Endoscopic facet joint denervation for treatment of chronic lower back pain

https://doi.org/10.1016/j.clineuro.2020.105904Get rights and content

Highlights

  • Endoscopic facet joint denervation (EFJD) significantly improves PROMs and reduces pain at 24 months of follow-up.

  • EFJD may yield a more sufficient long-term pain reduction compared to percutaneous techniques.

  • EFJD is associated with high success rates and can be re-done if necessary.

  • EFJD represent a “last resort” if percutaneous techniques fail to significantly reduce pain.

Abstract

Objectives

Percutaneous radiofrequency is an established method for treatment of chronic low back pain of intervertebral facet etiology. Endoscopic techniques have the advantage of visualization of the facet joint and the dorsal medial ramus and thus allow for more accurate denervation. It was thus hypothesized that pain reduction is vaster and longer enduring.

Patients and Methods

A total of 98 consecutive patients that underwent endoscopic facet joint denervation (EFJD) were included in this study. Prior to intervention and for follow-up, patients were asked to complete VASpain, ODI, COMI and EQ5D questionnaires.

Results

VASpain was reduced significantly (EFJD: p < 0.001) at last follow-up. Values for ODI, COMI and EQ5D showed significant improvements towards subjective well-being at last follow-up.

Conclusion

EFJD is a promising technique for the treatment of facet joint syndrome caused CLBP as it contributes to sustaining significant pain reduction and improvement of subjective quality of life parameters.

Introduction

Chronic low back pain (CLBP) has a life time prevalence reported to be as high as 85% [1]. As CLBP is associated with depression, immobilization, deactivation and limitation to participate on daily life, it does not only yield individual suffering but is of tremendous social and economic importance [9].

Although symptoms may be similar, CLBP can be caused by malfunction or structural deficits of different anatomical structures such as lumbar intervertebral discs, nerve roots, fascia, spinal ligaments, osteophytes and muscles. In the majority of cases, however, degenerated lumbar facet (zygapophyseal) joints account for the pain [21].

The treatment of CLBP due to facet joint (FJ) degeneration is usually initiated by conservative treatment procedures like physiotherapy and manual treatment. Eventually, psychological therapy and pharmacological/ analgesic measures are indicated. In clinical routine, periarticular FJ infiltration with steroids (e.g. cortisone) and local anesthetics (e.g. bupivacaine) are used for diagnostic and therapeutic purposes although the effectiveness of the latter remains questionable [16]. If patients reported relief of pain after infiltration, percutaneous radio-frequency ablation (PRFA) of the dorsal medial branch yields a better success rate [2]. Alternatively and only recently, the dorsal medial branch, which is innervating the (hypertrophic) FJ capsule, can be ablated endoscopically [24].

While PRFA is a well-established and described treatment procedure, there is only limited evidence on endoscopic techniques. This, however, is of special interest as endoscopic facet joint denervation (EFJD) allows for full visualization and selective ablation of the dorsal medial branch [7].

This study was set up to investigate clinical outcome parameters in a large cohort of patients that underwent EFJD and to compare EFJD results with PRFA results from literature.

Section snippets

Material and methods

In the time between 2015 and 2017 a total of 107 consecutive and eligible patients undergoing EFJD in our institution were included in this study.

Results

107 eligible and consecutive patients were prospectively enrolled. Of those, nine (6%) were lost to follow-up (2× movement to another state, 2× death not related to EFJD, 5× unwillingness to further participate in the study). Hence, data of 98 patients were used for final analysis. Demographic data of the study population are reported in Table 1. Mean follow-up time was 25.2 ± 2.8 months. EFCD was performed successfully in all cases without complications (wound infections, postoperative

Discussion

Although the effect of PRFA has been discussed thoroughly over the past decades, there is good evidence that this technique yields positive results for the treatment of facet joint derived CLBP [13, 15, 20]. Furthermore, this procedure is associated with a low percentage of minor complications only [10]. However, pain relieving effects of PRFA seem to be short-lasting – most likely contributed to limited precision and regeneration of the treated nerve [23]. An observational study by Gofeld

Conclusion

EFJD is a promising technique for the treatment of facet joint syndrome caused CLBP as it contributes to sustaining significant pain reduction and improvement of subjective quality of life parameters.

CRediT authorship contribution statement

Sebastian G. Walter: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Visualization, Writing - original draft, Writing - review & editing. Charlotte Struwe: Investigation, Project administration, Validation, Writing - original draft. Sebastian Scheidt: Data curation, Formal analysis, Methodology, Writing - review & editing. Lara Strohmenger: Data curation, Investigation, Methodology, Visualization, Writing - review & editing. Rahel Bornemann: Data

Declaration of Competing Interest

There are no conflicts of interest to declare.

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  • 1

    Authors contributed equally to this work.

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