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Jun 01, 2018

Low back pain ranges from 60 to 80% in general population. Chronic low back pain (CLBP) or lower back pain that persists for more than three months is reported to have a lifetime prevalence of 4 to 10% in the general population. This condition is associated with substantial health care cost and economic loss. For general practitioners and specifically for pain management specialist indentifying the source of chronic low back pain CLBP and selecting proper treatment for it is an issue of great concern.

by Dariusz Nasiek, M.D.

Intervertebral disc, facet joints and sacroiliac joints are the primary structures within the spinal component that are the most common causes of chronic low back pain CLBP. The pain arising from facet joint or facet joint syndrome FJS is a major source of CLBP and it is reported to be responsible for 15 to 45% of total low back pain in the suffering population. It is data for total number of patients in a population suffering from CLBP. The symptoms can be similar to those of herniated disc and can be exacerbated by back extension after flexion, flexion rotation and provocation maneuvers for facet joints, Kemp’s test, etc.

In the year 1933 Ghormley first described the term facet syndrome paraesthesia as the cause of referred pain and sciatica coming from direct root compression by the facets.

In the year 1941 Badgley was the first to report that facet joint could be an independent source of referred pain and since then many studies have been published about its clinical importance in general population in patients with chronic low back pain. He also describes this as following his discovery it was also considered as diagnostic method of confirming the facet syndrome and the way of treating it.

Facet joints have nodal linings and capsule and are highly innovative by three nerves ending, medial, intermediate and lateral. Facet joints can become inflamed as a result of progressive joint regeneration which increases friction between pain generators. The term FJS facet joint syndrome has been coined to describe conditions related to this chain of degeneration and the pain accompanying it. Facet joint degeneration progresses into bone spur formation which can cause additional pain.

Traditional treatment of facet joint pain includes the following:

  1. Intra-articular joint injection
  2. Medial branch blocks
  3. Radiofrequency ablation of targeted nerve roots

Numbers 1 and 2 namely intra-articular injections and medial branch blocks are easy to perform. They are nonsurgical procedures and they have diagnostic value. However, patient may experience recurrence of symptoms due to short effectiveness duration and there is always risk of local anesthetic complications associated with repeat injections specifically as regarding to the steroids.

Number 3 is facet joint radiofrequency denervation for treatment of facet joints and was first described by Shealy in the year 1975 and is a well-established treatment modality. The efficacy of radiofrequency denervation has been proven to significantly relieve pain in patients with chronic low back pain that are refractory to more conservative treatment options. Fluoroscopic guidance in denervation of the medial branch block provides long-lasting effect.

In addition in comparison to other injections to the joints intra-articular injections and medial branch blocks that are currently the preferred modalities, although their efficacy in short-term pain relief has been documented in numerous articles and number of studies which suggest that pain relief is only temporary usually lasting for only a few months, a number of patients experience recurrence which is significant and it depends upon dorsal ramus regeneration process. Moreover some papers based on categorical dissection stated branches of dorsal ramus has multiple variation in number of occasion due to variation in medium nerve passages not only at degenerative and postoperative spine but also in normal spine extensive ablation is required which would probably relive patients pain. Extensive ablation can scar adjacent muscles and ligamentous structures which in itself can be a source of additional chronic lower back pain CLBP. When the structures are taken into account successful selective ablation and denervation of the medial branch using traditional radiofrequency are done, it would not be easily achievable in all of patients when medial branch block is not confirmed by direct visualization.

To overcome this shortcoming for the last five years I have employed a novel method for radiofrequency denervation for treatment of FJS facet joint syndrome in which with endoscopic guidance endoablation under direct visualization of medial branches which were attempted prior to ablation for more precise lesioning and effective neural denervation without damaging nearby structures. Below I have reviewed clinical outcome and satisfaction which vary using endoscopic radiofrequency denervation methods (endoablation).

The next is endoablation. Endoscopic guided radiofrequency ablation of medial branch has many advantages over traditional radiofrequency ablations. High quality visualization of the target branch is possible with endoablation which may significantly increase the success rate of ablation. Moreover while only point ablation of target medial branch block can be achieved with traditional radiofrequency ablation, endoscopic guided ablation can de-nervate multiple spot of target medial branch within the view of endoscope. In addition by employing a bending maneuver of probe the targeted area is increased. Clear visualization of the operative field enables the surgeon to visually distinguish the target medial branch from other branches of the dorsal ramus even in cases where there is another mild variation of the dorsal ramus branches. In accordance with this my results show that visual analogue scale VAS pain score decreased significantly after the procedure.

When employing this endoscopic method for radiofrequency denervation, patient selection and strict adherence to inclusion criteria are critically important. In majority of cases the pain is multifactorial and includes disc and facet and sacroiliac joints. Medial branch block alone may not be sufficient and satisfactory to alleviate the patient’s symptoms. I exclude patients with discogenic pain, sacroiliac pain and instability of the main source of these symptoms. Physical, neurological examination as well as appropriate provocation test such as medial branch block should be performed therefore in order to exclude other possible pain mechanism. Endoscopic radiofrequency denervations of medial branches of the dorsal ramus significantly improved visual analogue scale VAS in removing the patient’s pain for up to 24 to 36 months and longer. Complications associated with the procedure are rare. The patient’s satisfaction is rated high. Endoscopic radiofrequency denervation of the medial branch could be safe and effective alternative treatment modality that offers long-term pain relief for chronic low back pain of facet origin.

Dariusz Nasiek, M.D.

Board Certified by American Board of Anesthesiology
Board Certified by American Board of Pain Medicine
Board Certified by American Board of Interventional Pain Physician

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