Baheti Jt Pain

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Facet Related Interventions

Who, When and Where

Prof & HOD Dept. of

Anesthesia & Pain, B.H.I.M.S.,

Pain Physician, Lilavati,Raheja, Shushrusha Hospital

Ex.President, IndianSocietyfor Study of Pain,

Executive President, PainManagement and ResearchFoundation

Hobbies-Music, Sports

[email protected]

Web-www.paincure.in

Dr.D.K. Baheti
mailto:[email protected]:[email protected]


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Facet Related InterventionsWho, When and Where

Dr.D.K.Baheti MD

Prof & HOD

Dept. Of Anaesthesia and Pain ManagementB.H.I.M.S.,Mumbai-India


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What are the Facet Joint?

Facet joints are located at the posterior (back)aspect of the spine.

Each back bone (vertebra) has four facet joints, anupper and a lower pair.

These joints link the back of the spine together.

They are designed to provide stability and control

motion between the vertebrae.


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Facet Jt. Pain Syndrome (FJPS)?

FJts are prone to injury, deterioration, &inflammation. FJPS can occur anywhere in thespine including the low back.

FJP is usually at the level of the affected facetjoint(s), and is made worse by activities that putpressure on these joints i.e. leaning backwardsand "extending" the lower back or twisting at thewaist.

Occasionally the pain may radiate to other areassuch as the buttocks.


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PAIN DISTRIBUTION


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What causes Facet Jt. Syndrome?-2

Degenerative Disc Disease occurs1-Irritated from trauma, repetitive movements,

arthritic changes

2-The damaged disc looses cushioning effect which

leads to more stress on facet joints , which may resultin degeneration of the facet joint.

3-Poor posture can also cause undue stress on the facetjoints.


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What cause Facet jt. Syndrome?3

The natural inward curve in the lumbar (low back) aredesigned and positioned to handle a certain amount ofstress.

When the natural curve of the lumbar spine is

exaggerated excess stress is placed on the facet joints. Poor body mechanics or how we use our body such as

bending from the back, improper lifting, poor restpositions, and prolonged sitting in poorly designed

chairs can all cause undo stress on the facet joints.


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Facet Joint Pain Syndrome-Diagnosis? Good medical history and a physical examination.

X-rays- AP/LAT/OBLIQUE of the lower back may

help to rule out degenerative changes in the facetjoints or degenerative disc disease.

MRI and CT scans.

Diagnostic blocks
http://backpaininfo.com/backDegenerativeDisc.htmlhttp://backpaininfo.com/backDegenerativeDisc.html


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Differential Diagnosis!!!

Herniated disc infllamation

Fracture Torn back muscle

Acute Intra abdominal problem


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SITES OF PAIN


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Symptoms FJPS Persistent joint tenderness

Muscle guarding

Discomfort in leaning forwards/backwards Radiating pain Lumbar- in to buttock and leg

Cervical- Shouldar, front and down arm even fingers


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WHOA 38 year old woman presented withLow Back

Pain with radiation along the Postero-Lateral

aspect of the Left Thigh to just abovethe

knee and also out to the Left Hiplateral aspect.


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Pain

The pain was described as a constant dull ache with asharp stabbing in left paravertebrally and over the SI

joint.

Pain varied between VAS 0.8----7.0: 4.5 mean


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Worse

= Sitting especially in a soft sofa.= Mornings

= Standing still

= Long walks

= Much pain when tired, often in the evenings

after work


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Weight Bearing on

the Left Leg and

pushing with the

Right leg


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Better

When she had got going in the mornings after getting up

Short Walks

Best

Not too Little ___ Not too Much Movement

Stand a Little, Sit a Little, Walk a Little


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Examination

Inspection Para-Vertebral muscle spasm

Palpation Tender Mid-line and Left Paravertebral

Movement Stiff, careful, reduced flexion, pain onextension.

S L R Left 80 C Right 90 C

Reflexes Brisk, Equal both sidesSensory Reduced along Postero-Lateral aspectLeft thigh.

Motor Normal


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Clinical Diagnosis

?

Facet (Z joint) Pain


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Medication

Gabapentin 300mg x 3 Daily

Paracetamol 1 g x 3 Daily

Tramadol 50 100 mg occasionally whenbad

Sertralin (Zoloft) 50 mg Daily (Anti-depressant)


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Previous Treatment Attempts

Physiotherapy, massage, exercise programs, twice a week

4 years -- No Effect.

Acupuncture -- No Effect.

TNS -- No Effect.ESI x 3 -- Minimal Effect.

MRI -- slightly bulging disc

Orthopedic surgeon -- surgery not indicated.

Condition -- variable but stable. Works half time now

after Rehab, been off-sick for 4 years


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Pain Left Gluteal and P/L Left Thigh

Trans Foraminal ESI L5 Left

Fantastic 80% Better 2 Months

Pains gradually back

Now only 10% Better


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Repeat L5 Trans Foraminal ESI

Not as Good -- Shorter Effect

Now Most Pain Both Hips Laterally andParavertebral more on left

BUT Better in the Leg

Pain Still provoked by

Sitting and Extension


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3 Months Later

Back Again, Was Fine 2 Months

Now only 40% Better

Patient mentions that she has

Even More Problems Passing UrineBeen to Urologists and Gynaecologists 4 Years

Did not mention it before as she thought it was notrelevant

Temp. Left foot 1,8C colder than rightPatient admits that Left Foot often Feels Colder


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Medial Branch Blocks

L3 - L4 - L5 - S1 Left

Bupivacaine 5 mg/ml

40 50% Better first 3 hours

50% Better 3 Weeks


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Repeat Medial Branch Blocks L3L4L5S1

Initially 60% better

then 70% better 10 days

But only 20% better at follow-up6 weeks later.


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Re-Examined

Tender Para-vertebral Upper Lumbar

So Medial Branch Blocks L1 L2 L3 Left30 minutes later - 90% Better

BUT

Still Tender Left Para-vertebral Low Lumbar

Medial Branch Blocks L4 L5 S1 Left

Pain free


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Lumbar Sympathetic Block

10 ml of Bupivacaine Injected at Antero-Lataspect lower border L4 Left

Temp Rise 13,6 C Left Big Toe

Passes Urine normally first time in 4 years


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Radio Frequency Lesioning L4 S1

with 40% Improvement

2 Months Later No More Leg Pain, Still cant Sit,Slight Urinary Problems only

Radio Frequency Lesioning L1 L4

3 Months Later 70% BetterLeg Feels Colder and still some Urinary Problems


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Repeat Lumbar Sympathetic Block x 2

Patient Been completely Painfree

Not had ANY Urinary Problems

At 6, 12 and 18 months Follow-up.

Has worked full time last 2 years

Has stopped all medication


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R.F. LUMBAR FACET JOINT


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FACET JOINT INJECTION


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Treatment

Physical therapy (joint mobilization ormanipulation)

Exercise, and education on good spineposture,

Anti-inflammatory medications, Pain medications and activity modification.

Injections (with a steroid) or R.F. to block thepain messages from the nerves

Rarely, surgery is required.


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Treatment-2 Heat (e.g. heat wraps, a hot water bottle, hot

showers) or cold (e.g. cold pad applications)

Changes in daily activities (e.g. shortening oreliminating a long daily commute), and addingfrequent rest breaks

Chiropractic manipulations or osteopathic

manipulations may provide pain relief


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Treatment-3For the neck, a restraining collar maybring temporary

relief, as may also cervical traction. A suitable supportive neck pillow is often

essential and abnormal nighttime flexionpositioning of the neck, such as when using a

pile of pillows, is to be avoided.


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PART OF THE PRESENTATION

COURTESY

DR.S.NATH(SWEDEN)


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Baheti Jt Pain

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