THE EXPERIENCE IN INTERVENTIONAL ANALGESIA TECHNIQUE FOR SPONDYLARTHROSIS OF FACET JOINTS OF THE THORACIC AND LUMBAR SPINE
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Back pain causes both suffering and significant social and economic losses. According to some epidemiologic studies in the countries with developed economics and medicine, more than 70 % of patients complain of pain relating to spinal diseases. It is caused by high rates of pathologic states of the spine such as osteochondrosis, spondylarthrosis, spondylosis and others [1-3].
Acute back pain converts to chronical pain in 10-20 % of patients of employable age. This group of patients is characterized by unfavorable prognosis of recovery, and it takes 80 % of all healthcare costs for treatment of back pain.
Spine and spinal cord injury is 5.5-17 % among closed locomotor injuries [4].
After spinal injuries more than 90 % of survivors acquire disability of the most severe degree (the first degree) and lose their abilities to independent moving and control of functions of the pelvic organs [5].
It is recognized that inflammation of facet joints is a cause of back pain in 10-15 % of patients. One of the causes is spine and spinal cord injuries.
During the recent years, the physicians of different specialties have been demonstrating their increasing interest in the problems of vertebrogenic pain, the methods of its research, and the ways of prevention and treatment [6-8]. Over the last years the range of the low invasive techniques of treatment of vertebrogenic pain syndrome has been offered, particularly, facet joint blocking: neurotripsia, interventional analgesia, facet joint infiltration. This technique is an alternative for traumatic medical interventions for the thoracic and lumbar spine in case of development of vertebrogenic pain or inefficient conservative treatment.
The objective of the study – by means of administration of interventional analgesia for the facet joints to improve results of treatment of patients with facet syndrome with degenerative dystrophic spinal changes and consequences of spine and spinal cord injury.
MATERIALS AND METHODS
130 patients received treatment in the neurosurgery department, Clinical Center of Miners’ Health Protection, in 2014. There were 71 (54 %) women and 59 (46 %) men. The mean age was 50.6 ± 10.8. According to nosology the patients were distributed to the following groups: 126 patients (97 %) with degenerative and dystrophic changes, 4 patients (3 %) with consequences of spine and spinal cord injuries. According to the social status the patients were classified as employable – 68 (52 %), nonworkers – 17 (13 %) and retirees – 45 (35 %) (the table). The employees with spine load (weight lifting, long duration of static position) prevailed among the working population.
| Table | ||||||
| Age and gender distribution of the patients (n = 130) | ||||||
Before hospital admission all patients received basic drug therapy in concordance with the available recommendations for treatment of back pain.
The main inclusion criteria were presence of the common signs of pain syndrome conditioned by facet syndrome (spondyloarthrosis):
– pain increases during extension and decreases during flexion;
– presence of short term restraint in the morning and pain increasing in the end of the day;
– pain increases after lasting standing, extension, especially in combination with inclination or rotation towards the painful side; pain increases after changing the body position from lying to siting and conversely;
– spine load relief (mild spinal flexion, passing to sitting position, use of support) decreases pain;
– some changes which do not require surgical interventions.
For confirmation of the diagnosis spondylarthrosis the following examinations were conducted:
– clinical and neurologic examination;
– X-ray examination of the lumbosacral spine in frontal and lateral view with and without functional tests;
– MSCT (MRI) of the thoracic or lumbosacral spine (in dependence on pain location);
– Estimation of pain intensity according to the visual analogue scale (0 – no pain, 10 – intolerable intense pain);
– Examination of the inclination angle with use of the clinometer.
All patients gave their written consent for participation in the study. The conducted studies corresponded to the ethical standards of the local bioethical committee and were developed in concordance with Helsinki Declare – Ethical Principles for Medical Research with Human Subjects 2000.
The technique of conduction of interventional analgesia for the facet joints [9-10]:
The paravertebral muscles were palpated and the painful points were found.
Marking was made with K-wire. Intrasurgical fluoroscopy was made (Fig. 1).
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Figure 1 The patient S, age of 34. Intrasurgical marking with k-wire
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Figure 2 The patient S., age of 34. Intrasurgical control of needle placement
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The surgical field was twice prepared with the solution of alcohol chlorhexidine. Local infiltration anesthesia was made with the solution of a local anesthetic drug, with introduction of the intramuscular needles 3 cm laterally the lower edge of the spinous process towards the transverse process. Intrasurgical fluoroscopy was conducted with the electronic optical transducer during the manipulation (Fig. 2).
The usual depth for placement of the needle was 5-7 cm, and the angle of introduction was close to the direct one. The local anesthetic drug and the glucocorticoids were introduced after appropriate placement of the needle.
The aseptic dressing was applied.
The patients had bed rest during 2 hours after interventional analgesia. Then the patients could stand up.
There were no complications during the intervention.
RESULTS AND DISCUSSION
The efficiency of treatment and the received results were estimated with the visual analogue scale (estimation of intensity of pain syndrome), with its maximal level of 10 points. The volume of motions was estimated with angle meter.
The examination of the short term results was conducted before interventional analgesia and on the second day after the procedures.
Interventional analgesia of the intervertebral joints showed the efficiency in 92 % of the cases. Pain syndrome disappeared within 1-22 days in 68 % of the patients. 24 % of the patients demonstrated significant improvement (decrease in intensity of pain syndrome according to VAS by 4 points at average, from 6.3 ± 0.5 points to 2.5 ± 0.3 points in 2 days after analgesia).
The volume of motions in the lumbar spine was measured with the angle meter before and 2 days after analgesia. It showed the significant increase in the range of motions in the spinal segments. The maximal level of flexion in the lumbar spine increased by 28 degrees at average (from 29 ± 3.4 degrees to 57 ± 5.1 degrees). The maximal level of extension increased by 18 degrees at average (from 7 ± 2.6 degrees to 25 ± 4.2 degrees).
There were no complications after the intervention.
The clinical cases
The patient S., age of 34. The case history #670/15
The patient was in the clinic during 7 bed-days. The diagnosis was: “Dorsopathy at lumbar level. Spondylarthrosis of the facet joints L3-L4, L4-L5 on both sides. Syndrome of lumbar ischialgia of reflectory pattern”.
The state upon admission: complaints of sharp pain in the lumbar spine with expansion to the lower extremities along the posterior surface to the knees. Pain was especially intense in the morning and after long term standing. Limited volume of motions in the lumbar spine, especially during extension. Constrained movements in the morning. Sleep disorders as result of pain.
The medical history: vertebrogenic anamnesis about 5 years. Exacerbation is 2-3 times per year. Worsening state within 3 months. Pain syndrome in the spine has become constant. Constrained movements in the lumbar spine are predominantly in the morning. Outpatient treatment according to place of residence has not produced any effects.
The objective status: the general condition is characterized by middle severity and is conditioned by neurologic symptoms and pain syndrome. Stable hemodynamics.
Local status: visual flatness of lumbar lordosis. There is strain and pain during palpation of the paravertebral muscles. The volume of motions in the lumbar spine is limited to the degree 2 during frontal inclination, and to the degree 3 to the back bend. Strength of all muscle groups is 5 points. The extremities are with normal tone. Tendon reflexes from the upper extremities are middle vivacity, without clear difference between the sides. Middle vivacity with evenness is from the lower extremities. No sensory disorders.
The X-ray examination of the lumbar spine has shown some degenerative and dystrophic changes in the lumbosacral spine, mainly for L3-S1, L1-S1 spondylodesis, L3-S1 spondylarthrosis of the degree 2-3.
The surgery was made under local infiltration anesthesia: interventional analgesia: infiltration of the facet joint L3-L4, L4-L5 on both sides.
At the background of the conducted complex treatment we noted some positive time trends such as decrease in intensity of pain vertebrogenic syndrome from 7 to 2 points according to VAS, and increase in the volume of motions in the lumbar spine (the flexion angle from 24 to 63 degrees, extension from 8 to 26 degrees).
The patient K., age of 49. The case history #52312/14
The patient was in the clinic during 56 bed-days. The diagnosis was: “Traumatic disease of the spinal cord. Late period. Disordered conduction through the spinal cord from Th8 – ASIA A. Lower paraplegia. Disorders of function of the pelvic organs such as incontinence. Spastic syndrome. The condition after interbody fusion and laminar fixation for Th4-5, Th8-9. Failure of the construct of posterior laminary fixation, loculation syndrome at the level of Th6-7. Syndrome of vegetative dysfunction with psychosomatic disorders”.
There were some complaints about spastic pain in the chest, absence of active motions and absent sensitivity in the lower extremities.
The disease history: a road injury on August, 2013. The victim suffered after his four-wheeler flipped over. After the injury he noted the pain in the thoracic chest and the chest, absence of active motions and sensitivity in the lower extremities. He was treated in the hospital in Ust Kamenogorsk and Novosibirsk.
The surgery was conducted on October, 5, 2010: removal of Th6-8 vertebral body, anterior interbody fusion, Th4-5, Th8-9 laminary fixation with use of Obelisk system.
On April, 30, 2014, in Regional Clinical Center of Miners’ Health Protection, the surgery was conducted: removal of the posterior fixing construction with laminary hooks, mounting of the device for transpedicular fixation, Th7-8 laminectomy, spinal cord revision, meningomyelitis, restoration of liquor circulation, plastic surgery of the spinal cord and the dural sac.
The pain spastic syndrome persisted in the chest. The following procedures were conducted for pain relief:
On May, 19, 2014, the operation with local infiltration anesthesia: interventional analgesia: infiltration of the facet joint Th5-6, Th6-7, Th7-8 to the right (Fig. 3).
On May, 27, 2014, the operation with local infiltration anesthesia: infiltration of the facet joint Th5-6, Th7-8 to the left (Fig. 4).
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Figure 3 The patient K., age of 49. Intrasurgical control of needle placement for Th5-6, Th6-7 and Th7-8 to the right
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Figure 4 The patient K., age of 49. Intrasurgical control of needle placement for Th5-6,Th7-8 to the left
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On May, 29, 2014, the operation under endotracheal narcosis: closed hypothermia of the spinal cord at the level of the lumbar enlargement and the spinal roots of cauda equine.
The neurologic status: clear consciousness, normal behavior, defense supination. The patient is adequate and ready to efficient contact, with good orientation in time and space. There are not any specific features from the side of 12 pairs of the cranial nerves. There is muscle hypotrophy of the lower extremities. Moderate tendon reflexes from the hands, D = S. Tendon reflexes from the lower extremities are absent. There are some pathologic signs on the feet. Muscular strength of the hands is 5 points. Plegia in the lower extremities. Muscular tone in the lower extremities is with some elements of spastics and pathologic muscular twitching. Hypesthesia with transition to anesthesia from Th8.
Electromyography (May, 19, 2014). Conclusion: polyneuropathy in the lower extremities, blocked conduction through the fibular nerves.
Some positive time trends were noted at the background of complex treatment, i.e. decreasing pain vertebrogenic syndrome with decrease in VAS from 7 to 4.
CONCLUSION
- Interventional analgesia of the intervertebral joints causes decrease in intensity of pain syndrome (decrease in VAS by 4 points) in 24 % of the patients on the second day after the procedures. Pain syndrome has disappeared in 68 %.
- The range of motions significantly increases in the vertebral segments. The level of flexion in the lumbar region increased by 28 degrees at average (from 29 ± 3.4 degrees to 57 ± 5.1). The maximal level of extension increased by 18 degrees at average (from 7 to 2.6 degrees to 25 ± 4.2 degrees).
- The main advantages of interventional analgesia are confirmation of correct positioning of the needle by means of X-ray control, conduction of manipulations under local anesthesia, low rate of complications, the possibility of recurrent manipulations.