Você está na página 1de 7

RESEARCH ARTICLE

Facet Joint Pain in Chronic Spinal Pain: An Evaluation of


Prevalence and False-positive Rate of Diagnostic Blocks
Rajeev Manchukonda, BDS, Kavita N. Manchikanti, BA, Kimberly A. Cash, RT,
Vidyasagar Pampati, MSc, and Laxmaiah Manchikanti, MD

Conclusions: This retrospective review once again conrmed the


Study Design: A retrospective review. signicant prevalence of facet joint pain in chronic spinal pain.
Objectives: Evaluation of the prevalence of facet or zygapophy- Key Words: facet joints, zygapophysial joints, medial branch
sial joint pain in chronic spinal pain of cervical, thoracic, and blocks, controlled comparative local anesthetic blocks, cervical
lumbar origin by using controlled, comparative local anesthetic pain, thoracic pain, lumbar pain
blocks and evaluation of false-positive rates of single blocks in
the diagnosis of chronic spinal pain of facet joint origin. (J Spinal Disord Tech 2007;20:539545)
Summary of Background Data: Facet or zygapophysial joints are
clinically important sources of chronic cervical, thoracic, and
lumbar spine pain. The previous studies have demonstrated the
value and validity of controlled, comparative local anesthetic
T he lifetime prevalence of spinal pain has been reported
as 54% to 80%.19 It is conventionally believed that
most episodes of low back pain will be short-lived, with
blocks in the diagnosis of facet joint pain, with a prevalence of 80% to 90% of attacks resolving in about 6 weeks,
15% to 67% variable in lumbar, thoracic, and cervical regions. irrespective of the administration or type of treatment,
False-positive rates of single diagnostic blocks also varied from and with only 5% to 10% of patients developing
17% to 63%. persistent back pain. However, this belief is awed as
Methods: Five hundred consecutive patients receiving con- the condition tends to relapse and most patients will
trolled, comparative local anesthetic blocks of medial branches experience recurrent episodes. Modern evidence has
for the diagnosis of facet or zygapophysial joint pain were shown that chronic persistent low back pain and neck
included. Patients were investigated with diagnostic blocks using pain are seen in up to 25% to 75% of patients, 1 year or
0.5 mL of 1% lidocaine per nerve. Patients with lidocaine- longer after the initial episode.1,1018 In addition, chronic
positive results were further studied using 0.5 mL of 0.25% pain with the involvement of multiple regions is a
bupivacaine per nerve on a separate occasion. Medial branch common occurrence in more than 60% of patients.1922
blocks were performed with intermittent uoroscopic visualiza- Yet, even with its high prevalence and scientic advances,
tion, at 2 levels to block a single joint. A positive response was it has been suggested that a specic etiology of back pain
considered as one with at least 80% pain relief from a block of can be diagnosed with certainty in only about 15% of
at least 2 hours duration when lidocaine was used, and at least 3 patients based on clinical examination, radiologic evalua-
hours or longer than the duration of relief with lidocaine when tion, and nerve conduction studies in the absence of disc
bupivacaine was used, and also the ability to perform prior herniation and radicular symptomatology.1,23,24
painful movements. However, on the basis of precision diagnostic blocks,
the diagnosis of the cause of spinal pain may be made in
Results: A total of 438 patients met inclusion criteria. The approximately 85% of the patients.1,24,25
prevalence of facet joint pain was 39% in the cervical spine [95% Intervertebral discs, facet joints, ligaments, fascia,
condence interval (CI), 32%-45%]; 34% (95% CI, 22%-47%) muscles, and nerve root dura have been identied as
in the thoracic pain; and 27% (95% CI, 22%-33%) in the tissues capable of transmitting pain in the low back.26
lumbar spine. The false-positive rate with a single block in the Facet joint pain, discogenic pain, and sacroiliac joint pain
cervical region was 45%, in the thoracic region was 42%, and in also have been proven to be common causes of pain with
the lumbar region 45%. proven diagnostic techniques.1,24,25 The facet or zygapo-
physial joints are paired diarthrodial articulations be-
tween posterior elements of adjacent vertebrae. Spinal
Received for publication December 14, 2006; accepted March 1, 2007.
From the Pain Management Center of Paducah, Paducah, KY. facet joints have been shown in normal volunteers to be a
Conict of Interest: None. source of pain in the neck and referred pain in the
Disclaimer: There was no external funding in preparation of this head and upper extremities,2730 upper back, mid back,
manuscript. and referred pain in the chest wall,31,32 and the low back
Reprints: Laxmaiah Manchikanti, MD, Pain Management Center of
Paducah, 2831 Lone Oak Road, Paducah, KY 42003 (e-mail:
and referred pain in the lower extremity.3337 Facet joints
drm@apex.net). are well innervated by the medial branches of the dorsal
Copyright r 2007 by Lippincott Williams & Wilkins rami.3840

J Spinal Disord Tech  Volume 20, Number 7, October 2007 539


Manchukonda et al J Spinal Disord Tech  Volume 20, Number 7, October 2007

Biomechanical studies have shown that lumbar and patient care and outcomes through systematic review of
cervical facet joint capsules can undergo high strains care against explicit criteria and the implementation
during spine-loading.41 Neuroanatomic studies have of the change.54 A recently published clinical audit of
demonstrated free and encapsulated nerve endings in results of radiofrequency neurotomy for chronic neck
facet joints, and also nerves containing substance P and pain provided evidence of ecacy and generalizability of
calcitonin gene-related peptide.41 Neurophysiologic the procedure in routine clinical practice.53
studies have shown that facet joint capsules contain In this study, we sought to evaluate the prevalence
low-threshold mechanoreceptors, mechanically sensitive of facet joint pain by spinal region in patients with
nociceptors, and silent nociceptors.41 chronic spinal pain presenting to an interventional pain
On the basis of controlled diagnostic blocks of facet management practice for diagnosis and treatment. We
joints, in accordance with the criteria established by the used the same protocol21 as was previously published to
International Association for the Study of Pain,42 facet determine the presence of facet joint pain using responses
joints have been implicated as responsible for spinal pain to controlled comparative local anesthetic facet joint
in 15% to 45% of the patients with chronic low back nerve blocks, performed in accordance with International
pain,21,25,4346 42% to 48% of patients with chronic Association for the Study of Pain criteria.42
thoracic pain,21,47 and 54% to 67% of patients with
chronic neck pain.21,4850
Multiple authors25,4350 in the past have studied MATERIALS AND METHODS
individual regions and presented the results in various In this retrospective evaluation, 500 consecutive
types of practices. Manchikanti et al21 evaluated 500 patients receiving controlled comparative local anesthetic
patients in an interventional pain management practice blocks were included. The patients presented with chronic
setting with comparative local anesthetic blocks in a neck, thoracic, or low back pain or a combination
prospective study and reported the prevalence of facet thereof. Patients were managed by one physician in a
joint pain in patients with chronic cervical spine pain as nonuniversity, private practice setting in the United
55%, chronic thoracic spine pain as 42%, and lumbar States. The procedures were performed in an interven-
spine as 31%. They also reported false-positive rates with tional pain management ambulatory surgery center. The
single blocks with lidocaine of 63% in the cervical spine, practice provides comprehensive, interventional pain
55% in the thoracic spine, and 27% in the lumbar spine. management services.
Systematic reviews51,52 also have established the preva- The chart review was performed by 3 investigators
lence, false-positive rates, and the value and validity of who were not involved in performing the procedures.
diagnostic facet or zygapophysial joint blocks. Even then, Inclusion criteria at the institution included: con-
all these studies were performed by 2 investigators of secutive patients undergoing controlled comparative local
heterogenous settings and populations. anesthetic blocks, of ages 18 to 90 years, who had pain for
Generalizability is a measure of the extent to which at least 6 months, which was nonspecic rather than
others can achieve the same outcomes as those of original radicular in nature. The treating physician excluded disc-
authors. Consequently, it is an important feature of any related pain with radicular symptoms in all patients based
intervention, either therapeutic or diagnostic. In practical on radiologic or neurologic testing, lack of a neurologic
terms, generalizability may be reected by the extent to decit, and radicular symptoms or pain that involved
which practitioners in a conventional practice can predominantly the upper or lower extremity or chest wall.
reproduce results obtained in academic research studies, All patients selected had failed conservative management
or reproduce the results in a large population base.53 including physical therapy, chiropractic manipulation,
Generalizability is also achieved by multiple prospective exercises, drug therapy, and bedrest.
or randomized trials. Consequently, in the case of Each of the patients had a work-up, which included
prevalence of spinal facet joint pain, all the prospective comprehensive history, physical examination, and evalua-
studies have been produced by only the 2 groups. Thus, tion of the results of prior procedures and investigations.
further trials by dierent groups are required. However, Of the 500 patients who had undergone controlled
another approach is to conduct a retrospective review in a comparative local anesthetic blocks, 438 patients were
substantial series of patients. Such an evaluation would eligible to be included in the retrospective review. The
demonstrate whether the same or similar outcomes can be study period lasted from January 2004 to March 2006.
achieved in practical settings as have been reported in Facet joint pain was investigated in all patients
research studies. starting with diagnostic blocks using 1% lidocaine.
Yet another method of conrming the results of a Patients with lidocaine-positive results were further
previous study and solving the problem of reproducibility studied using 0.25% bupivacaine on a separate occasion,
is to conduct a clinical audit on the basis of available data usually 3 to 4 weeks after the rst injection. The blocks
to ensure this knowledge is being used to the best eect. were performed on the ipsilateral side in patients with
Outcomes for a large series of patients, formerly unilateral pain or bilaterally in patients with bilateral or
initiated in 1993 at the United Kingdoms National axial pain. Blocks were performed at a minimum of 2
Health Service (NHS), clinical audit was dened as, a levels to block a single joint. Target joints were identied
quality improvement process that seeks to improve by the pain pattern, local or paramedian tenderness over

540 r 2007 Lippincott Williams & Wilkins


J Spinal Disord Tech  Volume 20, Number 7, October 2007 Facet Joint Pain in Chronic Spinal Pain

the area of the facet joints, and reproduction of pain with additional variable in the demographic characteristics was
deep pressure. Blocks were performed with intermittent height, which was greater in patients with involvement of
uoroscopic visualization using a 22-gauge, 2-inch spinal 1 region compared with 2 regions or 2 to 3 regions.
needle at each of the indicated medial branches in the Salient features based on regional involvement of
cervical and thoracic spine, and with a 22-gauge, 3.5-inch the spine are illustrated in Table 2. There were no
spinal needle at each of the indicated medial branches at signicant dierences noted in any of the variables.
the L1-L4 levels and the L5 dorsal ramus at the L5 level
of the lumbar spine. Results of Comparative Local Anesthetic Blocks
Intravenous access was established and light seda- Table 3 illustrates the results of diagnostic blocks
tion with midazolam was oered to all patients. Each evaluating facet joint pain in all 3 regions. In the cervical
facet nerve was inltrated with 0.5 mL of 1% lidocaine or spine, lidocaine blocks were performed in 251 patients, in
0.25% bupivacaine. Following each block, the patient 65 patients in the thoracic spine, and 303 patients in the
was examined and asked to perform previously painful lumbar spine. Of these, 175 of 251 patients in the cervical
movements. A positive response was dened as at least an spine reported a denite response with a positive result to
80% reduction of pain with ability to perform previously initial lidocaine blocks, whereas 38 of the 65 patients in
painful movements, as assessed using a verbal numeric the thoracic spine reported a positive result, and 150 of
pain rating scale. To be considered positive, pain relief 303 patients with lumbar spinal pain reported positive
from a block had to last at least 2 hours when lidocaine results with a single lidocaine block.
was used, and at least 3 hours, or longer than the duration Of the 175 patients positive for single blocks with
of relief with lidocaine, when bupivacaine was used. Any lidocaine, 97 patients reported positive response to
other response was considered as a negative outcome. bupivacaine blocks in the cervical spine, whereas 22 of
All patients judged to have a positive response with 38 patients in the thoracic spine positive for single
lidocaine blocks underwent subsequent bupivacaine lidocaine blocks were also positive with bupivacaine
blocks. Patients who were determined not to have facet blocks. Eighty-three patients in the lumbar spine showed
joint pain were oered other diagnostic or therapeutic positive results with bupivacaine from 150 of the
interventions, including discography, epidural injections, lidocaine positive patients.
or sacroiliac joint injections. The controlled comparative local anesthetic blocks
Data were recorded on a Microsoft Access 97 with positive results using double local anesthetic blocks
database. The SPSS version 9.0 Statistical Package was provided a prevalence rate of facet joint pain in patients
used to generate frequency tables. The prevalence and with chronic neck pain of 39% (95% CI, 32%-45%); 34%
95% condence intervals (CI) were calculated. Dier- (95% CI, 22%-47%) in patients with chronic thoracic
ences in proportions were tested using the w2 test. Fischer pain; and 27% (95% CI, 22%-33%) in patients with
exact test was used whenever the expected value was less chronic low back pain.
than 5. Results were considered statistically signicant if Table 3 also illustrates false-positive rates. False-
the P value was <0.05. positive rates were calculated by assuming all patients
with no response to lidocaine to be true negative, and all
RESULTS patients with a positive response to lidocaine and a
Five hundred consecutive patients undergoing con- negative response to bupivacaine or positive response to
trolled comparative local anesthetic blocks for the both lidocaine and bupivacaine as false-positives. The
evaluation of facet joint pain were reviewed. Of these, false-positive rates for cervical facet joints with a single
438 patients met the inclusion criteria. Sixty-two patients block were 45% (95% CI, 37%-52%), for thoracic facet
were excluded from the review. Patient ow is illustrated joints with a single lidocaine block were 42% (95% CI,
in Figure 1. 26%-59%), and for lumbar spine 45% (95% CI,
36%-53%).
Patient Evaluation Flow Pattern
All the patients were included in the analysis. As
Characteristics of Regional Involvement
shown in Figure 1, follow-up was not available after the Table 4 illustrates facet joint involvement by region
rst block in 4 patients in lumbar, 8 patients in cervical, on the basis of controlled comparative local anesthetic
and 3 patients in thoracic regions, whereas follow-ups blocks. Overall, at least one region was judged to be
were not available after the second block in 10 patients in positive in 156 patients or 36% of the 438 patients.
lumbar, 12 patients in cervical, and 2 patients in thoracic However, in 25% of the 181 patients were positive among
groups. The results were considered negative or false- patients with involvement of 2 and 3 regions.
positive for all the patients with lack of follow-up. Adverse Effects
Demographic Characteristics No major adverse eects were noted in this study.
Demographic characteristics are illustrated in Table 1.
Signicant dierences were identied in patients with DISCUSSION
involvement of 1 region and 2 regions with a greater This retrospective evaluation of patients with
proportion of female patients compared with male. An chronic nonspecic spinal pain involving the cervical,

r 2007 Lippincott Williams & Wilkins 541


Manchukonda et al J Spinal Disord Tech  Volume 20, Number 7, October 2007

Patients not meeting inclusion criteria = 62


Eligible PatientsAssessed
36 patients did not meet at least 6 months
500
duration of pain criteria
4 patients were less than 18 years of age
12 patients have undergone surgical
intervention within the past 6 months in
cervical, thoracic, or lumbar spine with disc
Patients included procedures or vertebroplasty
10 patients had no information with
for evaluation= 438
evaluation for disc-related problems or had
no information on conservative treatment
prior to facet joint blocks

Involvement of
Involvement of Involvement of
three regions = 15
one region = 272 two regions = 151

Thoracic pain = 65
Lumbar pain = 303
Cervical pain = 251

Patients included in Patients included in


analysis = 303 Patients included in analysis = 65
analysis = 251

Follow-up not available


Follow-up not available
after 1 block = 4 Follow-up not available
after 1 block = 3
Follow-up not available after 1 block = 8
Follow-up not available
after 2 block = 10 Follow-up not available
after 2 block = 2
Total = 14 after 2 block = 12
Total = 5
Total = 20

Results were considered Results were considered Results wereconsidered


negative = 4 negative = 8 negative = 3
Results were considered Results were considered Results were considered
FIGURE 1. Schematic representation of false-positive = 14 false-positive = 20 false-positive = 5
the review and patient flow.

thoracic, and lumbar regions, alone or in combination,


TABLE 1. Demographic Characteristics demonstrated by spinal region that the prevalence of
One Region Two Regions Three Regions Total cervical facet or zygapophysial joint pain in patients with
(272) (151) (15) (438) neck pain is 39%, thoracic facet joint pain in patients
Sex with mid back or upper back pain is 34%, and
Male 45% (122) 26% (39) 33% (5) 38% involvement of lumbar facet joints in patients with
(166)
Female 55%*(150) 74%*(112) 67% (10) 62%
chronic low back pain is 27%. The prevalence will be
(272) reduced if it is calculated on the basis of the total number
Age (y) of patients evaluated for the entire spine rather than
Range 18-92 17-84 25-57 17-92 regional. Thus, these numbers show regional involvement
Mean SEM 48 1.0 46 1.2 42 2.4 47 0.7 and evaluation of the patients for that particular region.
Weight (lbs)
Range 97-390 99-427 123-220 97-427
These results are in overall agreement with the previous
Mean SEM 187 2.9 180 4.1 173 7.2 184 2.3 studies, although somewhat less than the ones published
Height (in) by the same group.21
Range 57-76 58-76 60-72 57-76 The false-positive rates were quite high with single
Mean SEM 67.3w 0.2 65.9 0.3 65.1 1.0 66.8 0.2 blocks: 45% for the cervical spine, 42% for the thoracic
*Signicant dierence compared to the male with involvement of 1 or 2 spine, and 45% for the lumbar spine. Once again, the
regions (P<0.01). results are similar to previous ndings, even though there
wSignicant dierence compared to the group with involvement of 2 or 3
regions (P<0.05). are some dierences with the same group of authors with
the results published in a prospective evaluation.21,25,4352

542 r 2007 Lippincott Williams & Wilkins


J Spinal Disord Tech  Volume 20, Number 7, October 2007 Facet Joint Pain in Chronic Spinal Pain

joint is anesthetized by the medial branches of the


TABLE 2. Baseline Salient Features Based on Regional
Involvement of the Spine dorsal rami that innervate the target joint, if pain is
relieved, the joint is considered to be the source of pain.55
Cervical (251) Thoracic (65) Lumbar (303)
However, true-positive responses are determined by
Sex performing controlled blocks, either in the form of
Male 31% (79) 29% (19) 39% (117)
Female 69% (172) 71% (46) 61% (186)
placebo injection of normal saline or more commonly in
Age (y) the form of comparative local anesthetic blocks on
Range 17-78 20-92 17-89 2 separate occasions, when the same joint is anesthetized
Mean SEM 45.4 0.9 45.4 2.1 47.7 0.9 using local anesthetics with dierent durations of action.
Height (in) The value and validity of medial branch blocks and
Range 58-76 59-76 57-76
Mean SEM 66.4 0.2 66.1-0.5 66.7 0.2 comparative local anesthetic blocks in the diagnosis
Weight (lbs) of facet joint pain has been demonstrated.21,25,4352,5567
Range 99-427 113-287 97-427 In addition, because there are no clinical features or
Mean SEM 180.3 2.9 168.3 4.2 187.4 3.0 diagnostic imaging studies that can determine whether
Duration of Pain (mo)
Range 6-338 6-330 6-430
a facet joint is painful or not, controlled blocks seem
Mean SEM 85.6 5.3 75.8 9.6 107.5 6.2 to be a reliable tool in the diagnosis of chronic spinal
Mode of onset of pain pain.
Gradual 55% (138) 60% (39) 54% (164) The results noted in this study conrm the previous
Following an incident 45% (9113) 40% (26) 46% (139) results, lending external validity to the primary ndings.
Distribution of pain
Left 15% (38) 5% (3) 9% (26) The study was performed in the setting of an interven-
Right 13% (33) 15% (10) 12% (38) tional specialty practice in a private practice setting in the
Bilateral 72% (180) 80% (52) 79% (239) United States. Yet, it may be criticized that the authors
No. joints involved performing the procedures in the retrospective review also
2 50% (127) 19% (12) 63% (191)
3 49% (122) 29% (19) 36% (109)
was involved in the primary study. On the one hand, this
Z4 1% (2) 52% (34) 1% (3) may provide uniformity. On the other hand, it provides
basis for the criticism that the results are the same. This
criticism may be invalidated by the fact that the present
retrospective study shows lesser prevalence of facet
joint pain. Prevalence of facet joint pain was 55% in
The study also demonstrated bilateral involvement the cervical spine, 42% in the thoracic spine, and 31%
in 72% of patients in the cervical spine, 80% in the in the lumbar spine compared with 39% in the present
thoracic spine, and 79% in the lumbar spine. Overall 77% study in the cervical region, 34% in the thoracic
of the patients presented with bilateral involvement. In region, and 27% in the lumbar region. This study also
addition, this study also showed involvement of multiple reinforces that the results of a retrospective review can
regions with 38% of the patients with involvement of provide valuable information similar to a prospective
more than one region. evaluation.
This study once again rearms the evidence that Even though the existence of facet joint pain is not
involvement of facet joints, as a cause of chronic spinal universally accepted and the diagnostic methodology is
pain is real as proven overwhelmingly by numerous not endorsed, it is the best available method to diagnose
studies. Facet joints have been shown to be a source facet joint pain in chronic spinal pain. By conrming the
of chronic spinal pain by means of diagnostic techniques results of the original research studies of diagnostic facet
of known reliability and validity.21,25,4352,5559 Blocks of joint blocks, the results of the present study might
facet joints are performed to test the hypothesis that the encourage others to use appropriate diagnostic techniques
target joint is a source of the patients pain.55 Once a facet in managing chronic spinal pain.

TABLE 3. Results of Single and Double Facet Joint Nerve Blocks (Single Blocks With Lidocaine and Double Blocks With Lidocaine
and Bupivacaine)
Cervical (251) Thoracic (65) Lumbar (303)
Double Blocks* Double Blocks* Double Blocks*
Single Blocksw Positive Negative Positive Negative Positive Negative
Positive 97 78 22 16 83 67
Negative 76 27 153
Prevalence 39% (95% CI, 32%-45%) 34% (95% CI, 22%-47%) 27% (95% CI, 22%-33%)
False-positive rate 45% (95% CI, 37%-52%) 42% (95% CI, 26%-59%) 45% (95% CI, 36%-53%)
*With double blocks, 97 patients with neck pain, 22 with thoracic pain, and 83 with lumbar pain had positive responses.
wWith single blocks in the cervical spine, 175 patients (ie, 97+78) had positive responses with lidocaine blocks, 38 (22+16) patients with thoracic pain had positive
responses, and 150 (83+67) patients with lumbar pain had positive responses.

r 2007 Lippincott Williams & Wilkins 543


Manchukonda et al J Spinal Disord Tech  Volume 20, Number 7, October 2007

12. Croft PR, Lewis M, Papageorgiou AC, et al. Risk factors for neck pain:
TABLE 4. Facet Joint Involvement by Region on the Basis a longitudinal study in the general population. Pain. 2001;93:317325.
of Double Facet Joint Blocks 13. Cote P, Cassidy JD, Carroll LJ, et al. The annual incidence and
Double Blocks Number % of Positive course of neck pain in the general population: a population-based
cohort study. Pain. 2004;112:267273.
At least 1 region positive 438 36% (156) 14. Enthoven P, Skargren E, Oberg B. Clinical course in patients
At least 2 regions positive 166 26% (43) seeking primary care for back or neck pain: a prospective 5-year
All 3 regions positive 15 20% (3) follow-up of outcome and health care consumption with subgroup
analysis. Spine. 2004;29:24582465.
15. Elders LA, Burdorf A. Prevalence, incidence, and recurrence of low
back pain in scaolders during a 3-year follow-up study. Spine.
CONCLUSIONS 2004;29:E101E106.
This evaluation showed that patients with chronic, 16. Croft PR, Papageorgiou AC, Thomas E, et al. Short-term physical
risk factors for new episodes of low back pain. Prospective evidence
nonspecic spinal pain involving cervical, thoracic, from the South Manchester Back Pain Study. Spine. 1999;24:
and lumbar spine may be evaluated for the prevalence 15561561.
of facet joint pain. However, this should be performed 17. Miedema HS, Chorus AMJ, Wevers CWJ, et al. Chronicity of back
with controlled, comparative local anesthetic blocks problems during working life. Spine. 1998;23:20212028.
owing to the signicant rate of false-positive response. 18. Thomas E, Silman AJ, Croft PR, et al. Predicting who develops
chronic low back pain in primary care. A prospective study. Brit
Painful cervical facet joints were identied in 39% of the Med J. 1999;318:16621667.
patients in the cervical spine, 34% of the patients in the 19. Yeung SS, Genaidy A, Deddens J, et al. Prevalence of musculoske-
thoracic spine, and 27% of the patients in the lumbar letal symptoms in single and multiple body regions and eects of
spine. perceived risk of injury among manual handling workers. Spine.
2002;27:21662172.
20. Manchikanti L, Pampati V. Research designs in interventional pain
ACKNOWLEDGMENTS management: is randomization superior, desirable or essential? Pain
The authors thank Tonie Hatton and Diane Neiho, Physician. 2002;5:275284.
21. Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint
transcriptionists; Kim S. Damron, RN and Carla D. pain in chronic spinal pain of cervical, thoracic, and lumbar regions.
McManus, RN, BSN, clinical coordinators; and Doris E. BMC Musculoskelet Disord. 2004;5:15.
Brandon, CST; for their assistance in preparation of this 22. Jacob T, Zeev A. Are localized low back pain and generalized back
manuscript. pain similar entities? Results of a longitudinal community based
study. Disabil Rehabil. 2006;28:369377.
23. Bogduk N, McGuirk B. Causes and sources of chronic low back
pain. In: Bogduk N, McGuirk B, eds. Medical Management of Acute
REFERENCES and Chronic Low Back pain. An Evidence-Based Approach: Pain
1. Boswell MV, Shah RV, Everett CR, et al. Interventional techniques Research and Clinical Management. Amsterdam: Elsevier Science
in the management of chronic spinal pain: evidence-based practice BV; 2002;13:115126.
guidelines. Pain Physician. 2005;8:147. 24. Bogduk N, McGuirk B. An algorithm for precision diagnosis. In:
2. Elliott AM, Smith BH, Hannaford PC, et al. The course of chronic Bogduk N, McGuirk B, eds. Medical Management of Acute and
pain in the community: results of a 4-year follow-up study. Pain. Chronic Low Back pain. An Evidence-Based Approach: Pain Research
2002;99:299307. and Clinical Management. Amsterdam: Elsevier Science BV; 2002;
3. Bressler HB, Keyes WJ, Rochon PA, et al. The prevalence of low 13:177186.
back pain in the elderly. A systemic review of the literature. Spine. 25. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the relative
1999;24:18131819. contributions of various structures in chronic low back pain. Pain
4. Lawrence RC, Helmick CG, Arnett FC. Estimates of the prevalence Physician. 2001;4:308316.
of arthritis and selected musculoskeletal disorders in the United 26. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back
States. Arthritis Rheum. 1998;41:778799. pain and sciatica: a report of pain response to tissue stimulation
5. Cassidy JD, Carroll LJ, Cote P. The Saskatchewan Health during operation on the lumbar spine using local anesthesia. Orthop
and Back Pain Survey. The prevalence of low back pain and Clin North Am. 1991;22:181187.
related disability in Saskatchewan Adults. Spine. 1998;23: 27. Fukui S, Ohseto K, Shiotani M, et al. Referred pain distribution of
18601867. the cervical zygapophyseal joints and cervical dorsal rami. Pain.
6. Guo HR, Tanaka S, Halperin WE, et al. Back pain prevalence in US 1996;68:7983.
industry and estimates of lost workdays. Am J Public Health. 1999; 28. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain
89:10291035. patterns: a study in normal volunteers. Spine. 1990;15:453457.
7. Cote P, Cassidy JD, Carroll LJ. The Saskatchewan Health and Back 29. Aprill C, Dwyer A, Bogduk N. The prevalence of cervical
Pain Survey. The prevalence of neck pain and related disability in zygapophyseal joint pain patterns II: a clinical evaluation. Spine.
Saskatchewan adults. Spine. 1998;23:16891698. 1990;15:458461.
8. Linton SJ, Hellsing AL, Hallden K. A population based study of 30. Windsor RE, Nagula D, Storm S. Electrical stimulation induced
spinal pain among 3545-year old individuals. Spine. 1998;23: cervical medial branch referral patterns. Pain Physician.
14571463. 2003;6:411418.
9. Miemelainen R, Videman T, Battie MC. Prevalence and character- 31. Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophyseal joint
istics of upper or mid-back pain in Finnish men. Spine. pain patterns: a study in normal volunteers. Spine. 1994;19:807811.
2006;31:18461849. 32. Fukui S, Ohseto K, Shiotani M. Patterns of pain induced by
10. Cassidy JD, Cote P, Carroll LJ, et al. Incidence and course of low distending the thoracic zygapophyseal joints. Reg Anesth. 1997;
back pain episodes in the general population. Spine. 2005;30: 22:332336.
28172823. 33. Mooney V, Robertson J. The facet syndrome. Clin Orthop. 1976;
11. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is 115:149156.
the long-term course? A review of studies of general patient 34. McCall IW, Park WM, OBrien JP. Induced pain referral from
populations. Eur Spine J. 2003;12:149165. posterior elements in normal subjects. Spine. 1979;4:441446.

544 r 2007 Lippincott Williams & Wilkins


J Spinal Disord Tech  Volume 20, Number 7, October 2007 Facet Joint Pain in Chronic Spinal Pain

35. Marks R. Distribution of pain provoked from lumbar facet joints 52. Boswell MV, Singh V, Staats PS, et al. Accuracy of precision
and related structures during diagnostic spinal inltration. Pain. diagnostic blocks in the diagnosis of chronic spinal pain of facet or
1989;39:3740. zygapophysial joint origin: a systematic review. Pain Physician.
36. Fukui S, Ohseto K, Shiotani M, et al. Distribution of referred pain 2003;6:449456.
from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain. 53. Barnsley L. Percutaneous radiofrequency neurotomy for chronic
1997;13:303307. neck pain: outcomes in a series of consecutive patients. Pain Med.
37. Windsor RE, King FJ, Roman SJ, et al. Electrical stimulation 2005;6:282286.
induced lumbar medial branch referral patterns. Pain Physician. 54. National Institute for Clinical Excellence. Principles for Best
2002;5:347353. Practice in Clinical Audit. Oxon, UK: Radclie Medical Press Ltd;
38. Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine. 2002.
1982;7:319330. 55. Bogduk N. International Spinal Injection Society guidelines for the
39. Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. performance of spinal injection procedures. Part 1: zygapophyseal
J Anat. 1982;134:383397. joint blocks. Clin J Pain. 1997;13:285302.
40. Chua WH, Bogduk N. The surgical anatomy of thoracic facet 56. Dreyfuss P, Schwarzer AC, Lau P, et al. Specicity of lumbar medial
denervation. Acta Neurochir. 1995;136:140144. branch and L5 dorsal ramus blocks. Spine. 1997;22:895902.
41. Cavanaugh JM, Lu Y, Chen C, Kallakuri S. Pain generation in 57. Kaplan M, Dreyfuss P, Halbrook B, et al. The ability of lumbar
lumbar and cervical facet joints. J Bone Joint Surg Am. 2006; medial branch blocks to anesthetize the zygapophysial joint. Spine.
88:6367. 1998;23:18471852.
42. Merskey H, Bogduk N. Classication of Chronic Pain: Descriptions 58. Lord SM, Barnsley L, Bogduk N. The utility of comparative local
of Chronic Pain Syndromes and Denitions of Pain Terms. 2nd ed. anesthetic blocks versus placebo-controlled blocks for the diagnosis
Seattle: IASP Press; 1994. of cervical zygapophysial joint pain. Clin J Pain. 1995;11:208213.
43. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of 59. Lord S, Bogduk N. Comparative local anesthetic blocks in the
patients with pain stemming from the lumbar zygapophysial joints. diagnosis of cervical zygapophysial joints pain. Pain. 1993;55:
Is the lumbar facet syndrome a clinical entity? Spine. 99106.
1994;19:11321137. 60. Schwarzer AC, Aprill CN, Derby R, et al. The false-positive rate of
44. Manchikanti L, Pampati V, Fellows B, et al. Prevalence of lumbar uncontrolled diagnostic blocks of the lumbar zygapophysial joints.
facet joint pain in chronic low back pain. Pain Physician. 1999;2: Pain. 1994;58:195200.
5964. 61. Schwarzer AC, Derby R, Aprill CN, et al. The value of the
45. Manchikanti L, Pampati V, Fellows B, et al. The diagnostic validity provocation response in lumbar zygapophysial joint injections. Clin
and therapeutic value of medial branch blocks with or without J Pain. 1994;10:309313.
adjuvants. Curr Rev Pain. 2000;4:337344. 62. Barnsley L, Lord S, Wallis B, et al. False-positive rates of cervical
46. Schwarzer AC, Wang SC, Bogduk N, et al. Prevalence and clinical zygapophysial joint blocks. Clin J Pain. 1993;9:124130.
features of lumbar zygapophysial joint pain: a study in an Australian 63. Barnsley L, Bogduk N. Medial branch blocks are specic for the
population with chronic low back pain. Ann Rheum Dis. diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993;
1995;54:100106. 18:343350.
47. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the 64. Manchikanti L, Singh V, Pampati S. Are diagnostic lumbar medial
prevalence of facet joint pain in chronic thoracic pain. Pain branch blocks valid? Results of 2-year follow-up. Pain Physician.
Physician. 2002;5:354359. 2003;5:147153.
48. Barnsley L, Lord SM, Wallis BJ, et al. The prevalence of chronic 65. Manchikanti L, Pampati V, Damron KS, et al. A randomized,
cervical zygapophyseal joint pain after whiplash. Spine. 1995; prospective, double-blind, placebo-controlled evaluation of the
20:2026. eect of sedation on diagnostic validity of cervical facet joint pain.
49. Lord SM, Barnsley L, Wallis BJ, et al. Chronic cervical zygapo- Pain Physician. 2004;7:301309.
physial joint pain with whiplash: a placebo-controlled prevalence 66. Manchikanti L, Damron KS, Rivera J, et al. Evaluation of eect of
study. Spine. 1996;21:17371745. sedation as a confounding factor in the diagnostic validity of lumbar
50. Manchikanti L, Singh V, Rivera J, et al. Prevalence of cervical facet facet joint pain: a prospective, randomized, double-blind, placebo-
joint pain in chronic neck pain. Pain Physician. 2002;5:243249. controlled evaluation. Pain Physician. 2004;7:411417.
51. Sehgal N, Shah RV, McKenzie-Brown A, et al. Diagnostic utility 67. Manchikanti L, Pampati V, Fellows B, et al. Inuence of
of facet (zygapophysial) joint injections in chronic spinal pain: psychological factors on the ability to diagnose chronic low back
a systematic review of evidence. Pain Physician. 2005;8:211224. pain of facet joint origin. Pain Physician. 2001;4:349357.

r 2007 Lippincott Williams & Wilkins 545

Você também pode gostar