5/31/2013 Disclosures Lumbar Facet Joint Pain: Evidence I have nothing to disclose David J. Lee, MD Professor Pain Management Center Department of Anesthesia Facet Joint Pain Facet Joint Pain Prevalence � 60% with degenerative changes by age 30 � Spinal pain 54-80% lifetime � Clinical history, physical exam and diagnostic imagings 80-90% resolve in 6 weeks are unreliable for facet joint pain and can not reliably 5-10% persistent predict response to diagnostic facet injections 25-75% recurrent and persistent � There is no tissue diagnosis to confirm facet joint pain 60% multiple regions � Facet joint pain 54-67% chronic cervical pain 42-48% chronic thoracic pain 15-45% chronic lumbar pain 1
5/31/2013 Diagnostic Block Lumbar Facet Joint Pain Validity of comparative local anesthetic blocks confirmed with placebo controlled diagnostic blocks � Diagnostic block (single vs comparative) � Comparative local anesthetic blocks in the diagnosis of � Therapeutic intervention (intra-articular injection vs cervical zygapophysial joints pain medial branch block vs radiofrequency ablation) Barnsley et al 1993 Pain � Repeat radiofrequency ablation � The utility of comparative local anesthetic blocks versus � Spinal fusion placebo controlled blocks for the diagnosis of cervical zygapophysial joint pain Lord et al 1995 Clin J Pain Barnsley L, Lord S, Bogduk N: Comparative local anesthetic blocks in the diagnosis of cervical zygapophysial joints pain. Pain 1993; 55:99-106 Lord SM, Barnsley L, Bogduk N: The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygopophysial joint pain. Clin J Pain 1995: 11:208-13 Diagnostic Block Diagnostic Block � Retrospective review � 438 patients � False positive rate: high � Comparative local anesthetic blocks placebo (18-32%) � Outcome: >=80% pain relief and ability to perform sedation painful movement liberal superficial local anesthetic � Multiple regions: 38% spread of injectate Patient Single Double Prevalence False Positive Bilateral � False negative rate:11% Cervical 251 175 97 39% 45% 72% Thoracic 65 38 22 34% 42% 80% Lumbar 303 150 83 27% 45% 79% Hogan QH, Abram SE: Neural blockade for diagnosis and prognosis: a review. Anesthesiology 1997; 86:216-41 Manchukonda R, et al: Facet joint pain in chronic spinal pain: an evaluation of prevalence Kaplan M, et al: The ability of lumbar medial branch blocks to anesthetize and false-positive rate of diagnostic blocks. J Spinal Disord Tech 2007; 20:539-45 the zygapophysial joint: a physiologic challenge. Spine 1998; 23:1847-52 2
5/31/2013 Diagnostic Block Lumbar Facet Joint Pain � Review of literature � 10/2004 to 12/2006 � Diagnostic block (single vs comparative) (2) � Comparative local anesthetic blocks � Therapeutic intervention (intra-articular injection vs medial branch block vs radiofrequency ablation) � Outcome: >50% pain relief � Cervical: strong/II � Repeat radiofrequency ablation � Thoracic: moderate/III � Spinal fusion � Lumbar: strong/II � Intra-articular injections vs medial branch blocks Sehgal N, et al: Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician 2007; 10:213-28 Marks RC, Houston T, Thulbourne T: Facet joint injection and facet nerve block: a randomized comparison in 86 patients with chornic low back pain. Pain 1992; 49:325-8 Diagnostic Block Diagnostic Block � Review of literature � Level of evidence: U.S. Preventive Services Task Force (USPSTF) � 1966 to 6/2012 � Lumbar medial branch blocks Evidence � Single or comparative local anesthetic blocks Single block, 50-74% relief (1) Poor � Outcome: 50-74% or 75-100% pain relief and ability to Single block, 75-100% relief (4) Limited perform painful movement Comparative blocks, 50-74% relief (5) Fair Comparative blocks, 75-100% relief (13) Good Falco F, et al: An update of the systematic assessment of the diagnostic accuracy of lumbar Falco F, et al: An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician 2012; 15:869-907 facet joint nerve blocks. Pain Physician 2012; 15:869-907 3
5/31/2013 Level of Evidence Diagnostic Block � Retrospective � 262 patients Adapted and modified from methods developed by U.S. Preventive Services Task Force (USPSTF) � Single local anesthetic block � Outcome: >=50% pain relief after radiofrequency ablation Definition Grade persisting >=6 months and Global Perceived Effect (GPE) Evidence includes at least 2 consistent, higher quality RCTs or studies of diagnostic test accuracy. Good � Degree of pain relief from medial branch blocks does not Evidence is includes at least 1 higher quality RCT or study of diagnostic test accuracy. Fair correlate with outcome from radiofrequency ablation Limited Evidence is insufficient to assess effects on health outcome. or Poor � Not to be extrapolated to controlled or comparative local anesthetic blocks Patients Pain Relief GPE >=50%<80% 145 52% 67% >=80% 117 56% 66% Cohen S, et al: Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. The Spine Journal 2008; 8;498-504 Diagnostic Block Lumbar Facet Joint Pain � Strong evidence for diagnostic accuracy � Diagnostic block (single vs comparative) � No consensus � Therapeutic intervention (intra-articular injection vs Intra-articular injection vs medial branch block medial branch block vs radiofrequency ablation) (4) >=50% vs >=80% � Repeat radiofrequency ablation � Comparative blocks: decrease false positive rate, increase � Spinal fusion false negative rate 4
5/31/2013 Therapeutic Intervention Therapeutic Intervention � Level of evidence: Manchikanti et al � Review of literature � 11/2004 to 12/2006 Evidence Evidence � Outcome: pain relief, functional improvement, Short Term Long Term psychological status, and return to work Cervical Intra-articular (1) Limited IV IV MBB (1) Moderate III III � Intra-articular injections and medial branch blocks RFA (1) Moderate III III Short term: <6 weeks Thoracic MBB Moderate III III Long term: >=6 weeks RFA Indeterminate V V � Radiofrequency ablation Lumbar Intra-articular (2) Moderate III III Short term: <3 months MBB (2) Moderate III III Long term: >=3 months RFA (1) Moderate III III Boswell M, et al: A systematic review of therapeutic facet joint interventions in chronic Boswell M, et al: A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10:229-53 spinal pain. Pain Physician 2007; 10:229-53 Level of Evidence Therapeutic Intervention � Review of literature � 1966 to 12/2008 Conclusive: Research-based evidence with multiple relevant and high-quality scientific studies or Level I consistent reviews of meta-analyses � Diagnostic with controlled local anesthetic blocks Strong: Research-based evidence from at least 1 properly designed randomized, controlled trial; or Level II research-based evidence from multiple properly designed studies of smaller size; or multiple low quality Outcome: >=80% pain relief and ability to perform trials Moderate: painful activities a) Evidence obtained from well-designed pseudorandomized controlled trials (alternate allocation or some other method); � Therapeutic facet intra-articular injections, MBBs and RFA Level III b) Evidence obtained from comparative studies with concurrent controls and allocation not randomized (cohort studies, case-controlled studies, or interrupted time series with a control group); Primary outcome: pain relief and long-term follow up c) Evidence obtained from comparative studies with historical control, 2 or more single-arm studies, or interrupted time series without a parallel control group Secondary outcome: Limited: Evidence from well-designed nonexperimental studies from more than 1 center or research group; Level IV or conflicting evidence with inconsistent findings in multiple trials improved functional status, psychological Level V Indeterminate: Opinions of respected authorities, based on clinical evidence, descriptive studies, or reports of expert committees status, return to work, and reduction in opioids Manchikanti, et al: Methods for evidence synthesis in interventional pain management. Pain Physician 2003; 6:89-111 Datta S; et al: Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician 2009; 12:437-60 5
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