Fluoroscopically guided caudal epidural steroid injections for axial low back pain associated with central disc protrusions: a prospective outcome study.

PURPOSE: To determine if axial low back pain (LBP) associated with central disc protrusions can be improved by caudal epidural steroid injections (ESIs). METHODS: Adults with chronic (> 3 months) moderate-to-severe axial LBP with L4-5 and/or L5-S1 central disc protrusions were enrolled in this prospective study. Participants underwent caudal ESIs under standard-of-care practice. The numerical rating scale (NRS) pain score, modified North American Spine Society satisfaction, and Roland Morris Disability Questionnaire (RMDQ) were collected at one week, one month, three months, six months, and one year post-injection. Pre-injection magnetic resonance images were assessed by a musculoskeletal radiologist. RESULTS: Sixty-eight participants (42 males, 26 females) were analyzed. There were statistically significant improvements in all outcome measures at all follow-up time points, with the exception of NRS best pain at six months. Clinically significant improvements in outcomes were observed at various time points: at three months and one year for current pain; at one week, one month, three months, six months, and one year for worst pain; and at one month and one year for RMDQ. The proportion of satisfied participants ranged from 57 to 69% throughout the study. No adverse events were observed. CONCLUSIONS: This study demonstrated significant improvements in pain and function following caudal ESIs in a cohort of axial LBP with associated central disc protrusions. Further studies, including the use of randomized controlled trials, are needed to determine the ideal subset of candidates for this treatment and to explore additional applications that caudal ESIs may have for chronic LBP.

Intradiscal Leukocyte Rich Platelet Rich Plasma for Degenerative Disc Disease.

If we could choose a single non-fatal medical condition to find a better solution that would make the greatest impact on global health it would be a solution for degenerative disc disease (DDD) - the number one cause of chronic low back pain (CLBP).

Risks of Intradiscal Orthobiologic Injections: A Review of the Literature and Case Series Presentation.

BACKGROUND: Intervertebral disc disease (IDD) is responsible for a large portion of back pain with historically suboptimal treatments for long-term improvement. IDD pathogenesis is thought to arise at a cellular and biochemical level, making biologically based injections an area of clinical interest. Although human studies have shown promise, emerging data suggest there may be risks inherent to such injections that were previously unrecognized. The aim of this review is to summarize the known risks to date and provide mitigation steps to reduce potential complications in the future. In addition, we present a small case series of serious adverse events (SAEs) from our clinical practice. METHODS: A literature review was performed to identify human intradiscal autologous biologic injection studies to date, including mesenchymal signaling cells (MSCs) and platelet-rich plasma (PRP) preparations, which were reviewed for complications. Cases of complication following intradiscal orthobiologic injection were identified from a single outpatient center and reviewed. RESULTS: Publications of MSC-based intradiscal injection documented 136 total patients treated with two SAEs reported, one infection and one progressive disc herniation. Publications of PRP intradiscal injection included 194 patients with one SAE reported. We also review three cases of previously unpublished SAEs, including one case of confirmed infection with Cutibacterium acnes (C acnes) and two presumed cases of discitis without pathogen confirmation. Bone marrow concentrate was the injectate in all three cases. CONCLUSIONS: Although biologic intradiscal injection shows promise for the treatment of discogenic back pain, there are inherent risks to be considered and mitigated. We currently recommend a leukocyte-rich PRP and a two-needle delivery technique coupled with intradiscal gentamicin to mitigate the risk of postinjection spondylodiscitis. Further research is needed using large registries to not only track clinical outcomes but also complication rates.

A retrospective analysis of a commercially available platelet-rich plasma kit during clinical use.

INTRODUCTION: Point-of-care analyses of platelet-rich plasma (PRP) are not routine in the orthopedic regenerative medicine field. Therefore, many physicians rely on the manufacturer's reported content for commercial preparation kits. This contributes to a knowledge gap between injectate content and patient outcome. OBJECTIVE: To assess whether the EmCyte PurePRP II 60-mL preparation kit returns PRP content that meets the manufacturer's expectations when used during routine clinical care for a heterogenous patient population, and to determine whether a change in PRP yield volume affects injectate content. Protocol A (exclusion of granulocytes and low hematocrit) and Protocol B (inclusion of granulocytes and higher hematocrit) were evaluated. DESIGN: Retrospective review. SETTING: Private practice. PARTICIPANTS: One hundred five patients (118 preparations) treated for orthopedic conditions over an 8-month period via PRP injection. Thirteen patients had two independently made preparations on different treatment days that qualified for analysis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Complete blood count (absolute counts and calculated fold enrichment from baseline of platelets, white blood cells, red blood cells, granulocytes, lymphocytes, monocytes; and hematocrit levels). Confounding variables included age, gender, and preparation yield volume. RESULTS: During routine clinical use, the cellular content of both Protocols A and B met or exceeded the manufacturer's expectations of platelet enrichment and granulocyte inclusion or exclusion. Hematocrit values were slightly higher than anticipated from Protocol A preparations. The modification of yield volume from 7 to 4 mL led to a significant difference in platelet enrichment without affecting absolute cell counts (2.88; 95% confidence interval [CI] 1, 4.76; P = .003). Both gender and age moderately affected the level of platelet enrichment from baseline but did not significantly affect absolute platelet counts. CONCLUSION: In the absence of widespread characterization, confirming the variation in commercial PRP kits during clinical use is crucial.

Treatment of symptomatic degenerative intervertebral discs with autologous platelet-rich plasma: follow-up at 5-9 years.

Aim: This study assessed pain and function at 5-9 years postinjection in a subset of patients who received intradiscal platelet-rich plasma (PRP) injections for moderate-to-severe lumbar discogenic pain. Patients & methods: All patients received injections of intradiscal PRP in a previous randomized controlled trial. Data on pain, function, satisfaction, and need for surgery were collected at one time point of 5-9 years postinjection and compiled with existing data. Results: In comparison to baseline, there were statistically significant improvements in pain and function (p < 0.001). All improvements were clinically significant. Six patients had undergone surgery during the follow-up period. Conclusion: This subset of patients demonstrated statistically and clinically significant improvements in pain and function at 5-9 years postinjection.

Optimizing the safety of intradiscal platelet-rich plasma: an in vitro study with Cutibacterium acnes.

Aim: The most common risk associated with intradiscal injection of platelet-rich plasma (PRP) is discitis with Cutibacterium acnes. It is hypothesized that antimicrobial activity of PRP can be enhanced through inclusion of leukocytes or antibiotics in the injectate. Materials & methods: Multiple PRP preparations of varying platelet and leukocyte counts were co-cultured with C. acnes with or without cefazolin, with viable bacterial colony counts being recovered at 0, 4, 24 and 48 hours post-inoculation. Results: A direct correlation between C. acnes recovery and granulocyte counts were observed. Conclusion: We observed the greatest antimicrobial activity with the leukocyte-rich, high platelet PRP preparation combined with an antibiotic in the injectate. However, cefazolin did not completely clear the bacteria in this assay.

Percutaneous Rupture of Zygapophyseal Joint Synovial Cysts: A Prospective Assessment of Nonsurgical Management.

BACKGROUND: Although lumbar zygapophyseal joint synovial cysts are fairly well recognized, they are an uncommon cause of lumbosacral radicular pain. Nonoperative treatments include percutaneous aspiration of the cysts under computed tomography or fluoroscopic guidance with a subsequent corticosteroid injection. However, there are mixed results in terms of long-term outcomes and cyst reoccurrence. This study prospectively evaluates percutaneous ruptures of zygapophyseal joint (Z-joint) synovial cysts for the treatment of lumbosacral radicular pain. OBJECTIVES: Primary: To determine whether percutaneous rupture of symptomatic Z-joint synovial cysts leads to sustained improvements in radicular pain and function. Secondary: To assess the rates of cyst recurrence and progression to surgical intervention following percutaneous rupture of symptomatic Z-joint synovial cysts. DESIGN: Prospective cohort study. SETTING: Outpatient academic spine practice. PARTICIPANTS: Adults with primary radicular pain due to a facet synovial cyst. METHODS: Participants underwent fluoroscopically guided percutaneous Z-joint synovial cyst ruptures under standard-of-care practice. Data on pain, physical function, satisfaction, and progression to surgery were collected at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after rupture. An intention-to-treat analysis was used for assessment of patient-reported outcome measures. MAIN OUTCOME MEASURES: The Numerical Rating Scale, Oswestry Disability Index, and modified North American Spine Society questionnaires were used to measure pain, function, and satisfaction with the procedure, respectively. RESULTS: Thirty-five participants were included in the study, and data were analyzed by an independent researcher. Statistically significant changes in Oswestry Disability Index were reported at 2 weeks, 3 months, and 1 year postintervention (P = .034, .040, and .039, respectively). A statistically and clinically significant relief of current pain was reported at 2 weeks (P = .025) and 6 weeks (P = .014) with respect to baseline. Patients showed significant improvements for best pain at 6 weeks with respect to baseline (P = .031). Patients' worst pain showed the greatest amount of improvement with clinically meaningful changes at all time points compared with baseline. Patient-reported satisfaction was found nearly 70% of the time at all time points. Forty percent (14/35) of participants required repeat cyst rupture, and 31% (11/35) required surgical interventions. CONCLUSIONS: There were statistically and clinically significant improvements in pain and function after percutaneous rupture of Z-joint synovial cysts. In addition, the outcomes support previous retrospective studies indicating that approximately 40% of patients will need surgery. This study provides further research to determine the utility of this procedure and to precisely define a subset of ideal candidates. LEVEL OF EVIDENCE: Level II.

Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study.

OBJECTIVE: To determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain and function. DESIGN: Prospective, double-blind, randomized controlled study. SETTING: Outpatient physiatric spine practice. PARTICIPANTS: Adults with chronic (≥6 months), moderate-to-severe lumbar diskogenic pain that was unresponsive to conservative treatment. METHODS: Participants were randomized to receive intradiskal PRP or contrast agent after provocative diskography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at 8 weeks were offered the option to receive PRP and subsequently followed. MAIN OUTCOME MEASURES: Functional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey, and the modified North American Spine Society (NASS) Outcome Questionnaire were used. RESULTS: Forty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow-up rate. Over 8 weeks of follow-up, there were statistically significant improvements in participants who received intradiskal PRP with regards to pain (NRS Best Pain) (P = .02), function (FRI) (P = .03), and patient satisfaction (NASS Outcome Questionnaire) (P = .01) compared with controls. No adverse events of disk space infection, neurologic injury, or progressive herniation were reported following the injection of PRP. CONCLUSION: Participants who received intradiskal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared with controls. Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up. Although these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP injectate.

Lumbar intraspinal synovial cysts: conservative management and review of the world's literature.

BACKGROUND CONTEXT: Lumbar intraspinal synovial cysts are an important cause of axial and radicular spine pain. Controversy about nonsurgical versus surgical treatment persists. PURPOSE: To evaluate the efficacy of nonsurgical management of symptomatic lumbar intraspinal synovial cysts (LISCs). STUDY DESIGN/SETTING: Retrospective review set in outpatient physiatry office. PATIENT SAMPLE: Ten patients (8 women, 2 men; average age, 60 years) with LISCs and average symptom duration of 7.9 months. OUTCOME MEASURES: Numerical pain rating scale (NRS-11), Roland-Morris disability outcome measure, patient satisfaction, and surgery. METHODS: Patients with LISCs were identified and their charts were reviewed. Those patients whose symptoms correlated with the level of LISC-induced extradural compression were eligible. All patients received conservative care and a fluoroscopic-guided lumbar spine injection. The primary author conducted telephone follow-up. RESULTS: All 10 patients had unilateral radicular pain. Seven had stable neurologic deficits. Magnetic resonance imaging and computed tomography/myelography, respectively, identified a LISC in 8 and 2 patients. Five patients had cyst aspiration followed by steroid instillation; 5 patients had cyst aspiration followed by a transforaminal epidural steroid injection. Average length of follow-up was 50.4 weeks. Only 1 patient had sustained benefit. One patient had no benefit and refused surgery. Eight patients underwent surgery and had a good result. CONCLUSION: In our opinion, nonsurgical management in patients with LISC-induced radicular pain does not appear to be as successful as surgery.

Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a restrospective evaluation of long term efficacy.

BACKGROUND: Degenerative lumbar spinal stenosis is a frequent cause of disability in the elderly population. Epidural steroid injections are a commonly used conservative modality in the treatment of patients with degenerative lumbar spinal stenosis. Relatively few studies have specifically addressed the efficacy of epidural steroid injections for spinal stenosis, with success rates varying from 20% to 100%. OBJECTIVE: To assess the efficacy of fluoroscopically guided caudal epidural steroid injections in the management of degenerative lumbar spinal stenosis. DESIGN: Retrospective chart review and follow-up study. METHODS: All the patients who had undergone at least one fluoroscopically guided caudal epidural steroid injection between 1995 and 2002 were reviewed. All of the caudal epidural steroid injections were done with fluoroscopic guidance. MAIN OUTCOME MEASURES: Visual Numeric Scale (VNS), Roland-Morris Disability Questionnaire (RMDQ), North American Spine Society Patient Satisfaction Index (NASS), and subsequent surgery. RESULTS: Ninety-five patients selected from chart review met inclusion criteria. Eighty (84%) completed the follow-up questionnaire by mail or telephone interview. Patients received an average of 1.6 epidural steroid injections. Twelve patients subsequently underwent surgical procedures. A VNS improvement of 50% or greater was seen in 35% of patients. A functional improvement of 2 points or greater was seen on the RMDQ in 36% of patients. Long-term success of treatment was seen in 35% of patients. The concurrent presence of degenerative spondylolisthesis was the only variable which was found to have a significant positive correlation with successful outcomes (P < 0.009). CONCLUSION: Caudally placed fluoroscopically guided epidural steroid injections offered a safe, minimally invasive option for managing pain caused by lumbar spinal stenosis. The concurrent presence of degenerative spondylolisthesis appears to be an independent positive prognostic factor for successful outcome.

Effectiveness of transforaminal epidural steroid injections in patients with degenerative lumbar scoliotic stenosis and radiculopathy.

BACKGROUND: The use of epidural steroid injections as a treatment for patients with degenerative lumbar scoliotic spinal stenosis and radiculopathy has received sparse attention in the literature. Even though it has been reported that patients with scoliosis may respond differently than other patient groups to conservative therapeutic interventions for low back pain and radiculopathy, patients with scoliosis have rarely, if ever, been excluded from clinical studies of epidural steroid injections. To date, there are no studies investigating the efficacy of fluoroscopic transforaminal epidural steroid injections as a treatment for patients with radiculopathy and radiographic evidence of degenerative lumbar scoliotic stenosis. OBJECTIVE: To evaluate the effectiveness of fluoroscopically guided transforaminal epidural steroid injections as a conservative treatment for patients with degenerative lumbar scoliotic stenosis and radiculopathy. DESIGN: Retrospective case series. METHODS: The study was performed in an academic outpatient physical medicine and rehabilitation spine practice. Participants included 61 patients with radiographic evidence of degenerative lumbar scoliotic stenosis and radiculopathy. Patients who had undergone at least one fluoroscopic-guided transforaminal epidural steroid and anesthetic injection were included. MAIN OUTCOME MEASURES: Numeric Rating Scale (NRS) for worst pain experienced, North American Spine Society (NASS) satisfaction scale, amount of pain medication used, and adapted Stucki questionnaire to assess function and pain status. RESULTS: We obtained follow-up on 52 (85.2%) of 61 included patients. We defined a successful outcome as a patient who was both satisfied with his or her results and experienced at least a 2-points improvement in NRS, Summary Pain, and Summary Function scores. Using these criteria for success, 59.6% of our patients had a successful outcome at one week post-injection, 55.8% at one month post-injection, 37.2% at one year post-injection, and 27.3% had a successful outcome at two years post-injection (p < 0.01). CONCLUSION: Fluoroscopic transforaminal epidural steroid injections appear to be an effective nonsurgical treatment option for patients with degenerative lumbar scoliotic stenosis and radiculopathy and should be considered before surgical intervention.

Histologic characterization of coblation nucleoplasty performed on sheep intervertebral discs.

OBJECTIVE: To characterize the histologic effects of coblation nucleoplasty on sheep intervertebral discs. DESIGN: In vitro histologic study. METHODS: Five sheep lumbar discs treated with nucleoplasty and two control discs were evaluated. Specimens were received frozen and thawed to room temperature. A segment consisting of the intervertebral disc and vertebral body above and below the disc was dissected. Using a posterolateral approach, a Perc-DLE SpineWand attached to a standard radiofrequency power generator was bluntly advanced to the annulonuclear junction of each disc. The SpineWand was advanced initially in cauterization mode 8mm into the disc and withdrawn in coagulation mode. The SpineWand was reinserted 8mm into the disc and secured in place. The specimens were fixed in 10% buffered formalin for 1-2 weeks. They were then decalcified in 10% ethylenediaminetetraacetic acid (EDTA) and embedded in paraffin. Specimens were subsequently stained with H & E, Alcian Blue, and Trichrome stain. They were examined under light microscopy and polarized light. RESULTS: There were no gross changes in disc appearance. In the experimental disc, the fenestration created by the procedure left a 1mm diameter hollow channel through which tissue was cauterized leaving little visible debris or residual material. In the area immediately surrounding the channel, the fibrocartilage cells and the collagen matrix arrangement remained intact and resembled the control untreated disc tissue. There was no loss or re-distribution of proteoglycans, no alterations in collagen orientation, nor any indication of damage to the matrix surrounding the probe channel. CONCLUSION: Radiofrequency nucleoplasty creates a hollow channel leaving surrounding soft tissue intact in the immediate post-procedure period. In vivo studies will be necessary to delineate the longitudinal histologic effects of radiofrequency nucleoplasty on discs.

Are fluoroscopic caudal epidural steroid injections effective for managing chronic low back pain?

OBJECTIVE: This study sought to determine the efficacy of fluoroscopic caudal epidural steroid injections as a conservative treatment in patients with presumably chronic lumbar discogenic pain. SUMMARY OF BACKGROUND DATA: Epidural steroid injections have been used in the treatment of lumbar radicular pain with success. However, despite their widespread use, there are few, if any, reports of the efficacy of Epidural steroid injections in patients with predominantly axial lumbar pain. Prior studies have been limited by the use of non-fluoroscopically guided injections and failing to apply a specific injection approach (i.e. transforaminal, interlaminar, or caudal) to a specific patient population. METHODS: Ninety-seven patients with chronic axial low back pain and Magnetic Resonance Imaging evidence of disc pathology without stenosis were selected from chart review. All patients received at least one fluoroscopically guided caudal epidural injection with 12 mg of betamethasone and 8 cc of 0.5% lidocaine. Collected follow-up information included Roland-Morris Disability, Visual Numeric Pain Scale, and patient satisfaction scores. RESULTS: Only nineteen patients (23%) were determined to have a successful long- term (> 1 year) outcome and 65 (77%) were deemed failures. Average follow-up was 28.6 +/- 15.6 months. Successes were found to differ significantly from failures in pre-injection pain scores and patient satisfaction. Overall patient satisfaction was 45%. CONCLUSION: At greater than two year follow-up, the efficacy of fluoroscopically guided caudal epidural steroid injections in patients with chronic lumbar discogenic pain is poor. Patient satisfaction exceeds the reported rate of efficacy. Patients responding to injection have significantly lower pre-injection pain scores.

Intradiscal electrothermal therapy (IDET) for treatment of chronic lumbar discogenic pain: a minimum 2-year clinical outcome study.

OBJECTIVE: To determine the long-term efficacy of IDET in the treatment of chronic lumbar discogenic pain. DESIGN: Prospective case series clinical outcome study. METHODS: IDET was performed on 62 consecutive patients with chronic discogenic pain of greater than 6 months duration and consecutively enrolled in a non-randomized prospective case series outcome study. Outcome measures included visual numeric pain scale (VNS) for low back (LB) and lower extremity (LE) pain, Roland-Morris disability scale (RM), and North American Spine Society (NASS) patient satisfaction index. Outcome success was defined as a change of more than 2 points on VNS and RM as well as a positive NASS satisfaction response. Data were collected at baseline and post-procedure at 1, 3, and 6 months and then annually for up to 4 years. RESULTS: Fifty-one out of 62 patients (82%) were available for a minimum of 2-year follow-up. Average age was 41.4 years; average symptom duration was 46 months; and average follow-up was 34 months. Overall, there was statistically significant improvement in LB-VNS, RM, and LE pain scores of 3.2, 6.6, and 2.3 (p<0.001), respectively. Twenty-seven of 51 (53%) patients demonstrated clinically significant VNS and RM improvements of greater than 2. On NASS index, 63% (32/51) responded positively. Neither the number of disc levels treated nor the insurance status of patients made any difference in outcome. CONCLUSION: IDET appears to be an effective treatment for chronic lumbar discogenic pain in a well-selected group of patients with favorable long-term outcome.

Role of radiofrequency denervation in lumbar zygapophyseal joint synovitis in baseball pitchers: a clinical experience.

Lumbar zygapophyseal joints have long been considered a source of low back pain with or without leg pain. The objective of this prospective study was to investigate the therapeutic effectiveness of lumbar zygapophyseal joint radiofrequency denervation (RFD) followed by physical therapy, for the treatment of refractory lumbar zygapophyseal joint mediated low back pain secondary to lumbar zygapophyseal joint synovitis, in baseball pitchers. Participants included twelve male baseball pitchers with a diagnosis of lumbar zygapophyseal joint synovitis mediated low back pain and a subsequent difficulty in pitching. These athletes underwent a trial of treatment, including oral anti-inflammatory medication, physical therapy, osteopathic manipulations, and fluoroscopically guided intra-articular zygapophyseal joint injection utilizing steroid and local anesthetic agent. Failure to progress led to these athletes receiving percutaneous, fluoroscopically-guided, radiofrequency denervation of the bilateral L 4-L5 and L5-S1 zygapophyseal joints. A good response to a diagnostic medial branch block was a prerequisite for RFD treatment. In all cases, the medial branch above and below the involved level was treated. Post procedure, all athletes participated in a phased physical therapy program followed by a progressive return to pitching. Success was defined as the ability to return to pre-procedure level of baseball pitching combined with greater than 50% low back pain reduction. Pre- and post-RFD, Visual Analog (Numeric) Scale (VAS) and Roland-Morris (R-M) tests were administered. Ten out of 12 (83%) athletes were able to return to pitching at a level attained prior to RFD. All 12 patients, experienced statistically significant low back pain relief, with a mean pre-RFD VAS of 8.4; mean post-RFD VAS of 1.7; mean pre-RFD R-M score of 12.3; and mean post-RFD R-M score of 22.3. In conclusion, athletes, experiencing lumbar zygapophyseal joint mediated low back pain secondary to zygapophyseal joint synovitis and have failed more conservative management may benefit from radiofrequency zygapophyseal joint denervation followed by a formal rehabilitation program.

Percutaneous intradiscal aspiration of a lumbar vacuum disc herniation: a case report.

We report a case of an 83-year-old gentleman presenting with acute low back pain and radicular left lower extremity pain after golfing. A magnetic resonance imaging (MRI) of the lumbar spine revealed a low-signal-density lesion compressing the L5 nerve. A computed tomography scan was then ordered, confirming an extra-foraminal disc protrusion at the L5-S1 level, containing a focus of gas that was compressing the left L5 nerve root and communicating with the vacuum disc at L5-S1. After a failed left L5 transforaminal epidural steroid injection, the patient was brought back for a percutaneous intradiscal aspiration of the vacuum disc gas. This resulted in immediate relief for the patient. A follow-up MRI performed 2 months after the procedure found an approximate 25% reduction in the size of the vacuum disc herniation. Six months after the procedure, the patient remains free of radicular pain. This case report suggests that a percutaneous aspiration of gas from a vacuum disc herniation may assist in the treatment of radicular pain.

Synovial cysts: to fuse or not to fuse?

COMMENTARY ON: Bydon A, Xu R, Parker SL, et al. Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systemic review of reported postoperative outcomes. Spine J 2010;10:820-826 (in this issue).

Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a clinical outcome study.

BACKGROUND CONTEXT: Lumbar zygapophyseal joint (Z-joint) synovial cysts can cause low back pain (LBP), spinal stenosis, and lower extremity radiculopathy. In the literature, there are several minimally invasive techniques described with mixed results. Typical recommended treatment is surgical resection of the cyst. Currently, there is little information available concerning the efficacy and outcome with treatment of Z-joint synovial cyst by percutaneous, fluoroscopic, contrast-enhanced distention, and rupture. PURPOSE: To evaluate the therapeutic value and safety of Z-joint cyst rupture in symptomatic patients. STUDY DESIGN/SETTING: Retrospective cohort study in an academic outpatient physiatric spine practice. PATIENT SAMPLE: Thirty-two patients with moderate-to-severe LBP and leg pain (18 women and 14 men with an age range of 46-86 y; mean age, 66 y) with an average preprocedure symptom duration of 5 months. The patient's clinical symptoms correlated with magnetic resonance imaging studies documenting the presence of a synovial cyst at the corresponding level and side of symptoms. Patients had at least 6 months follow-up (range, 6-24). OUTCOME MEASURES: Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, North American Spine Society four-point patient satisfaction survey, recurrence of synovial cyst requiring repeat rupture, and need for surgical intervention. METHODS: Patients with symptomatic lumbar Z-joint synovial cyst were identified and their charts were reviewed. Patients included in the study either had symptomatic lumbar LBP or LBP with associated lower extremity radiculopathy. All patients in the study had magnetic resonance imaging's documenting Z-joint synovial cyst that corresponded with the patients' clinical symptoms. All patients received fluoroscopically guided, contrast-enhanced, percutaneous facet cyst distention and rupture followed by an intra-articular facet joint injection of 1 cc kenalog and 1 cc of 1% lidocaine. Seventeen of the patients also received a transforaminal epidural steroid injection just before facet cyst rupture. Telephone follow-up was conducted on all patients. RESULTS: Excellent long-term (average follow-up 1 y; range, 6-24 mo) pain relief was achieved in 23 (72%) of 32 patients undergoing facet cyst rupture. Twelve patients (37.5%) had synovial cyst recurrence and 11 chose to undergo repeat rupture, which resulted in 5 patients (45%) obtaining complete relief of symptoms and 6 patients (55%) requiring surgical intervention for cyst removal. Fisher exact test demonstrated that all patients who did not have a cyst recurrence were a success and obtained complete relief of symptoms (p<.0002). Patients who underwent a repeat rupture had a 50% chance of a successful outcome. There was no statistical significance between a successful outcome and level of facet cyst rupture, the presence of spondylolisthesis, sex, age, or having a transforaminal epidural steroid injection at the time of the procedure. Wilcoxon signed-rank test demonstrated that the difference in Numerical Pain Rating Scale and Roland-Morris Disability Questionnaire scores before and after the procedure was statistically significant (p<.0001). No complications were reported. CONCLUSIONS: Fluoroscopic percutaneous Z-joint cyst rupture appears to be a safe and effective minimally invasive treatment option. This procedure should be considered before surgical intervention.

Lumbar zygapophysial joint radiofrequency denervation: a long-term clinical outcome study.

Zygapophysial joint (z-joint) pain has long been suggested to be one of the sources of low back pain. Radiofrequency denervation of the medial branches of the dorsal rami to treat z-joint pain is an outpatient minimally invasive treatment option. There have been many short-term studies to determine the outcome of the procedure, but few long-term studies have been conducted. Our goal is to clarify whether radiofrequency denervation has any long-term clinical benefit. In this retrospective cohort study, a total of 42 patients (25 women and 17 men), with an average follow-up of 3.5 years, with clinical signs of zygapophysial joint involvement who had failed conservative treatment (pre-procedure symptom duration mean 6.03 years; range 5 months to 48 years) and had a favorable response to a diagnostic medial branch block or zygapophysial joint injection, were identified. The identified subjects underwent radiofrequency denervation at the Hospital for Special Surgery Physiatry Department from 1998 to 2006. Patient's records were reviewed, and a questionnaire was provided, completed on phone call follow-up, or mailed by the patient. The success of this intervention in providing improvement in pain and function was analyzed using the Numerical Rating Scale (NRS)-11, North American Spine Society (NASS) four-point satisfaction index, and a modified Roland-Morris Disability Questionnaire (RMDQ). Fifty-two percent of patients reported a successful outcome with improved function at a minimum follow-up period of 2 years (mean 3.5 years, range 2-8.8 years). Patients in the failure group were more likely to be older and have moderate to severe neuroforaminal stenosis (77.8%) compared to patients in the success group (24.2%). Radiofrequency denervation in selected patients with chronic zygapophysial joint-mediated low back pain provides long-term reduction in pain and improved function with minimum morbidity.