Facet joint injections, intraarticular and medial branch blocks, are considered as helpful tests in the diagnosis of facet pain in persons with chronic back or neck pain that lasts more than 3 months, despite appropriate conservative treatment.
A facet block is an injection of local anesthetic and/or steroids into or near the facet joint of the spine.
Degenerative changes in the posterior lumber facet joints are a source of LBP that may radiate to the leg.
Pain impulses from the medial branches of lumbar dorsal rami can be int2242upted by blocking these nerves with local anesthetic or coagulating them with a radiofrequency wave facet denervation.
If the patient gets relief of pain with facet block and the pain recurs, denervation of the facet joint may be considered.
Randomized controlled trials have failed to demonstrate a benefit of facet injections, and such injections has not been accepted as efficacaciuos for back and neck pain.
Facet joints of the spine have joint capsules that are supplied by a branch of the posterior ramus of the spinal nerve.
Percutaneous radiofrequency facet denervation, involves selective denervation using radiofrequency under fluoroscopic guidance.
As a method of neurolysis, radio-frequency facet denervation offers relief for many patients with mechanical LBP in whom organic pathology, most commonly a herniated lumbar disc, has been eliminated.
Non-pulsed radiofrequency facet denervation is considered for treatment for intractable cervical or back pain with or without sciatica in the outpatient setting when pain limits activities of daily living for at least 6 months, and neuroradiologic studies are negative or fail to confirm disc herniation, and there no significant narrowing of the vertebral canal or spinal instability requiring failed conservative treatments, and trial of facet joint injections have been successful in relieving the pain.
Successful relief of pain by injections of an anesthetic agent into the joints are necessary before proceeding with radiofrequency facet denervation.
Radiofrequency facet denervation results in significant pain relief, reduced use of pain medication, and is associated with few complications.
Trigger point injections of corticosteroids and/or local anesthetics, for treating patients with chronic neck or back pain or myofascial pain syndrome, are utilized when conservative therapies such as bed rest, exercises, heating or cooling modalities, massage, non-steroidal anti-inflammatory drugs, muscle relaxants, non-narcotic analgesics, have been tried and failed, and symptoms have persisted for more than 3 months.
Trigger points injections require that they have been identified by palpation, and they are part of a comprehensive pain management program.
A trigger point is defined as a specific point where, if stimulated by touch or pressure, a painful response will be induced.
Trigger point injections are injections of local anesthetic medication, saline, and/or steroids into trigger points.
A myofascial trigger point is a discrete focal tenderness located in distinct bands or knots of skeletal muscle.
Trigger point injection for myofasial provides pain relief and elimination of muscle spasm, and facilitates physical therapy aimed at reducing muscle contracture and increasing range of motion.
Epidural injections of corticosteroid preparations with or without added anesthetic agents, are medically necessary in the outpatient setting for management of persons with radiculopathy or sciatica when intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain has been ruled out, the patient has failed to improve after 2 or more weeks of conservative measures, and injections are provided as part of a comprehensive plan.
Up to 3 epidural injections are considered necessary to diagnose a patient’s pain and achieve a therapeutic effect.
It is rarely medically necessary to repeat epidural injections more frequently than once every 2 months as maintenance therapy.
Chymopapain chemonucleolysis is considered medically necessary for the treatment of sciatica due to a herniated disc when leg pain is worse than low back pain, radicular symptoms are reproduced by sciatic stretch tests; and there is only a single level herniated disc with nerve root impingement at clinically suspected level demonstrated by MRI, CT, or myelography, and objective neurologic deficit is present, and pain is not relieved by at least 6 weeks of conservative therapy.
Percutaneous lumbar discectomy, is considered for treatment of herniated lumbar discs when the patient. is otherwise a candidate for open laminectomby, the patient has failed 6 months of conservative management, and the herniated disc is contained, and the patient has typical clinical symptoms of radicular pain corresponding to the level of disc involvement.
Implantable infusion pumps are used to administer drugs intrathecally or epidurally for treatment of severe chronic intractable pain of malignant or non-malignant origin in patients with life expectancies of more than 3 months who have proven unresponsive to less invasive medical therapy.
A trial of intraspinal opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to demonstrate adequate pain relief, the side effects, and the patient’s acceptance of the procedure.
Pedicle screws for spinal fixation are utilized for lumbar fusion, fusion after decompression, pseudoarthrosis repair, and revision of lumbar disc surgery because of instability, scoliosis, and kyphosis requiring spinal instrumentation, defects or loss of posterior elements following tumor resection, spinal trauma, including fractures and dislocations, spondylolisthesis, and thoracic fractures.
Decompressive laminectomy is used for spinal stenosis, degenerative disc disease, failed lumbar surgery, low back pain without spinal instability or neurologic deficits, and single level discectomy. Intervertebral body fusion devices or spine cages, are used with autogenous bone graft in patients requiring spinal fusion.
Percutaneous polymethylmethacrylate vertebroplasty (PPV) or kyphoplasty are used in patients with persistent, debilitating pain in the cervical, thoracic or lumbar vertebral bodies resulting from multiple myeloma, hemangiomas; osteoporotic collapse/compression fractures, malignant neoplasm, granulomatous infiltrating disease, osteolytic metastases, or steroid-induced fractures.
The above procedures are used when debilitating pain or loss of mobility that cannot be relieved by optimal medical therapy, and affected vertebra has not been extensively destroyed and has maintained at least one-third of its original height.
An epidural steroid injection is an injection of long lasting steroid in the epidural space, the area which surrounds the spinal cord and the nerves coming out of it.
The efficacy of epidurally administered steroids has been demonstrated in a large number of studies to provide long-term relief of pain of greater than 3 months in at least 10 to 30 % of patients, while short-term relief can be achieved in 60 to 100 % of patients.
Cervical epidural steroid injections are somewhat less effective than those for lumbar pain.
Epidural steroid therapy is considered forin patients with low back and cervical pain that has not resolved after only a short period of more conservative measures since studies have shown a better response to therapy in patients whose pain is of shorter duration.
Most patients will respond with 3 or fewer injections. and epidural steroid injections for radicular lumbosacral pain has noimpact on average impairment of function, on need for surgery, or on long-term pain relief beyond 3 months.
Most individuals with acute low back problems spontaneously recover activity tolerance within 4 to 6 weeks of conservative therapy.
If conservative therapy fails to relieve symptoms of sciatica and radiculopathy and there is strong evidence of dysfunction of a specific nerve root confirmed by CT/MRI, lumbar laminectomy may be a treatment option.
Lumbar laminectomy provides decompression of the affected nerve root to relieve symptoms and involves the removal of all or part of the lamina of a lumbar vertebra.
Cauda equina is the name given to the lumbar and sacral nerve roots within the dural sac caudal to the conus medullaris.
Cauda equina syndrome is usually the result of a ruptured, midline intervertebral disk, most commonly occurring at the L4 to L5 level.
Tumors and other masses may also cause the cauda equina syndrome.
Cauda equina syndrome presents with symptoms of fecal or urinary incontinence, impotence, distal motor weakness, and sensory loss in a saddle distribution.
Muscle stretch reflexes may be reduced. In cauda equina syndrome.
Urinary retention is the single most consistent finding in cauda equine syndrome.
In acute cauda equine syndrome, immediate surgical decompression is recommended.
In a more chronic presentation, decompression is performed when medically feasible.
A cervical laminectomy can be performed when acute cervical disc herniation causes central cord syndrome or in cervical disc herniations refractory to conservative measures.
Anterior discectomy with fusion is the recommended procedure for central or anterolateral soft disc herniation, while a posterior laminotomy-foraminotomy may be considered when technical limitations for anterior access exist or when the individual has had prior surgery at the same level.
Anterior discectomy alone most frequently results in spontaneous fusion in 70 to 80 % of cases.
Additional fusion techniques for anterior discectomy include the use of bone grafts with or without cages and use of an anterior plate.
A Cochrane systematic review concluded that discectomy alone has a shorter operation time and hospital stay than discectomy with fusion with difference in pain relief and rate of fusion.
Chemonucleolysis refers to a procedure that involves the dissolving of the gelatinous material in an intervertebral disk by the injection of chymopapain or other enzyme.
Chemonucleolysis (CNL) with chymopapain is safe and effective as an alternative to surgical disc excision in the majority of patients who are candidates for surgery for intractable sciatica due to herniated nucleus pulposus (HNP).
Chemonucleolysis involves the enzymatic degradation of the nucleus pulposus.
Chemonucleolysis may be more effective than percutaneous discectomy since it can utilized for protruded and extruded discs, as long as the herniated disc material is still in continuity with the disc.
Overall success rate for chemonucleolusis ranges from 70-90%, similar to surgical discectomy.
Chemonucleolysis approved only for lumbar spine injections.
Pedicle screw fixation systems consist of steel or titanium plates that are longitudinally inter-connected and anchored to adjacent vertebrae using bolts, hooks, or screws to produce a rigid connection between 2 or more adjacent vertebrae to correct deformities and to stabilize the spine.
Pedicle screw fixation systems are most often used in the lumbosacral spine from L1 though S1, but may also be used in the thoracic spine.
Posterior decompression of the spinal cord to can be employed to excise herniated or subluxed vertebrae, degenerative intervertebral discs, vertebral fractures, or spinal tumors is a common procedure.
Spinal instability following posterior decompression may require stabilization by bony fusion of affected and adjacent vertebrae using implanted autologous bone grafts, and surgically implanted hooks, rods, or wires may be needed to complete the process.
In the presence of severe instability following posterior spinal decompression, surgical implantation of plates or rods anchored to vertebral pedicles using screws to provide rigid fixation and minimize the risk of incomplete fusion is required.
Rigid fixation of the lumbar spine with pedicle screws improves the chances of successful fusion compared with patients with lumbar spine fusion not supplemented with internal fixation.
Internal fusion and fixation procedures are reserved for patients with spinal instability associated with neurological deficits, major spinal deformities, spinal fracture, spinal dislocation or complications of tumor, not for the treatment of isolated chronic back pain.
Pedicle screw spinal systems intended to provide immobilization and stabilization of spinal segments as an adjunct to fusion in the treatment of acute or chronic instabilities or deformities of the thoracic, lumbar, and sacral spine as a result of degenerative spondylolisthesis with objective evidence of neurological impairment, fracture, dislocation, scoliosis, kyphosis, spinal tumor, and failed fusion.
A spine cage, also ref2242ed to as an interbody cage, is a hollow cylindrical device, usually made of titanium, placed in the disc space between 2 vertebrae.
A spine cage is utilized to restore lost disc height resulting from a collapsed disc and to relieve pressure on nerve roots.
An intervertebral body fusion device has a wedge body, a cage component with spines having end plate penetrating teeth, and a contraction mechanism for drawing the wedge body into the cage component.
The above device is surgically placed intervertebrally into the spine from an anterior surgical approach. The wedge body is drawn within the cage component, resulting in deployment of teeth and associated spines into the adjacent end plates of the vertebral bodies, and simultaneously restoring the angle of lordosis to the spine.
Intervertebral body fusion devices are permanent implants.
Safety and effectiveness of these fusion devices have not been established in 3 or more levels to be fused.
Percutaneous polymethylmethacrylate vertebroplasty (PPV) is a therapeutic radiologic procedure, which consists of the injection of a bone cement, usually methyl methacrylate, into a cervical, thoracic or lumbar vertebral body lesion for the relief of pain and the strengthening of bone.
Vertebroplasty is used for patients with lytic lesions, aggressive hemangiomas, or multiple myeloma, and for patients with debilitating pain from osteoporotic vertebral collapse.
Percutaneous vertebroplasty can produce significant pain relief and increase mobility in 70 % to 80 % of patients with osteolytic lesions in the vertebrae.
Percutaneous vertebroplasty can provide pain relief within 1 to 2 days, and appears to persist for several months up to several years.
Percutaneous vertebroplasty associated with clinically insignificant leakage of bone cement into the paravertebral tissues.
Leakage of polymer can caused compression of spinal nerve roots or neuralgia.
Cement leakage with vertebroplasty, especially with lyric lesions, can occur in 30-70% of cases, most of which are asymptomatic.
Randomized control studies as in the Investigational Vertebroplasty Safety and Efficacy Trial (INVEST), Kallmes et al reported that pain and disability outcomes at 1 month in a group of patients who underwent vertebroplasty were similar to those in a control group that underwent a sham procedure.
Buchanan et al measured pain, quality of life, and functional status at 1 week and at 1, 3, and 6 months after sham and active vertebroplasty and found there were no significant between-group differences at any time point.
Repeating percutaneous vertebroplasty may be effective in patients that did not receive pain-relief with previous PV, as absent or inadequate filling of cement may have occurred in the fractured areas of the vertebral body.
Kyphoplasty, balloon-assisted vertebroplasty, is a minimally-invasive orthopedic procedure to restore bone height lost due to painful osteoporotic compression fractures.
Kyphoplasty involves the insertion of 1 or 2 balloons into the fractured vertebral body, with inflation of the balloons to create a cavity restoring vertebral height.
The cavity created by the above efforts is then filled with bone filler material, creating stebilzation for the fractured area.
Patients who have undergone balloon kyphoplasty have improved pain scores compared with the control group treated with conventional therapy at a maximum follow-up of 24 months.
The most common complication following balloon kyphoplasty is cement leakage, occurring in up to 11 % of patients, and potential complications include infection, spinal cord or nerve root injury caused by needle placement.
Balloon kyphoplasty has a lower reported peri-operative and long-term complications rate than percutaneous vertebroplasty.
Sacroplasty involves the injection of polymethylmethacrylate cement into sacral insufficiency fractures for is an image-guided procedure that attempts to solve the problem of cement leakage out of the vertebral body, which can happen during both vertebroplasty and kyphoplasty.
Vesselplasty is a technique that uses a porous polyethylene terephthalate balloon to create both a cavity and contain the cement, thereby, allowing only a small amount of cement to permeate into the vertebral body.
The Racz catheter is a small caliber, flexible catheter that is introduced into the sacral hiatus and into the lumbro-sacral epidural space used to release adhesions, and deliver steroids and anesthetics into the epidural space.
There is no evidence supporting the safety and effectiveness of manipulation of an indwelling epidural Racz catheter.
Microsurgical anterior foraminotomy for the treatment of intractable cervical radiculopathy, is a technique that provides direct anatomical decompression of compressed nerve roots by removing the compressive spondylotic spur or disc fragments through the holes of unilateral anterior foraminotomies.
Using microsurgical instruments only the herniated portion of the disc is removed, preserving normal disc function and avoiding bone fusion.
Arthroscopic microdiskectomy or percutaneous endoscopic diskectomy are endoscopic approaches to lumbar disc surgery that involves a multi-channel scope and special access cannulae that allow spinal probing, diagnostic endoscopy, and minimally invasive surgery.
The spinal endoscope is used to remove disc herniation fragments, foraminoplasty, to widen the exit route foramina of the lumbar spine and ablate any protruding portions of the intervertebral disk.
Spinal endoscopic procedures can be performed at several levels of the spine, and other procedures may be performed such as applying chemonucleolytic agents, lasers, radiofrequency , electrothermal energy, or steroids.
These procedures are performed while the patient is conscious under moderate sedation, and are associated with smaller incisions, reduced blood loss, fewer anesthesia risks, and faster recovery.
Minimally invasive surgery with endoscopic procedures has limited visualization of the spine, such that one cannot reliably identify and ensure complete removal of bone spurs and other structures impinging on nerves.
Laser diskectomy refers to the use of a laser to vaporize a portion of the nucleus pulposus in order to decompress a herniated disc.
In laser diskectomy, the surgeon may use an endoscope to visualize the disc space and nucleus pulposus, or the procedure may be done percutaneously.
Percutaneous laser disc decompression uses an x-ray to localize the tip of the needle to ensure that it is in the appropriate level and location.
Microdiscectomy refers to removal of protruding disc material, using an operating microscope to guide surgery.
For ruptured intervertebral discs, there is no differences in clinical outcomes between microdiscectomy and standard open discectomy.
Microdiscectomy surgery takes longer to perform than standard open discectomy.
Microendoscopic Discectomy (MED) procedure combines conventional lumbar microsurgical techniques with endoscopy for the treatment of lumbar spine stenosis and lumbar disc herniation.
MED may be less invasive compared with traditional open procedure but is difficult because of the limited exposure and video display.
Failed back surgery syndrome (FBSS) is reported to occur in 5 to 50 % of cases of lumbar spine operation.
Surgical interventions used for FBSS treatment include decompression, stabilization and fusion.
Rigid instrumentation in the treatment of degenerative spinal disorders increases the fusion rate of the lumbar spine and are associated with adverse effects such as pseudoarthrosis and adjacent segment degeneration.
Semi-rigid and dynamic devices have been utilizes to decrease the adverse effects of rigid fixation and to obtain a more physiological bony fusion.
Dynamic stabilization systems use flexible materials threaded through pedicle screws rather than rigid rods or bone grafts alone as an adjunct to fusion.
If conservative measures fail to reduce symptoms in lumbar spinal stenosis, surgical options available are: laminectomy, facetectomy, multi-level laminotomies, fenestration, distraction laminoplasty, and microscopic decompression, with or without fusion.
While surgical options for lumbar spinal stenosis (LSS)have better shorter outcomes than non-surgical measures, their results deteriorate with time.
Concerns over the long-term effects of fusion on adjacent spinal segments has led to the development of inter-spinous distraction procedures that decompress the affected spinal segment and maintain it in a slightly flexed position, preventing extension, and relieving the symptoms of lumbar spinal stenosis.
Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with benefits compared to non-surgical therapy, in the short-term, but diminish with long-term follow-up in some trials.
Endoscopic laser foraminoplasty is primarily used to treat patients with back pain caused by a prolapsed intervertebral disc.
The laser is inserted to ablate portions of the intervertebral disc that have protruded.
Complication rate of endoscopic laser foraminoplasty is significantly lower than that reported following spinal surgery.
Percutaneous disc decompression is a procedure for a herniated disc in which the core of the disc has not broken through the disc wall.
Percutaneous disc decompressio is a form of surgery in which small amounts of disc are removed to relieve pressure on the nerves surrounding the disc performed with a cutting instrument or laser.
Percutaneous discectomy is a method of treatment for contained and non-migrated sequestered herniated discs, and involves the removal of nucleus pulposus from the herniation site under endoscopic control.
Automated percutaneous discectomy uses minimal skin incisions to allow small instruments to be inserted, and by using radiography to visualize these instruments, and extensions the ability exists to reach the operative site without having to dissect tissues.
Percutaneous lumbar discectomy has potential benefits over open discectomy procedures, including reduced morbidity, less perineural scarring, less blood loss, fewer complications of epidural fibrosis, transverse myelitis, disc space infection, shortened recovery times, and a faster return to normal activities.
Radiofrequency (RF) neurotomy is a therapeutic procedure designed to decrease pain by destroying the nerves that innervate a joint, and it uses RF-generated localized heat to ablate the nerves int2242upting the nervous pathway that transmits pain sensation from the spine.
Facet and sacroiliac joint pain are often targeted by neurotomy.
Facet joint implantations are employed to replace a bony portion of the facets so as to remove the source of pain.
Facet implants include a superior implant for placement on a superior articulating surface and an inferior implant for placement on an inferior articulating surface.
These facet implants inserted via a lateral or posterior approach, increase the area of the canals and openings through which the spinal cord and nerves must pass, and decreasing pressure on the spinal cord and/or nerve roots.
Lateral interbody fusion in the lumbar spine avoids major muscle groups in the back by the posterior approach or the organs and blood vessels in the abdomen via the anterior approach.
The process is achieved by placing a probe is under fluoroscopic guidance through the psoas muscle, to lie alongside the affected disc, via a lateral approach.
Nerve monitoring is recommended to avoid damage to motor nerves, as up to 30 % of patients may develop post-operative numbness.
Minimally invasive lumbar decompression (MILD) is a procedure for pain relief from symptomatic central lumbar canal stenosis involving limited percutaneous laminotomy and thinning of the ligamentum flavum in order to increase the critical diameter of the stenosed spinal canal.
Minimally invasive transforaminal lumbar interbody fusion is perfojrmed through small incisions opening an operative corridor through the muscles using endoscopes to with less trauma to soft tissues.