Diagnostic Value of Lumbar Facet Joint Injection: A Prospective Triple Cross-Over Study

Abstract

The diagnosis “lumbar facet syndrome” is common and often indicates severe lumbar spine surgery procedures. It is doubtful whether a painful facet joint (FJ) can be identified by a single FJ block. The aim of this study was to clarify the validity of a single and placebo controlled bilateral FJ blocks using local anesthetics. A prospective single blinded triple cross-over study was performed. 60 patients (31 f, 29 m, mean age 53.2 yrs (22–73)) with chronic low back pain (mean pain persistance 31 months, 6 months of conservative treatment without success) admitted to a local orthopaedic department for surgical or conservative therapy of chronic LBP, were included in the study. Effect on pain reduction (10 point rating scale) was measured. The 60 subjects were divided into six groups with three defined sequences of fluoroscopically guided bilateral monosegmental lumbar FJ test injections in “oblique needle” technique: verum-(local anaesthetic-), placebo-(sodium chloride-) and sham-injection. Carry-over and periodic effects were evaluated and a descriptive and statistical analysis regarding the effectiveness, difference and equality of the FJ injections and the different responses was performed. The results show a high rate of non-response, which documents the lack of reliable and valid predictors for a positive response towards FJ blocks. There was a high rate of placebo reactions noted, including subjects who previously or later reacted positively to verum injections. Equivalence was shown among verum vs. placebo and partly vs. sham also. With regard to test validity criteria, a single intraarticular FJ block with local anesthetics is not useful to detect the pain-responsible FJ and therefore is no valid and reliable diagostic tool to specify indication of lumbar spine surgery. Comparative FJ blocks with local anesthetics and placebo-controls have to be interpretated carefully also, because they solely give no proper diagnosis on FJ being main pain generator.

Advances in the diagnosis and management of neck pain

“…A crossover study evaluating the accuracy of diagnostic intra-articular facet blocks found no significant difference in positive rates between anesthetic, placebo, and sham injections. 97 Intra-articular steroid injections are sometimes used to treat cervical facet joint pain, but the technical failure rate is high, the only controlled trial evaluating steroid injections found no benefit, 98 and most systematic reviews have concluded that these injections are ineffective. 91 Clinical studies have found C2-3 and C5-6 to be the most commonly symptomatic levels, 99 100 whereas r adiological studies have found C3-4, C4-5, and C2-3 A hallmark of myofascial pain is the presence of palpable trigger points, which are taut muscle bands that refer pain in a defined pattern spontaneously or after stimulation, although their clinical relevance is controversial.…”

Infiltrationen und Radiofrequenztherapie der lumbalen und zervikalen Facettengelenke und der Iliosakralgelenke: Überblick, Evidenz und Ergebnisse

“…Die Genese von Lumbalgien und Lumboischialgien ist oftmals komplex und in praktisch allen Fällen multifaktoriell. Die Erstbeschreibung lumbaler Facettengelenke als mögliche schmerzauslösende Ursache erfolgte bereits 1911 durch Goldthwait [1,2], Ghormley beschrieb 1933 den Begriff des Facettengelenks-Syndroms als Kombination aus klinischer Symptomatik und einer Degeneration der lumbalen Facettengelenke [3]. Nach der Einführung des Novokains in 1905 beschrieben eine Reihe von Autoren unterschiedliche Injektionen im Bereich der Wirbelsäule zur Schmerzprovokation als auch -reduktion [4].…”

“…In der Betrachtung der Evidenz für eine diagnostisch positive Facettengelenksinfiltration der Lendenwirbelsäule ist allen Studienbedingungen gemein das das Ausmaß der Schmerzreduktion das maßgebliche Beurteilungskriterium darstellt. Darüber hinaus fehlt ein Gold-Standard [2].…”

“…Zur optimalen Aussage, sowie zur Differenzierung falschund richtig-positiver Responder können auch placebo-kontrollierte Blockaden mit NaCl durchgeführt werden [2].…”

“…Während Infiltrationen unter Studienbedingungen bei den allermeisten Autoren eine zusätzliche Validierung durch Wiederholingsinjektionen mit unterschiedlich langwirkenden Lokalanästhetika oder auch NaCl beschreiben, ist dies im klinischen Alltag nicht routinemäßig etabliert. Schütz et al beschreiben eine hohe Rate falsch positiver Befunde im Rahmen einer prospektiven Triple-crossover.Studie [2].…”