Facet Injections and Ablation: They can Work! Let me Tell You How - - PowerPoint PPT Presentation

Facet Injections and Ablation: They can Work! Let me Tell You How

COLIN B. HARRIS, MD

ASSISTANT PROFESSOR DEPARTMENT OF ORTHOPAEDICS RUTGERS – NEW JERSEY MEDICAL SCHOOL NEWARK, NJ

Disclosures

• Consulting – Globus, Inc.

Background

• Lumbar central canal stenosis common in patients >65 yrs
• f age
• Clinical syndrome of low back pain (LBP) +/-
• Radiculopathy
• Neurogenic claudication
• Conservative treatment
• NSAID’s
• Physical Therapy

Treatment algorithm

• NSAID’s
• Physical

Therapy

Conservative

• Epidural
• Facet injection
• Medial branch

blocks

Injections

• Laminectomy
• Fusion
• Interspinous

device

Surgery

“Three Joint Complex”

• Spinal motion segment
• Intervertebral disc + 2 paired facet

(zygaphophyseal) joints

• Disc degeneration -> micro-

instability -> facet degeneration

• Late stabilization (osteophytes)

Kirkaldy-Willis, Farfan Clin Orthop 1982

Anatomy of Facet

• Superior articular process “SAP”

(dorsomedial)

• Inferior articular process “IAP”

(ventrolateral)

• Capsule
• 1 mm thick
• Attaches 2 mm from articular surface
• Innervation: two medial branches of dorsal

primary ramus and level above (MBB)

SAP IAP

“Facet Syndrome”

• Sagittally oriented in lumbar spine
• Unlike disc -> restricts rotatory motion, allows

flexion and extension

• Protects disc from excessive shear / torsional strain
• Disc degen -> load shifts posteriorly to facets
• Aging
• Micro-instability
• Often accompanies spinal stenosis

CT Grading of Facet Degeneration

Types of Facet Injections

• Intra-articular blocks
• Medial branch blocks
• Radiofrequency ablation (RFA)

Intra-articular injections

• Mooney and Robertson 1976
• Target joint capsule
• Anesthetic of known half-life -> Diagnostic block
• <50% maintain response over 3-6 months
• Lowest level of evidence but commonly performed

Mooney V, Robertson J. Clin Orthop 1976;115:149-57.

Protocol

• Facets postulated as pain generator
• Controlled, diagnostic block with arthrogram
• Zygapophyseal pain likely if 100% relief

Varlotta G, et al. Skeletal Radiol 2011;40:149-157

Medial branch blocks “MBB”

• Innervation to joint directly targeted
• Significant improvements in pain reported at

3,6, 9 and 12 months (Manchikanti et al 2007)

• Pain fibers inhibited by anesthetic alone

(steroids not critical)

• Risk of complications low

Medial branch neurotomy (ablation)

• Shealy 1974 -> “facet denervation”
• Percutaneous coagulation / denervation (RF

electrode)

• Later found to be anatomically flawed
• Renamed “Medial Branch Neurotomy”

Bogduk et al. 1980

• Nerve proteins denatured-> lasting

effect

• 60-90% of patients good relief at 9-12

months (Dreyfuss, Gofeld et al.)

Bogduk N. Spine J 2008;1:56-64.

• Review of 21 RCT and 5 observational studies (chronic LBP)
• At least 50% improvement in pain and functional status = effective
• Long-term effectiveness Level II for radiofrequency neurotomy and lumbar

facet joint nerve blocks

• Level III for lumbar intra-articular injections
• Level IV for cervical intra-articular injections

Lumbar facet injections work…

But what about for spinal stenosis?

• Retrospective review (N=42 pts)
• Mean age 58 yrs
• All patients with central canal stenosis or severe stenosis (Guen

grade 3) with a “bleeding diathesis”

• 25/42 (59.5%) received effective treatment (median 145 days)
• 72% effective (pts with mild stenosis) vs. 41% effective (severe stenosis)
• No incidence of bleeding or major complications
• Conclusion: FJI are viable and safer alternative to ESI

• Retrospective review (N=73 pts over 1 year period)
• All pts underwent facet joint injections (FJI) and epidural steroid

injections (ESI) for lumbar central stenosis

• Mean age 69.7 yrs, 66% received FJI as 3rd injection (patient choice)
• 13/19 (68%) reported FJI to be effective after initial ineffective ESI
• 3/6 (50%) reported ESI to be effective after initial ineffective FCI

Conclusions

• Facet injections / MBB can play an important role in chronic

LBP and spinal stenosis

• Risk of complications is low (vs. ESI)
• Diagnostic injections useful prior to starting treatment
• Best data is for Medial Branch Neurotomies (vs. intra-articular)

Conclusions

• However…
• Procedures may be over-utilized ->
• High level evidence lacking to make definite recommendation
• Surgical decompression still best for neuro deficits, progressive symptoms,

severe stenosis

Conclusions

• However…
• Procedures may be over-utilized -> Must accurately diagnose pain generator
• High level evidence lacking to make definite recommendation
• Surgical decompression still best for neuro deficits, progressive symptoms,

severe stenosis

Thank you!