Nikolai Bogduk

Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint-pain

BACKGROUND Chronic pain in the cervical zygapohyseal joints is a common problem after whiplash injury, but treatment is difficult. Percutaneous radiofrequency neurotomy can relieve the pain by denaturing the nerves innervating the painful joint, but the efficacy of this treatment has not been established. METHODS In a randomized, double-blind trial, we compared percutaneous radio-frequency neurotomy in which multiple lesions were made and the temperature of the electrode making the lesions was raised to 80 degrees C with a control treatment using an identical procedure except that the radio-frequency current was not turned on. We studied 24 patients (9 men and 15 women; mean age, 43 years) who had pain in one or more cervical zygapophyseal joints after an automobile accident (median duration of pain, 34 months). The source of their pain had been identified with the use of double-blind, placebo-controlled local anesthesia. Twelve patients received each treatment. The patients were followed by telephone interviews and clinic visits until they reported that their pain had returned to 50 percent of the preoperative level. RESULTS The median time that elapsed before the pain returned to at least 50 percent of the preoperative level was 263 days in the active-treatment group and 8 days in the control group (P=0.04). At 27 weeks, seven patients in the active-treatment group and one patient in the control group were free of pain. Five patients in the active-treatment group had numbness in the territory of the treated nerves, but none considered it troubling. CONCLUSIONS In patients with chronic cervical zygapophyseal-joint pain confirmed with double-blind, placebo-controlled local anesthesia, percutaneous radio-frequency neurotomy with multiple lesions of target nerves can provide lasting relief.

The Sacroiliac Joint in Chronic Low Back Pain

Study Design. This was a cross-sectional analytic study. Objectives. In relation to pain from the sacroiliac joint, this study sought to establish 1) its prevalence, 2) the validity of pain provocation, 3) whether any arthrographic abnormalities predict a response to joint block, and 4) whether certain pain patterns discriminate patients with this diagnosis. Summary of Backgound Data. The true prevalence of sacroiliac joint pain is unknown and despite a plethora of clinical tests, none of these tests has been validated against an established criterion standard. To our knowledge, arthrography of the sacroiliac joint had never been studied. Methods. Forty-three consecutive patients with chronic low back pain maximal below L5-S1 were investigated with sacroiliac joint blocks under image intensifier using radiographic contrast followed by 2% lignocaine, Information was obtained on pain provocation, analgesia, and image pattern. Results. Thirteen patients (30%) obtained gratifying relief of their pain. Nine of these also exhibited tears of their ventral capsule. Groin pain was the only pain referral pattern found to be associated with response to sacroiliac joint block. Conclusion. The sacroiliac joint is a significant source of pain in patients with chronic low back pain and warrants further study.

The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.

Study Design This was a cross-sectional analytic study of patients with chronic low back pain. Objective To investigate whether the criteria for internal disc disruption, as adopted by the International Association for the Study of Pain, could be satisfied in patients with chronic low back pain and to test whether there were any conventional clinical features that could identify this condition. Summary of Background Data Internal disc disruption has been postulated as an important cause of low back pain. To diagnose this condition, the International Association for the Study of Pain taxonomy requires that pain be reproduced on provocation discography and that computed tomography discography reveal internal disc disruption, provided that as a control, stimulation of at least one other disc fails to reproduce pain. Methods Ninety-two consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied. Each patient underwent a standard physical examination. Computed tomography discography was performed at a minimum of two levels. Results The diagnostic criteria for internal disc disruption were fully satisfied in 39% of patients, most commonly at L5-S1 and L4-L5. None of the clinical tests used could differentiate between those patients with internal disc disruption and other patients. Conclusions A diagnosis of internal disc disruption can be made in a significant proportion of patients with chronic low back pain, but no conventional clinical test can discriminate patients with internal disc disruption from patients with other conditions.

The prevalence of chronic cervical zygapophysial joint pain after whiplash.

Study Design. A survey of the prevalence of cervical zygapophysial jooint pain was conducted. Objectives. To determine the prevalence of cervical zygapophysial joint pain in patients with chronic neck pain after whiplash. Summary of Backgound Data. In a significant porportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggests many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic blocks. Methods. Fifty consecutive, referred patients with chronic neck pain after whiplash injury were studid using double-blind, controlled, diagnotic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. Results. A positive diagnosis was made only if both blocks relieved the patients pain and bupivacaine provided longer relief, Painful joints were identified in 54% of the patients (95% confidence interval, 40% to 68%). Conclusion. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.

Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity

Study Design This study is a prospective cross-sectional analytic study. Objectives The authors determined the prevalence and clinical features of patients with pain stemming from the lumbar zygapophysial joints. Summary of Background Data Previous studies have demonstrated a wide range of prevalence for zygapophysial joint pain and conflicting results with regard to clinical signs. Methods One hundred and seventy-six consecutive patients with chronic low back pain were investigated with a series of screening zygapophysial joint blocks using lignocaine and confirmatory blocks using bupivacaine. Results Forty-seven percent of patients had a definite or greater response to the screening injection at one or more levels but only 15% had a 50% or greater response to a confirmatory block. Response to zygapophysial joint injection was not associated with any single clinical feature or set of clinical features. Conclusions The zygapophysial joint is an important source of pain but the existence of a “facet syndrome” must be questioned.

The value of medical history and physical examination in diagnosing sacroiliac joint pain.

Study Design This prospective study evaluated the diagnostic utility of historically accepted sacroiliac joint tests. A multidisciplinary expert panel recommended 12 of the “best” sacroiliac joint tests to be evaluated against a criterion standard of unequivocal pain relief after an intra‐articular injection of local anesthetic into the sacroiliac joint. Objectives To identify a single sacroiliac joint test or ensemble of tests that are sufficiently useful in diagnosing sacroiliac joint disorders to be clinically valuable. Summary of Background Data No previous research has been done to evaluate any physical test of sacroiliac joint pain against an accepted criterion standard. Methods Historical data was obtained, and the 12 tests were performed by two examiners on 85 patients who subsequently underwent sacroiliac joint blocks. Ninety percent or more relief was considered a positive response, and less then 90% relief was considered a negative response. Results There were 45 positive and 40 negative responses. No historical feature, none of the 12 sacroiliac joint tests, and no ensemble of these 12 tests demonstrated worthwhile diagnostic value. Conclusion Sacroiliac joint pain is resistant to identification by the historical and physical examination data from tests evaluated in this study.

The Innervation of the Lumbar Spine

The lumbar intervertebral discs are innervated posteriorly by the sinuvertebral nerves, but laterally by branches of the ventral rami and grey rami communicantes. The posterior longitudinal ligament is innervated by the sinuvertebral nerves and the anterior longitudinal ligament by branches of the grey rami. Lateral and intermediate branches of the lumbar dorsal rami supply the iliocostalis lumborum and longissimus thoracis, respectively. Medial branches supply the multifidus, intertransversarii mediales, interspinales, interspinous ligament, and the lumbar zygapophysial joints. The distribution of the intrinsic nerves of the lumbar vertebral column systematically identifies those structures that are potential sources of primary low-back pain.

Efficacy and Validity of Radiofrequency Neurotomy for Chronic Lumbar Zygapophysial Joint Pain

STUDY DESIGN A prospective audit. OBJECTIVE To establish the efficacy of lumbar medial branch neurotomy under optimum conditions. SUMMARY OF BACKGROUND DATA Previous reports of the efficacy of lumbar medial branch neurotomy have been confounded by poor patient selection, inaccurate surgical technique, and inadequate assessment of outcome. METHODS Fifteen patients with chronic low back pain whose pain was relieved by controlled, diagnostic medial branch blocks of the lumbar zygapophysial joints, underwent lumbar medial branch neurotomy. Before surgery, all were evaluated by visual analog scale and a variety of validated measures of pain, disability, and treatment satisfaction. Electromyography of the multifidus muscle was performed before and after surgery to ensure accuracy of the neurotomy. All outcome measures were repeated at 6 weeks, and 3, 6, and 12 months after surgery. RESULTS Some 60% of the patients obtained at least 90% relief of pain at 12 months, and 87% obtained at least 60% relief. Relief was associated with denervation of the multifidus in those segments in which the medial branches had been coagulated. Prelesion electrical stimulation of the medial branch nerve with measurement of impedance was not associated with outcome. CONCLUSIONS Lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. Adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. Electrical stimulation before lesioning is superfluous in assuring correct placement of the electrode.

Biomechanics of the cervical spine. I: Normal kinematics

UNLABELLED This review constitutes the first of four reviews that systematically address contemporary knowledge about the mechanical behavior of the cervical vertebrae and the soft-tissues of the cervical spine, under normal conditions and under conditions that result in minor or major injuries. This first review considers the normal kinematics of the cervical spine, which predicates the appreciation of the biomechanics of cervical spine injury. It summarizes the cardinal anatomical features of the cervical spine that determine how the cervical vertebrae and their joints behave. The results are collated of multiple studies that have measured the range of motion of individual joints of the cervical spine. However, modern studies are highlighted that reveal that, even under normal conditions, range of motion is not consistent either in time or according to the direction of motion. As well, detailed studies are summarized that reveal the order of movement of individual vertebrae as the cervical spine flexes or extends. The review concludes with an account of the location of instantaneous centres of rotation and their biological basis. RELEVANCE The fact and precepts covered in this review underlie many observations that are critical to comprehending how the cervical spine behaves under adverse conditions, and how it might be injured. Forthcoming reviews draw on this information to explain how injuries might occur in situations where hitherto it was believed that no injury was possible, or that no evidence of injury could be detected.

The relative contributions of the disc and zygapophyseal joint in chronic low back pain.

Study Design. A prospective cross-sectional analytic approach was taken. Objectives. This study sought to determine the relative contribution of the disc and the zygapophyseal Joint as a pain source in patients with chronic low back pain. Summary of Background Data. Previous studies have employed either zygapophyseal joint blocks or discography, but in no studies have both procedures been performed. Methods. Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints. Results. Thirty-six patients (39%) had at least one positive discogram as defined by exact pain reproduction, an abnormal image, and a negative control. Eight patients responded to both a screening zygapophyseal joint block using lignocaine and confimatory block using bupivacaine. Only three patients had both a positive discogram and a symptomatic zygapophyseal joint. Conclusions. In patients with chronic low back pain, the combination of discogenic pain and zygapophyseal joint pain is uncommon.