Specificity of lumbar medial branch and L5 dorsal ramus blocks. A computed tomography study.

STUDY DESIGN: A cross-sectional study. OBJECTIVES: To determine the face validity of lumbar medial branch blocks. SUMMARY OF BACKGROUND DATA: Lumbar medial branch blocks have been used increasingly to diagnose zygapophysial joint pain. The course and relations of the medial branches of the dorsal rami have been demonstrated in previous anatomic studies. What is not known is whether blocks of the medial branches anesthetize these nerves exclusively or whether they anesthetize other structures that are potential sources of pain. METHODS: In a cadaveric study, the branches of the dorsal rami were exposed. Spinal needles were placed over the nerves, and plain radiographs were taken to demonstrate the precise radiographic locations of the nerves. In the second phase of the study, healthy volunteers underwent injections of radiographic contrast over the nerves, and plain radiographs and computed tomographic images were taken. Injections were performed using different rates of injection and in two positions for each nerve. RESULTS: Radiographic contrast incorporated the medial branches of the dorsal rami in every injection. When injections were performed using the upper position, aberrant flow of contrast medium was demonstrated with extension into the epidural space or intervertebral foramina. When a position lower on the transverse process was selected, aberrant flow was very uncommon. Eight percent of injections were found to be intravenous. CONCLUSIONS: When the appropriate technique is used, medial branch blocks are target specific. To guard against false-negative responses due to intravenous up-take, contrast medium must be used before the injection of local anaesthetic.

The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.

STUDY DESIGN: This was a cross-sectional analytic study of patients with chronic low back pain. OBJECTIVE: To investigate whether the criteria for internal disc disruption, as adopted by the International Association for the Study of Pain, could be satisfied in patients with chronic low back pain and to test whether there were any conventional clinical features that could identify this condition. SUMMARY OF BACKGROUND DATA: Internal disc disruption has been postulated as an important cause of low back pain. To diagnose this condition, the International Association for the Study of Pain taxonomy requires that pain be reproduced on provocation discography and that computed tomography discography reveal internal disc disruption, provided that as a control, stimulation of at least one other disc fails to reproduce pain. METHODS: Ninety-two consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied. Each patient underwent a standard physical examination. Computed tomography discography was performed at a minimum of two levels. RESULTS: The diagnostic criteria for internal disc disruption were fully satisfied in 39% of patients, most commonly at L5-S1 and L4-L5. None of the clinical tests used could differentiate between those patients with internal disc disruption and other patients. CONCLUSIONS: A diagnosis of internal disc disruption can be made in a significant proportion of patients with chronic low back pain, but no conventional clinical test can discriminate patients with internal disc disruption from patients with other conditions.

The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain.

STUDY DESIGN: A prospective cross-sectional analytic study. OBJECTIVES: To assess in patients with chronic low back pain whether the presence or absence of pain originating from the lumbar zygapophysial joints correlates with changes seen on computed tomography. SUMMARY OF BACKGROUND DATA: Results of studies have been divided as to whether or not radiologic imaging is able to predict those patients with pain originating from the zygapophysial joints. METHODS: Sixty-three patients with low back pain lasting for longer than 3 months underwent computed tomography and blocks of the zygapophysial joints at L5-S1, L4-L5, and L3-L4. The zygapophysial joints of all images were scored by three independent, masked radiologists. RESULTS: Interobserver agreement was poor with intraclass correlation coefficients of 0.34-0.66 using total joint scores for all three assessors. Using the results of a repeat assessment with two radiologists there was no statistically significant difference in joint scores between those with and those without pain originating from the zygapophysial joint. CONCLUSIONS: Computed tomography has no place in the diagnosis of lumbar zygapophysial joint pain.

Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain.

OBJECTIVES: To determine the prevalence of pain arising from the zygapophysial joint in patients with chronic low back pain and to determine whether any clinical features could distinguish patients with and without such pain. METHODS: Sixty three patients with chronic low back pain were studied prospectively. All patients underwent a detailed history and physical examination as well as a series of intra-articular zygapophysial joint injections of 0.5% bupivacaine starting at the symptomatic level to a maximum of three levels or until the pain was abolished. They also received injections of normal saline into paraspinal muscles to act as controls. RESULTS: All patients proceeded with the injections. Twenty (32%; 95% confidence interval (CI) 20 to 44%) obtained greater than 50% relief of their pain following the administration of saline. Fifty seven patients completed the study; 23 of them (40%; 95% CI 27 to 53%) failed to obtain relief following the injection of saline but obtained relief following one or more intra-articular injections of local anaesthetic. None of the historical features or clinical tests could discriminate those patients with and those without zygapophysial joint pain. CONCLUSION: Pain originating from the zygapophysial joint is not uncommon, but this study failed to find any clinical predictors in patients with such pain.

The sacroiliac joint in chronic low back pain.

STUDY DESIGN: This was a cross-sectional analytic study. OBJECTIVES: In relation to pain from the sacroiliac joint, this study sought to establish 1) its prevalence, 2) the validity of pain provocation, 3) whether any arthrographic abnormalities predict a response to joint block, and 4) whether certain pain patterns discriminate patients with this diagnosis. SUMMARY OF BACKGROUND DATA: The true prevalence of sacroiliac joint pain is unknown and despite a plethora of clinical tests, none of these tests has been validated against an established criterion standard. To our knowledge, arthrography of the sacroiliac joint had never been studied. METHODS: Forty-three consecutive patients with chronic low back pain maximal below L5-S1 were investigated with sacroiliac joint blocks under image intensifier using radiographic contrast followed by 2% lignocaine. Information was obtained on pain provocation, analgesia, and image pattern. RESULTS: Thirteen patients (30%) obtained gratifying relief of their pain. Nine of these also exhibited tears of their ventral capsule. Groin pain was the only pain referral pattern found to be associated with response to sacroiliac joint block. CONCLUSION: The sacroiliac joint is a significant source of pain in patients with chronic low back pain and warrants further study.

The value of the provocation response in lumbar zygapophyseal joint injections.

OBJECTIVE: To determine the relationship between pain provocation and the analgesic response in lumbar zygapophyseal joint blocks. DESIGN: Consecutive patients undergoing intraarticular zygapophyseal joint blocks for the investigation of low back pain were included in this prospective study. SETTING: The referred sample was from the metropolitan areas of New Orleans and San Francisco. PATIENTS: Ninety patients with low back pain of > 3 months' duration and no history of lumbar surgery. INTERVENTIONS: All patients underwent one or more intraarticular injections of radiographic contrast followed by lignocaine (lidocaine) 2% into zygapophyseal joints between L2-3 and L5-S1. Those with definite responses at one or more levels underwent confirmatory blocks using 0.5% bupivacaine. OUTCOME MEASURES: Provocation of familiar pain and relief of pain after the injection of local anesthetic. Patients were assessed by an independent observer. RESULTS: A total of 203 joints were studied. Adopting liberal criteria, either exact or similar reproduction of pain on the one hand correlated with either definite or complete relief of pain after a single, analgesic block on the other (p < 0.0001). However, when more stringent criteria were adopted, such as response to a confirmatory block using bupivacaine, there was no significant association. CONCLUSIONS: This study calls into question the validity of pain provocation alone as a criterion standard in patients undergoing diagnostic lumbar zygapophyseal joint blocks.

The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints.

One hundred and seventy-six consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied to determine the false-positive rate of single diagnostic blocks of the lumbar zygapophysial joints. All patients underwent diagnostic blocks using lignocaine. Those patients who obtained definite or complete relief from these blocks subsequently underwent confirmatory blocks using bupivacaine. Eighty-three patients (47%) had a definite or greater response to the initial, lignocaine injection at one or more levels but only 26 (15%) had a 50% or greater response to a confirmatory injection of 0.5% bupivacaine. Using the response to confirmatory blocks as the criterion standard, the false-positive rate of uncontrolled diagnostic blocks was 38% and the positive predictive value of these blocks was only 31%. Because the positive predictive value of a test is lower when the pre-test probability (prevalence) is low, and because the prevalence of lumbar zygapophysial joint pain is likely to be less than 50%, uncontrolled diagnostic blocks will always be associated with an unacceptably low positive predictive value. These features render uncontrolled diagnostic blocks unreliable for the diagnosis of lumbar zygapophysial joint pain not only in epidemiologic studies but also in any given patient.

Pain from the lumbar zygapophysial joints: a test of two models.

One hundred seventy-six consecutive patients with chronic low-back pain and no history of previous lumbar surgery were studied to test the clinical criteria of Fairbank et al. and Helbig and Lee for zygapophysial joint pain. All patients underwent a history, examination, and a series of zygapophysial joint injections or blocks of the medial branches of the dorsal ramus with lignocaine. Those patients responding to the first series of blocks were given confirmatory blocks using bupivacaine. None of the clinical features tested was found to be associated with response to the confirmatory block. The Fairbank et al. and Helbig and Lee criteria were shown to be unreliable in distinguishing pain of zygapophysial joint origin from pain of other origins.

Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?

STUDY DESIGN: This study is a prospective cross-sectional analytic study. OBJECTIVES: The authors determined the prevalence and clinical features of patients with pain stemming from the lumbar zygapophysial joints. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated a wide range of prevalence for zygapophysial joint pain and conflicting results with regard to clinical signs. METHODS: One hundred and seventy-six consecutive patients with chronic low back pain were investigated with a series of screening zygapophysial joint blocks using lignocaine and confirmatory blocks using bupivacaine. RESULTS: Forty-seven percent of patients had a definite or greater response to the screening injection at one or more levels but only 15% had a 50% or greater response to a confirmatory block. Response to zygapophysial joint injection was not associated with any single clinical feature or set of clinical features. CONCLUSIONS: The zygapophysial joint is an important source of pain but the existence of a "facet syndrome" must be questioned.

The relative contributions of the disc and zygapophyseal joint in chronic low back pain.

STUDY DESIGN: A prospective cross-sectional analytic approach was taken. OBJECTIVES: This study sought to determine the relative contribution of the disc and the zygapophyseal joint as a pain source in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Previous studies have employed either zygapophyseal joint blocks or discography, but in no studies have both procedures been performed. METHODS: Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints. RESULTS: Thirty-six patients (39%) had at least one positive discogram as defined by exact pain reproduction, an abnormal image, and a negative control. Eight patients responded to both a screening zygapophyseal joint block using lignocaine and a confirmatory block using bupivacaine. Only three patients had both a positive discogram and a symptomatic zygapophyseal joint. CONCLUSIONS: In patients with chronic low back pain, the combination of discogenic pain and zygapophyseal joint pain is uncommon.

Rheumatic manifestations of neoplasia.

Neoplasia in an important cause of rheumatic disease. The mechanisms are either direct infiltration of the bone and joint, or indirect infiltration with manifestations distant from the site of neoplastic involvement. Many of the reports reviewed in this article center on direct associations. In particular, there is a report on polymyositis and dermatomyositis and the link with neoplasia. Cases of reflex sympathetic dystrophy are also described in association with neoplasia. There is further discussion on the link of hairy cell leukemia and vasculitis. Other case reports highlight the multiple associations of musculoskeletal disease and neoplasia. These reports include patients with subcutaneous sarcoidosis, ankylosing spondylitis, polychondritis, and systemic sclerosis. Articular manifestations of benign pleural fibromas are described. The existence of these reports, however, does not constitute proof of a causal relationship and the possibility of chance occurrences of two conditions must be considered. Finally, various therapies for cancer are associated with rheumatologic manifestations. Intravesical bacillus Calmette-Guérin has been found to cause an inflammatory polyarthritis. This form of arthritis is similar to experimentally induced adjuvant arthritis in rats that follows immunization with Freund's adjuvant containing Mycobacterium tuberculosis.

The cycling of combination antirheumatic drug therapy in rheumatoid arthritis.

In this open pilot study a combination of hydroxychloroquine, prednisolone and alternating months of treatment with sulphasalazine or oral weekly pulse methotrexate has been investigated in 16 patients with rheumatoid arthritis (RA) refractory to a total of 67 disease suppressive medications. Results at 3 months indicated significant improvements in visual analogue score for pain, joint count, Ritchie index, scale of disability related to activities of daily living, ESR, rheumatoid factor and C-reactive protein. This degree of improvement, however, was not maintained 6 and 12 months after commencement of treatment. Pain score, Ritchie index and ESR were the only parameters demonstrating significant improvement at 12 months. Therapy was terminated in eight patients, half due to lack of efficacy and half because of side effects.

Tenoxicam compared with diclofenac in patients with ankylosing spondylitis.

A randomized study was performed on 24 patients with ankylosing spondylitis to compare the efficacy and tolerability of 20 mg tenoxicam daily with 50 mg diclofenac twice daily. There were 6 withdrawals from the group taking tenoxicam and 4 from the diclofenac group. Depression in 1 patient taking tenoxicam was the only significant adverse event. Both drugs were otherwise well tolerated. Tenoxicam and diclofenac were rated as good or excellent by 27% and 55% of patients, respectively. Global assessment, pain and duration of morning stiffness were improved with both drugs but this improvement was not statistically significant and there was no statistically significant difference between the two groups. This study confirms that tenoxicam is effective and well tolerated but larger numbers would be required to detect a small difference between groups.

Rheumatic manifestations of neoplasia.

The important association of neoplasia and rheumatic disease was reviewed. The literature in the last year included case reports of neoplasia, particularly hematologic, causing arthritis by direct joint involvement. Immunocytologic techniques may help in the diagnosis. The evidence linking dermatomyositis and polymyositis to malignancy was reviewed, although analysis of the literature was hampered by poor documentation and lack of control subjects. HOA may occur secondary to mediastinal or pulmonary metastases from nonbronchogenic malignancies. The important association of hematologic malignancy with vasculitis was highlighted.