Computerized tomography–guided kryorhizotomy in 76 patients with lumbar facet joint syndrome
MARKO STAENDER, M.D., ULRICH MAERZ, M.D., JÖRG CHRISTIAN TONN, M.D., AND ULRICH STEUDE, M.D.
Department of Neurosurgery, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany
Object. The authors prospectively evaluated the therapeutic effect ofcomputerized tomography (CT)–guided kryorhizotomy in the treatment of patients with lumbar facet joint syndrome (LFJS) and assessed prognostic factors that predict this effect. Methods. Between February 2001 and March 2004, CT-guided kryorhizotomy of facet joints was performed in 76 patients with LFJS. A diagnosis was established after three positive CT-guided medial nerve branch blocks. Outcome wasdetermined by evaluating the results of a standardized questionnaire, including visual analog scale (VAS) score, use of medication, ability to work, and physical conditions. Measurement was performed before treatment and repeated postoperatively at 3 days, 3 months, and every 6 months thereafter. On September 2004 all patients underwent clinical reevaluation. The median follow-up period was 22.5months (range 6–43 months); the median interval to pain reduction was 6 months (range 0.1–31 months) after the first kryorhizotomy. The mean VAS pain score was 6.7 preoperatively and 2.9, 3.2, and 3.4 at 3 days, 3 months, and 6 months postoperatively, respectively. In 40% of patients pain was reduced for 12 months or longer. In patients in whom there was no prior surgical treatment of the relevantspinal segment, the duration of pain relief was significantly longer than in patients who had previously undergone surgery (p 0.03). Eighteen patients underwent a second, seven a third, and one a fourth kryorhizotomy. No patient reported any side effect. The use of CT guidance guarantees an exact needle-tip position control and documentation for repeated procedures. Conclusions. Computerizedtomography–guided kryorhizotomy is a minimally invasive and repeatable treatment that yields good long-term results in patients with LFJS.
KEY WORDS • lumbar facet joint syndrome • kryorhizotomy low-back pain • computerized tomography scanning
• chronic pain •
CUTE low-back pain is one of the most common symptoms in our civilization and the second most common reason to visit a primary carephysician.6 A significant portion of these patients experience chronic low-back pain.5,25 Lumbar facet joint syndrome is the cause of low-back pain in 15 to 52% of individuals.3,14,18 In LFJS the individual experiences a dull, deep ache in the spine, with pain typically distributed to both posterior lower extremities, and no neurological deficit; this definition of the syndrome was first introduced byGhormly9 in 1933. Pain is commonly aggravated by movement, such as lumbar rotation or hyperextension or by direct palpation of the affected joints. The syndrome is generated by osteochondrotic changes in the zygapophysial (facet) joints caused by microinstability of the segment due to disc degeneration. The capsule and synovia of these joints are richly innervated with nociceptive nerve endingsfrom
Abbreviations used in this paper: CT = computerized tomography; LFJS = lumbar facet joint syndrome; RF = radiofrequency; VAS = visual analog scale; WHO = World Health Organization.
the medial branches of the posterior branch of the spinal nerve root.10,23 There are only a few—and unreliable— means by which to diagnose LFJS clinically. The diagnosis is based on imaging-guidedzygapophysial joint anesthetic injections (medial branch nerve block).3 In addition to conservative treatment, lumbar stabilization is a surgical option. Percutaneous facet joint denervation is a minimally invasive alternative first introduced in clinical practice in 1971 by Rees.17 His open surgery method, however, was associated with technical problems; later in the decade Shearly19–21 introduced an...