Ossification of the mamillo-accessory ligament: a review of the literature and clinical considerations / 대한해부학회지

Ossification of the mamillo-accessory ligament (MAL) is a misunderstood phenomenon; however, many have posited that it can result in nerve entrapment of the medial branch of the dorsal ramus causing zygapophyseal joint related low back pain. The MAL has been studied anatomically by few, yet the data indicate possible associations between ossification of this ligament and spondylosis. It has been proposed that mechanical stress upon the lumbar spine may also lead to progressive ossification of the MAL into a bony foramen.

Postdural Puncture Headache after Cervical Medial Branch Block

Cervical medial branch block (MBB) is a frequently performed procedure for management of neck pain that rarely has complications. With fluoroscopic guidance, the procedure is considered a relatively safer procedure than epidural block. We report a case of a 27-year-old woman presenting with postural headache after cervical MBB. Dural penetration by inappropriate needle placement was suspected after reviewing fluoroscopic images of the procedure. After conservative treatment, including bed rest and analgesic treatment, the patient completely recovered without any neurological complications. Complications associated with MBB are rare and previous case reports have focused only on infection or vascular injection as etiologies. This is the first report of complications related to dural puncture after cervical MBB. Our findings suggest that misplacement of the block needle by inaccurate alignment of both sides of the cervical articular pillar, assessed by fluoroscopic view during the procedure, can result in dural injury.

Clinical therapeutic effect of spinal nerve medial branch ablation through transforaminal endoscopic in treatment of lumbar zygapophysial joint pain / 实用医学杂志

Objective To investigate the clinical value and effect of spinal nerve medial branch ablation through transforaminal endoscopic in treatment of lumbar zygapophysial joint pain. Methods From August 2008 to October 2013 ,96 patients diagnosed as lumbar zygapophysial joint pain were included in the research. 36 patients were treated by spinal nerve medial branch ablation through transforaminal endoscopic ,while 60 patients received conservative treatment. The visual analogue scale (VAS) and Japanese Orthopedics Association(JOA) scores before treatment,1,3,6 and 12 months after treatment were recorded and analyzed. The MacNab scores were recorded and analyzed 12 months after treatment. Results The VAS and JOA scores of surgical treatment group showed significant improvement compared with that before operation (P < 0.05),and there were no significant difference at each time point after surgery. The VAS and JOA scores of conservative treatment group in showed significant improved at 1 months after treatment compared with that before treatment(P<0.05),but there were no significant difference at each time after treatment compared with pretreatment. The VAS and JOA scores of surgical treatment group showed significant improvement compared with conservative treatment group at each time after treatment(P<0.05). The MacNab scores of surgical treatment group(94.44%)was significantly higher than that of conservative treatment group(33.33%). Conclusion The spinal nerve branches ablation under transforaminal endoscopic is an effective and safe minimally invasive spine surgery technique with important clinical value in the treatment of lumbar zygapophysial joint pain.

Distribution characteristics of the medial branch of the posterior branch of the spinal nerves around the lumbar facet joints and its clinical significance / 局解手术学杂志

Objective To examine the distribution characteristics the medial branch of the posterior branch of the spinal nerves around the lumbar facet joints, so as to explore the localization and targeting of the medial branch of the posterior branch in neurectomy.MethodsFive corpses were dissected, and the anatomical relationships between the medial branches of the posterior branch of the spinal nerves and the facet joints were examined.Measured the distances from the lateral port of the bone fiber tube,the articular process of the facet joint and the superior articular process to the spinous processes.Results The medial branch of the posterior branch of the spinal nerve was close to the root of the articular process and the transverse process,which was not easy to be explored and dissected.Meanwhile, it was easily traced after the medial branch of the posterior branch of the spinal nerve ran through the fibrous tube.Conclusion It may improve the safety and effective when the techniques of medial branch block is performed after the medial branch ran through the fibrous tube.

Prognostic Factor Analysis for Management of Chronic Neck Pain: Can We Predict the Severity of Neck Pain with Lateral Cervical Curvature?

OBJECTIVE: Although little is known about its origins, neck pain may be related to several associated anatomical pathologies. We aimed to characterize the incidence and features of chronic neck pain and analyze the relationship between neck pain severity and its affecting factors. METHODS: Between March 2012 and July 2013, we studied 216 patients with chronic neck pain. Initially, combined tramadol (37.5 mg) plus acetaminophen (325 mg) was administered orally twice daily (b.i.d.) to all patients over a 2-week period. After two weeks, patients were evaluated for neck pain during an outpatient clinic visit. If the numeric rating scale of the patient had not decreased to 5 or lower, a cervical medial branch block (MBB) was recommended after double-dosed previous medication trial. We classified all patients into two groups (mild vs. severe neck pain group), based on medication efficacy. Logistic regression tests were used to evaluate the factors associated with neck pain severity. RESULTS: A total of 198 patients were included in the analyses, due to follow-up loss in 18 patients. While medication was successful in reducing pain in 68.2% patients with chronic neck pain, the remaining patients required cervical MBB. Lateral cervical curvature, such as a straight or sigmoid type curve, was found to be significantly associated with the severity of neck pain. CONCLUSION: We managed chronic neck pain with a simple pharmacological management protocol followed by MBB. We should keep in mind that it may be difficult to manage the patient with straight or sigmoid lateral curvature only with oral medication.

Improvement in Dropped Head Syndrome (DHS) Following Corticosteroid Injections on the Tender Points at the Upper Thoracic Spine : A Case Report / The Japanese Journal of Rehabilitation Medicine

　An 83-year-old woman presented with dropped head syndrome (DHS), that had been progressing during the previous 6 months. She had no history of neuromuscular diseases and, on examination, no neuromuscular abnormalities were observed except for isolated weakness of the neck extensors, mainly of the semispinalis cervicis. On the paravertebral sites of the T1-T5 spine on both sides, a total of eight points with marked tenderness were noted, four on each side. These eight points coincided with the anatomically narrow spaces through which the posterior rami emerged from their deep exits in the spine (i.e., the intervertebral foramina) to the superficial paravertebral sites, where they bifurcated into the lateral and medial branches, the latter innervating the semispinalis cervicis. Repeated local corticosteroid injections once a week on these eight tender points, with 3.3 mg Decadron (dexamethasone sodium phosphate) mixed with 20 mL of 0.5% xylocaine divided among the eight tender points, improved DHS in 3 months. This case suggests that the anatomically narrow pathway of the medial branches of the posterior rami at the upper thoracic spine could induce inflammations of the passing nerves, resulting in neck extensor weakness.

Efficacy of Cervical Medial Branch Block in Two Patients with Refractory Occipital Neuralgia.

Occipital neuralgia is often characterized by severe, paroxysmal and debilitating pain in the distribution of greater and lesser occipital nerve. It can cause severe refractory headache. Occipital nerve blocks have been used for long in diagnosis and treatment. We describe the efficacy of cervical medial branch block in patients with refractory occipital neuralgia. Two patients with refractory occipital neuralgia who were earlier treated with medications and occipital nerve block without much benefit were given cervical medial branch block. Visual analogue scale (VAS) score was checked for evaluation of effect of cervical medial branch block. The VAS score at 3 month after cervical medial branch block was significantly decreased compared to baseline scores in both patients. There were no major complications. Our case report suggests that cervical medial branch block can be used as a treatment modality in patients with refractory occipital neuralgia. This also suggests that cervical medial branches are important pain generators located in cervical region, could be an important source of pain in occipital neuralgia.

Detection Rate of Intravascular Injections during Cervical Medial Branch Blocks: A Comparison of Digital Subtraction Angiography and Static Images from Conventional Fluoroscopy

BACKGROUND: The most definitive diagnosis of neck pain caused by facet joints can be obtained through cervical medial branch blocks (CMBBs). However, intravascular injections need to be carefully monitored, as they can increase the risk of false-negative blocks when diagnosing cervical facet joint syndrome. In addition, intravascular injections can cause neurologic deficits such as spinal infarction or cerebral infarction. Digital subtraction angiography (DSA) is a radiological technique that can be used to clearly visualize the blood vessels from surrounding bones or dense soft tissues. The purpose of this study was to compare the rate of detection of intravascular injections during CMBBs using DSA and static images obtained through conventional fluoroscopy. METHODS: Seventy-two patients were included, and a total of 178 CMBBs were performed. The respective incidences of intravascular injections during CMBBs using DSA and static images from conventional fluoroscopy were measured. RESULTS: A total of 178 CMBBs were performed on 72 patients. All cases of intravascular injections evidenced by the static images were detected by the DSAs. The detection rate of intravascular injections was higher from DSA images than from static images (10.7% vs. 1.7%, P < 0.001). CONCLUSIONS: According to these findings, the use of DSA can improve the detection rate of intravascular injections during CMBBs. The use of DSA may therefore lead to an increase in the diagnostic and therapeutic value of CMBBs. In addition, it can decrease the incidence of potential side effects during CMBBs.

Comparison of Lidocaine and Bupivacaine in Lumbar Medial Branch Block

STUDY DESIGN: This is a retrospective clinical study. OBJECTIVES: To compare the efficacy of lidocaine and bupivacaine for the ultrasound-guided lumbar medial branch block in chronic low back pain. SUMMARY OF LITERATURE REVIEW: There is no study for comparison of the efficacy between lidocaine and bupivacaine for the medial branch block. MATERIALS AND METHODS: From August 2011 to May 2013, 186 patients were assigned 0.5% lidocaine(n=136) or 0.25% bupivacaine(n=45) for the ultrasound-guided lumbar medial branch block. All procedures have been performed by the same operator, and 23G, 10 cm needle was placed and drug was injected under ultrasound guide. To target medial branches from lumbar spinal nerve, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were evaluated by pre- and post-interventional(1 hour) Visual Analog Scale and analyzed statistically. RESULTS: Reduction of VAS score in bupivacaine group is significantly greater than that in lidocaine group and post-interventional VAS score in bupivacaine group is significantly lower than that in lidocaine group through analysis of covariance test with adjusted pre-interventional VAS score. In multivariate analysis, while age, sex and treatment level were not significant factors, pre-interventional VAS score and the kind of drug were significant factors. Severe pain before treatment and bupivacaine was indicator of better result. Bupivacaine group reduced pain score in the VAS 2.285 more than lidocaine group with adjustment with other factors. CONCLUSIONS: Bupivacaine is more effective than lidocaine in the reduction of pain after ultrasound-guided lumbar medial branch blocks in posterior facet joint syndrome.

Survey of Sonoanatomic Distances For Lumbar Medial Branch Nerve Blocks in Healthy Volunteers

BACKGROUND: The precise knowledge of anatomy and the region of transverse process (TP) and superior articular processes (AP) and their distance from the skin are important in blocking and treating lumbar facet syndrome. Evaluation of these anatomic distances from 3rd and 5th lumbar vertebrae in both sides and in different body mass index (BMI) in healthy volunteers might improve knowledge of ultrasound (US) lumbar medial branch nerve blocks (LMBB). METHODS: Bilateral US in the 3rd and 5th lumbar vertebrae of 64 volunteers carried out and the distance between skin to TP and skin to AP was measured. These distances were compared on both sides and in different BMI groups. The analysis was done using SPSS 11. Analysis of variance was used to compare the means at three vertebral levels (L3-L5) and different BMI groups. P values less than 0.05 were considered statistically significant. The paired t-test was used to compare the mean distance between skin to TP and skin to AP on both sides. RESULTS: The distance between skin to TP and skin to AP of 3rd vertebrae to 5th vertebrae was increased in both right and left sides (P < 0.001) from up to down. The mean distance from skin to TP were greater on the left side compared to the right in all three vertebral levels from L3 to L5 (P values 0.014, 0.024, and 0.006 respectively). The mean distance from skin to TP and the skin to AP was statistically significant in different BMI groups (P < 0.001). CONCLUSIONS: We found many anatomic distances which may increase awareness of US guided LMBB.

The Effectiveness of Endoscopic Radiofrequency Denervation of Medial Branch for Treatment of Chronic Low Back Pain

OBJECTIVE: The aim of this study is to evaluate the clinical results of endoscopic radiofrequency ablation of medial branch in patients with chronic low back pain originating from facet joints. METHODS: Between October 2010 and December 2013, 52 consecutive patients had suffering from chronic low back pain had undergone endoscopic radiofrequency denervation of medial branch of dorsal ramus. The clinical outcomes of these 52 patients were reviewed retrospectively. Preoperative and postoperative Visual Analogue Scale (VAS) and Korean version of Oswestry Disability Index (K-ODI), and patients' satisfaction with the procedure were assessed. RESULTS: The pain scores on the VAS for back pain had improved significantly from a preoperative mean of 7.1 to a postoperative mean of 2 at the last follow-up (p<0.001). The clinical outcomes based on the K-ODI had also improved significantly from a preoperative mean of 26.5% to postoperative mean of 7.7% at the last follow-up (p<0.001). 80% of patients were satisfied with the procedure. There were no complications associated with the procedure. CONCLUSION: Our preliminary results demonstrate that endoscopic radiofrequency denervation of medial branch could be an effective alternative treatment modality for chronic back pain originating from facet joints that provides long-term pain relief.

Effect of Ultrasound-guided Lumbar Medial Branch Block in Chronic Low Back Pain / 대한정형외과연구학회지

PURPOSE: To examine the use of ultrasound as an alternative imaging technique to block lumbar medial branches in chronic low back pain. MATERIALS AND METHODS: From August 2011 to September 2012, 27 patients with lumbar facet joint syndrome diagnosed by strict inclusion criteria among chronic low back pain patients have undergone medial branch block. All procedures have been performed by the same operator, and 23G, 10cm needle was placed and 0.5% lidocine was injected under ultrasound guide. To target medial branches from L1 to L5, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were followed up by Visual Analog Scale and Oswestry Disability Index at 1 week after medial branch block. RESULTS: VAS showed that preprocedure pain(7.0+/-1.4; mean+/-SD) significantly decreased after block(1.8+/-1.6)(p=0.0000). ODI also showed that preprocedure score(30.3+/-6.4) significantly decreased(9.0+/-7.7)(p=0.0000). Analysis of patient-reported pain and functional scores measured with VAS and ODI showed definite improvements after ultrasound-guided medial branch block. There was one complication of dizziness and weakness in both lower extremities immediate after procedure. CONCLUSION: Ultrasound guidance offers a reliable alternative to fluoroscopy or computed tomography for lumbar medial branch blocks and can be safely performed without radiation exposure.

Effect of Ultrasound-guided Lumbar Medial Branch Block in Chronic Low Back Pain / 대한정형외과연구학회지

PURPOSE: To examine the use of ultrasound as an alternative imaging technique to block lumbar medial branches in chronic low back pain. MATERIALS AND METHODS: From August 2011 to September 2012, 27 patients with lumbar facet joint syndrome diagnosed by strict inclusion criteria among chronic low back pain patients have undergone medial branch block. All procedures have been performed by the same operator, and 23G, 10cm needle was placed and 0.5% lidocine was injected under ultrasound guide. To target medial branches from L1 to L5, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were followed up by Visual Analog Scale and Oswestry Disability Index at 1 week after medial branch block. RESULTS: VAS showed that preprocedure pain(7.0+/-1.4; mean+/-SD) significantly decreased after block(1.8+/-1.6)(p=0.0000). ODI also showed that preprocedure score(30.3+/-6.4) significantly decreased(9.0+/-7.7)(p=0.0000). Analysis of patient-reported pain and functional scores measured with VAS and ODI showed definite improvements after ultrasound-guided medial branch block. There was one complication of dizziness and weakness in both lower extremities immediate after procedure. CONCLUSION: Ultrasound guidance offers a reliable alternative to fluoroscopy or computed tomography for lumbar medial branch blocks and can be safely performed without radiation exposure.

Transient Adverse Neurologic Effects of Spinal Pain Blocks

OBJECTIVE: Chronic neck or back pain can be managed with various procedures. Although these procedures are usually well-tolerated, a variety of side effects have been reported. In this study we reviewed cases of unexpected temporary adverse events after blocks and suggest possible causes. METHODS: We reviewed the records of patients treated with spinal pain blocks between December 2009 and January 2011. The types of blocks performed were medial branch blocks, interlaminar epidural blocks and transforaminal epidural blocks. During the first eight months of the study period (Group A), 2% mepivacaine HCL and triamcinolone was used, and during the last six months of the study period (Group B), mepivacaine was diluted to 1% with normal saline. RESULTS: There were 704 procedures in 613 patients. Ten patients had 12 transient neurologic events. Nine patients were in Group A and one was in Group B. Transient complications occurred in four patients after cervical block and in eight patients after lumbar block. Side effects of lumbar spine blocks were associated with the concentration of mepivacaine (p<0.05). The likely causes were a high concentration of mepivacaine in five patients, inadvertent vascular injection in three patients, intrathecal leak of local anesthetics in one, and underlying conversion disorder in one. CONCLUSION: Spinal pain blocks are a good option for relieving pain, but clinicians should always keep in mind the potential for development of inevitable complications. Careful history-taking, appropriate selection of the anesthetics, and using real-time fluoroscopy could help reduce the occurrence of adverse events.

Value of Bone Scintigraphy and Single Photon Emission Computed Tomography (SPECT) in Lumbar Facet Disease and Prediction of Short-term Outcome of Ultrasound Guided Medial Branch Block with Bone SPECT

BACKGROUND: Facet joint disease plays a major role in axial low-back pain. Few diagnostic tests and imaging methods for identifying this condition exist. Single photon emission computed tomography (SPECT) is reported that it has a high sensitivity and specificity in diagnosing facet disease. We prospectively evaluated the use of bone scintigraphy with SPECT for the identification of patients with low back pain who would benefit from medial branch block. METHODS: SPECT was performed on 33 patients clinically suspected of facet joint disease. After SPECT, an ultrasound guided medial branch block was performed on all patients. On 28 SPECT-positive patients, medial branch block was performed based on the SPECT findings. On 5 negative patients, medial branch block was performed based on clinical findings. For one month, we evaluated the patients using the visual analogue scale (VAS) and Oswestry disability index. SigmaStat and paired t-tests were used to analyze patient data and compare results. RESULTS: Of the 33 patients, the ones who showed more than 50% reduction in VAS score were assigned 'responders'. SPECT positive patients showed a better response to medial branch blocks than negative patients, but no changes in the Oswestry disability index were seen. CONCLUSIONS: SPECT is a sensitive tool for the identification of facet joint disease and predicting the response to medial branch block.

The Effect of Radiofrequency Neurotomy of Lower Cervical Medial Branches on Cervicogenic Headache

OBJECTIVE: Cervicogenic headache (CGH) is known to be mainly related with upper cervical problems. In this study, the effect of radiofrequency neurotomy (RFN) for lower cervical (C4-7) medial branches on CGH was evaluated. METHODS: Eleven patients with neck pain and headache, who were treated with lower cervical RFN due to supposed lower cervical zygapophysial joint pain without symptomatic intervertebral disc problem or stenosis, were enrolled in this study. CGH was diagnosed according to the diagnostic criteria of the cervicogenic headache international study group. Visual analogue scale (VAS) score and degree of VAS improvement (VASi) (%) were checked for evaluation of the effect of lower cervical RFN on CGH. RESULTS: The VAS score at 6 months after RFN was 2.7+/-1.3, which were significantly decreased comparing to the VAS score before RFN, 8.1+/-1.1 (p<0.001). The VASi at 6 months after RFN was 63.8+/-17.1%. There was no serious complication. CONCLUSION: Our data suggest that lower cervical disorders can play a role in the genesis of headache in addition to the upper cervical disorders or independently.

Significant Motion Factors Affecting the Outcome of a Medial Branch Block in Patients with Low Back Pain Developing after Trivial Trauma

OBJECTIVE: The aim of this study was to analyze significant motion factors that affected the outcome of medial branch blocking(MBB) in patients with low back pain(LBP) after trivial trauma. METHODS: Twenty-four patients(10men and 14 women; 70 vertebrae) complained of LBP after trivial trauma and under went bilateral MBB in the lumbar spine between January 2007 and August 2008. Visual Analogue Scale(VAS) scores of discomfort were measured before and after MBB. The motion factors considered were sitting, standing, flexion, extension and rotation. RESULTS: Sitting-, standing- and rotation-related LBPs were identified in 11 patients(44.5%, 11/24), 10 patients(41.7 %, 10/24) and 8 patients(33.3%, 8/24), respectively. The ratios of flexion- and extension-related LBPs in the enrolled patients were 66.7%(16/24) and 54.2%(13/24), respectively. The reduction in VAS score after treatment in the patients with sitting-related LBP was less than that of patients without sitting-related LBP(3.2+/-2.27 and 5.2+/-2.87, p=0.169). There was no difference between patients with standing-related LBP and those without(4.3+/-2.75 and 4.3+/-2.86). Although the mean VAS score improvement of the patients with extension- and rotation-related LBP(4.4+/-2.99 and 5.4+/-2.67) was higher than that of patients without extension and rotation LBP(4.1+/-2.59 and 3.7+/-2.71), the difference was not significant(p=0.721 and p=0.552, respectively). The mean VAS score improvement of the patients with flexion- related LBP was significantly higher than that of patients without it(6.1+/-1.81 vs 2.8+/-2.59, p=0.042). CONCLUSIONS: In patients with LBP after trivial trauma, flexion- and extension-related LBP was more common than sitting-, standing- and rotation-related LBP. Flexion was a significant motion factor affecting the outcome of MBB after trivial trauma.

Severe back pain following surgery was successfully treated by a lumbar medial branch block : A case report / 대한마취과학회지

Lower back pain commonly develops following spinal anesthesia. This pain is likely caused by strain on the ligaments associated with paraspinous muscle relaxation and positioning during the operation. We describe a case involving a healthy 61-year-old woman with a varicose vein that was scheduled for phlebotomy under spinal anesthesia. Two days after spinal anesthesia, the patient experienced severe lower back pain that was markedly aggravated by twisting and extension of the spine, but subsided with rest. Immediately after a lumbar medial branch block was performed at the area of tenderness the pain subsided. Thease results suggest that immediate treatment of acute lower back pain is important for preventing progression to chronic low back pain.

Intravascular injection in cervical medial branch block: an evaluation of 361 injections

BACKGROUND: The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 39% to 67%. Cervical medial branch block (MBB) represents a useful interventional pain management procedure indicated in patients with a chronic neck pain of facet joint origin. In the current study, we prospectively evaluated the incidence of, and the factors associated with, intravascular injection during block. In addition, we assessed the efficiencies of generally accepted safety measures, such as pre-injection aspiration and intermittent fluoroscopy to avoid intravascular injections. METHODS: We prospectively examined 361 cervical MBBs in 158 patients performed by 2 physicians. Aspiration test, spot radiography, and contrast injection under real-time fluoroscopic visualization were performed sequentially without repositioning the needle. Incidences of blood flash back and the presence of intravascular contrast spread on spot radiographic images and during real-time fluoroscopy were checked. The factors studied for intravascular injection included patient age and sex and block spinal level. RESULTS: No specific factors were found to affect the incidence of intravascular uptake during block. The overall incidence of intravascular uptake was 3.3% per nerve block (12/361), and 7 of these were predicted by pre-injection aspiration (sensitivity = 58.3%) and 8 by spot radiography (sensitivity = 66.7%). CONCLUSIONS: The aspiration test with or without spot radiography frequently missed the intravascular uptake of contrast during cervical MBBs. We strongly advocate the use of real-time fluoroscopy during contrast injection to increase diagnostic and therapeutic value and to avoid possible complications.

Ultrasound-guided Distance Measurements of Vertebral Structures for Lumbar Medial Branch Block / 대한통증학회지

BACKGROUND: Selective diagnostic blocks of the medial branches of the dorsal primary ramus are usually performed under the guidance of fluoroscopic or computed tomography. Recently, however, ultrasound guidance has been suggested as an alternative method. In this study, the distances between the vertebral structures were measured and compared with the values measured using magnetic resonance imaging (MRI) to assess the clinical feasibility of using ultrasound-guided block in Korean patients. METHODS: Five male and 15 female patients were enrolled in this study. The target point of the medial branch block in our study was the groove at the base of the superior articular process. We measured the depth from the skin to the target point at the transverse process (d-TP) and to the most superficial point of the superior articular process (d-AP). RESULTS: The d-TP and d-AP values measured under ultrasound guidance were concordant with the values measured using MRI. CONCLUSIONS: The images of the bony landmarks obtained under ultrasound examination could be useful for ultrasound-guided lumbar medial branch block.