fluoroscopy for level identification. While there were pros and cons with either procedure, the efficacy findings of previous papers were not replicated on elderly cadavers with arthritic necks.

Accuracy and efficacy of ultrasound-guided puncture (vs. computed tomography-guided) in cervical medial branch blocks for cervicogenic pain: A randomized controlled study.

Cervical medial branch block (CMBB) has been recognized as an effective treatment for cervicogenic pain. Previous studies mostly used ultrasound-guided out-of-plane puncture for CMBB, while this prospective study was designed to investigate the efficacy of ultrasound-guided in-plane puncture, specifically focusing on the new target of CMBB for cervical pain. This study includes two parts: the accuracy study (N = 15, CMBB was completed by ultrasound and confirmed by computed tomography [CT], in which a good distribution percentage of the analgesic solution was observed) and the efficacy study (N = 40, CMBB was completed by ultrasound or CT, while the proportion of pain relief (numerical rating scale) decrease by more than 50% postoperatively was analyzed). The results showed that the good distribution percentage of the analgesic solution was 97.8%. Furthermore, in the early period (30 min and 2 h postoperatively), the proportion of patients with pain relief was lower in the ultrasound group than that in the CT group, especially at 2 h postoperatively (52% vs. 94%). However, at 24 h postoperatively and later, the proportion of patients with pain relief gradually stabilized to about 60%-70%, and lasted for about 2 weeks to 1 month. Therefore, the new target for CMBB, guided by ultrasound in-plane, offers high visibility and accuracy. A single CMBB performed under ultrasound guidance resulted in pain relief comparable to that of a CT-guided procedure (1 day to 1 month postoperatively). This study indicated that CMBB guided by ultrasound in-plane could be regarded as a promising approach for treatment of cervicogenic pain.

Efficacy and Accuracy of Ultrasound Guided Injections in the Treatment of Cervical Facet Joint Syndrome: A Systematic Review.

Background/Objectives: Cervical facet joint syndrome (CFJS) is a frequent cause of neck pain and motor disability. Among the available therapies for CFJS, ultrasound (US)-guided injections are becoming more and more widespread, but the evidence about their accuracy and effectiveness is still debated in the scientific literature. The aim of this systematic review is to assess efficacy, accuracy and feasibility of US-guided cervical facet injections for the related chronic neck pain treatment. Methods: This review was conducted following the preferred reporting items for systematic reviews and meta-analysis 2020 (PRISMA) statement guidelines. The scientific articles were identified through the PubMed, Google Scholar and Cochrane Library databases. Qualitative assessment of the selected studies was carried out using the modified Oxford quality scoring system. Nine studies with a total of 958 patients were included in this review. The risk of bias was assessed using the Cochrane Collaboration tool. The protocol was registered at PROSPERO 2024 (n°CRD42024512214). Results: The results of this review suggest that the US-guided cervical facet injection for CFJS treatment is an effective technique in terms of accuracy (using the lateral technique it ranges from 92% to 98%), and efficiency (it grants pain relief with a decrease in the procedure time and fewer needle passes in comparison with the X-ray-guided technique, which also involves radiation exposure). Conclusions: US-guided injections are a safe and effective method to treat this musculoskeletal disease, granting a high functional recovery and long-lasting pain relief, net of the used drugs. However, these procedures are strictly operator-dependent and require important training to acquire good expertise.

Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline.

STUDY DESIGN: Systematic review of the literature and subsequent meta-analysis for the development of a new guideline. OBJECTIVES: This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure. METHODS: A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. RESULTS: 20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications. CONCLUSION: Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.

Comparative Outcome of Lidocaine Versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study.

OBJECTIVE: This study evaluated the effect of prolonged concordant response and functional clinical improvement between lidocaine and bupivacaine for cervical medial branch block (CMBB) in chronic cervical facet syndrome. METHODS: Sixty-two patients diagnosed with chronic cervical facet syndrome were randomized into either lidocaine or bupivacaine groups. The therapeutic CMBB was performed under ultrasound guidance. Either 2% lidocaine or 0.5% bupivacaine with a volume of 0.5-1 mL per level was injected according to the patient's pain symptoms. The patients, pain assessor, and pain specialist were blinded. The primary outcome was the duration of pain reduction by at least 50%. The Numerical Rating Scale of 0-10 and the Neck Disability Index questionnaire were recorded. RESULTS: There was no significant difference in the duration of 50% and 75% pain reduction and Neck Disability Index between the lidocaine and bupivacaine groups. Lidocaine provided significant pain reduction up to 16 weeks (P < 0.05) and significant improvement in neck functional outcomes up to 8 weeks (P < 0.01) compared to the baseline. While bupivacaine yielded significant pain alleviation for up to 8 weeks for pain upon neck mobilization (P < 0.05) and demonstrated notable improvement in neck function up to 4 weeks (P < 0.01) compared to the baseline. CONCLUSION: CMBB using lidocaine or bupivacaine provided clinical benefits in prolonged analgesic effect and improving neck functions for chronic cervical facet syndrome. Lidocaine illustrated better performance and could be considered a local anesthetic of choice regarding the prolonged concordance response.

Comparative Evaluation of Intraarticular Facet Joint Injection Versus Medial Branch Block in Patients With Low Back Pain: A Randomised Controlled Study.

INTRODUCTION: Lumbar facet joint pain may refer to the back, buttocks, and proximal parts of the lower extremities. Intraarticular facet joint injections, facet joint nerve blocks, or facet joint neurolytic procedures are popular for the management of facet joint pain. MATERIAL AND METHODS: In this prospective, randomised study, 60 patients with a medical evaluation and pain pattern consistent with lumbar facet joint pain were randomly allocated to two groups. Group Ⅰ (n=30) patients were administered fluoroscope-guided lumbar facet joint injection, and group Ⅱ (n=30) patients were administered fluoroscope-guided lumbar facet joint nerve block. The primary objective is to compare the efficacy of both in managing facet joint pain in terms of pain and disability improvement. Secondary objectives were to compare the requirement for repeat injections and parameters related to the block, such as ease of administering the block, and to note the side effects pertaining to either of the blocks. RESULTS: There was a statistically significant improvement in pain score after injection in both groups (p>0.05). The mean pain score in both groups remained less than two at all time intervals throughout the study period (p>0.05) Excellent patient satisfaction was reported by the majority of the patients at different time intervals in both groups. CONCLUSION: Both lumbar facet joint injection and lumbar facet joint nerve block are safe and effective techniques for managing lower back pain patients. Both techniques provide adequate pain relief and disability improvement.

Comparison of Intravascular Uptake Using Touhy or Quincke Needle During Lumbar Medial Branch Block.

BACKGROUND: Inadvertent intravascular injection of local anesthetics can lead to false negative results following a lumbar medial branch block (MBB) performed to diagnose facet joint origin pain. A previous study demonstrated that the type of needle could affect the incidence of intravascular injection rates. OBJECTIVES: The primary endpoint of this study was to compare the incidence of intravascular injection during lumbar MBB between the Quincke and Touhy needles. The secondary endpoint of this study was to compare the injection time, radiation dose, and patient discomfort during lumbar MBB between the needle types. STUDY DESIGN: Prospective randomized trial. SETTING: An interventional pain management practice in South Korea. METHODS: The incidence of intravascular uptake of contrast medium was compared using the Touhy and Quincke needles under real-time fluoroscopy during lumbar MBB. Injection time, radiation dose, and patient discomfort during lumbar MBB were also compared. RESULTS: The incidence of intravascular injection was 21.8% (21/102) in the Touhy needle group and 21.2% (22/99) in the Quincke needle group. The odds ratio for the association between the needle types and intravascular injection was 1.1. The injection time, radiation dose, and patient discomfort during lumbar MBB were similar between the Touhy and Quincke needle groups. LIMITATIONS: This study was performed from L2 to L4 MBB of the unilateral lumbar region. Although the type of needle assigned to the patient was randomized, 3 needles, which are used for 3 levels of MBB, were identical. CONCLUSIONS: The overall incidence rate of intravascular injection during lumbar MBB was nearly 20% under real-time fluoroscopy for both types of needle. Use of the Touhy needle did not reduce the intravascular injection rate nor the injection time, radiation dose, and patient discomfort.

Effect of Opioid Use on Results of Interventional Back Pain Management on Patients With Suspected Face-mediated Chronic Back Pain.

BACKGROUND: Preoperative exposure to opioids has recently shown to be associated with poor outcomes after elective major surgery, but little is known as to how pretreatment opioid use affects results of interventional back pain management. OBJECTIVE: We aimed to determine the effect of pretreatment opioid use on outcomes after interventional pain management procedures on patients with chronic back pain. STUDY DESIGN: A retrospective study. SETTING: Department of Physical Medicine and Rehabilitation at Satakunta Central Hospital (Satasairaala), Finland. METHODS: A high-volume, single-center, quality register analysis was performed on patients who underwent interventional pain management for suspected facet-mediated chronic back pain as a part of a multidisciplinary pain management program. Chronic opioid use was defined as having a concurrent opioid prescription for 90 days. RESULTS: A total of 797 patients underwent an intervention during the study period from August 1, 2019 through December 31, 2020. Pretreatment opioid use was present in 262 patients (33%). Patients with chronic back pain using opioids reported significantly more pain and discomfort before treatment as well as lowered working ability. Facet joint medial branch blocks resulted in significant improvement for both groups directly after the treatment as well as at 2-hours follow-up. However, the nonopioid group reported significantly more improvement at 2-days follow-up as well as at one month follow-up compared to opioid users. Opioid users reported nearly the same pain level at one-month follow-up as they did before treatment. LIMITATIONS: As a single-center analysis, these data may not be generalizable to other institutions. A retrospective study may include inevitable bias. The disease processes themselves may possibly predispose patients to different degrees of opoid use. Although we have identified preoperative opioid use as a risk factor for treatment failure, we were unable to determine the size of the association based on our statistical analysis and sample size. Pain intensity evaluation using the visual analog scale is inevitably subjective. CONCLUSION: Pretreatment opioid use is associated with greater pain discomfort, impairment, and reduced functional ability, as well as poorer long-term effect of interventional back pain treatment at one-month follow-up. In our study, opioid users reported the same positive effects of facet joint nerve blocks immediately after the treatment and 2 hours after the treatment, but a significantly smaller effect at one-month follow-up. This could indicate that opioid use may diminish the effects of pain treatments by affecting relearning, behavioral changes, and central pain modulation. These findings may help providers understand the effect of pretreatment opioid use on patient care, and its implications on hospital and societal costs.

Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta-analysis.

There is great interest in expanding the use of ultrasound (US), but new challenges exist with its application to lumbar facet-targeted procedures. The primary aim of this systematic review and meta-analysis was to determine the risk of incorrect needle placement associated with US-guided lumbar medial branch blocks (MBB) and facet joint injections (FJI) as confirmed by fluoroscopy or computerized tomography (CT). An a priori protocol was registered, and a database search was conducted. Inclusion criteria included all study types. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the National Heart, Lung, and Blood tool for assessing risk bias for observational cohort studies. Pooled analysis of the risk difference (RD) of incorrect needle placement was calculated. Pooled analysis of 7 studies demonstrated an 11% RD (P < 0.0009) of incorrect needle placement for US-guided MBB confirmed using fluoroscopy with and without contrast. Pooled analysis of 3 studies demonstrated a 13% RD (P < 0.0001) of incorrect needle placement for US-guided FJI confirmed using CT. The time to complete a single-level MBB ranged from 2.6 to 5.0 minutes. The certainty of evidence was low to very low. Ultrasound-guided lumbar MBB and FJI are associated with a significant risk of incorrect needle placement when confirmed by fluoroscopy or CT. The technical limitations of US and individual patient factors could contribute to the risk of incorrect needle placement.

The positive prediction of single photon emission computed tomography/ computed tomography (SPECT/CT) in the outcome of intervention for cervical facet pain.

BACKGROUND CONTEXT: Previous studies have reported that magnetic resonance imaging (MRI) and computed tomography (CT) do not predict response to facet blocks. However, single photon emission computed tomography (SPECT) uptake within facet joints has been shown to correlate with pain relief after intervention in the lumbar spine. There is minimal data regarding the predictive value of single photon emission computed tomography/computed tomography (SPECT/CT) for neck pain. PURPOSE: The aim of this study was to evaluate the utility of SPECT/CT in patients with axial neck pain for the identification of specific facet joints that would benefit from diagnostic and therapeutic facet joint steroid injections and/or medial branch block/RFA treatments. STUDY DESIGN: A retrospective cohort study. PATIENT SAMPLE: One hundred seventy-nine patients at a single institution pain center with neck pain and a SPECT/CT scan between 2009 and 2015. One hundred twelve patients had no prior intervention at the level of interest and met inclusion criteria. OUTCOME MEASURES: Pain reduction at 50% and 80% thresholds within 24 hours of facet intervention. Concordance of facet intervention with the focus of maximal uptake on SPECT/CT scan. METHODS: All patients were referred to our institution's Center for Pain Medicine and were treated with facet interventions. The site of facet intervention was determined by pain center providers based on their clinical examination and interpretation of images. Groups were formed based on whether the facet intervention included the level of maximal uptake on SPECT/CT scan. A positive response to intervention was defined at both 50% and 80% thresholds for reduction in pain within 24 hours of facet injection with steroid and local anesthetic or medial branch block with local anesthetic only. These were the facet interventions used for our data collection. A Chi-square statistic was used to analyze categorical data and a Student's t-test was used to analyze non-categorical data. SPSS (IBM Corp. IBM SPSS Version 24.0) was used for all analyses. RESULTS: Of our 112 patients, Group 1 consisted of 89 with an intervention occurring at the level with increased uptake on SPECT/CT. Group 2 consisted of 23 patients with an intervention at a level without uptake on SPECT/CT. Demographic data did not significantly differ between cohorts. A Chi-square test of independence demonstrated that intervention at a level concordant with SPECT/CT was significantly correlated with self-reported pain relief thresholds of both 50% and 80% (p=.0002). CONCLUSIONS: Facet interventions based on SPECT/CT scan uptake were more successful in pain reduction than those which were not. This suggests a role for SPECT/CT in diagnosing therapeutic targets for neck pain.