Manchikanti Laxmaiah, Kaye Alan D, Boswell Mark V, Bakshi Sanjay, Gharibo Christopher G, Grami Vahid, Grider Jay S, Gupta Sanjeeva, Jha Sachin Sunny, Mann Dharam P, Nampiaparampil Devi E, Sharma Manohar Lal, Shroyer Lindsay N, Singh Vijay, Soin Amol, Vallejo Ricardo, Wargo Bradley W, Hirsch Joshua A
Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY; LSU Health Science Center, New Orleans, LA; Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY; Manhattan Spine an.
Pain Physician. 2015 Jul-Aug;18(4):E535-82.
The therapeutic spinal facet joint interventions generally used for the treatment of axial spinal pain of facet joint origin are intraarticular facet joint injections, facet joint nerve blocks, and radiofrequency neurotomy. Despite interventional procedures being common as treatment strategies for facet joint pathology, there is a paucity of literature investigating these therapeutic approaches. Systematic reviews assessing the effectiveness of various therapeutic facet joint interventions have shown there to be variable evidence based on the region and the modality of treatment utilized. Overall, the evidence ranges from limited to moderate.
To evaluate and update the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain.
A systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic spinal pain.
The available literature on lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain was reviewed. The quality assessment criteria utilized were the Cochrane Musculoskeletal Review Group criteria and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized trials and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for observational studies. The level of evidence was classified at 5 levels from Level I to Level V. Data sources included relevant literature identified through searches on PubMed and EMBASE from 1966 through March 2015, and manual searches of the bibliographies of known primary and review articles.
The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake consumption.
A total of 21 randomized controlled trials meeting appropriate inclusion criteria were assessed in this evaluation. A total of 5 observational studies were assessed. In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In the cervical spine, for long-term improvement, there is Level II evidence for cervical radiofrequency neurotomy and cervical facet joint nerve blocks, and Level IV evidence for cervical intraarticular injections. In the thoracic spine there is Level II evidence for thoracic facet joint nerve blocks and Level IV evidence for radiofrequency neurotomy for long-term improvement.
The limitations of this systematic review include an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injections.
Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy.
治疗性脊柱小关节干预通常用于治疗源于小关节的轴性脊柱疼痛，包括关节腔内小关节注射、小关节神经阻滞和射频神经切断术。尽管介入手术作为小关节病变的治疗策略很常见，但研究这些治疗方法的文献却很少。评估各种治疗性小关节干预有效性的系统评价表明，基于所采用的治疗区域和方式，证据存在差异。总体而言，证据范围从有限到中等。
评估并更新治疗性腰椎、颈椎和胸椎小关节干预在管理慢性脊柱疼痛方面的临床效用。
对治疗性腰椎、颈椎和胸椎小关节干预治疗慢性脊柱疼痛进行系统评价。
回顾了关于腰椎、颈椎和胸椎小关节干预治疗慢性脊柱疼痛的现有文献。所采用的质量评估标准是Cochrane肌肉骨骼评价组标准以及用于随机试验的介入性疼痛管理技术 - 可靠性和偏倚风险评估的质量评估（IPM - QRB），以及用于观察性研究的介入性疼痛管理技术 - 非随机研究的可靠性和偏倚风险评估的质量评估（IPM - QRBNR）。证据水平从I级到V级分为5个级别。数据来源包括通过在1966年至2015年3月期间在PubMed和EMBASE上进行搜索确定的相关文献，以及对已知的主要和综述文章的参考文献进行手动搜索。
主要结果指标是疼痛缓解（短期缓解 = 长达6个月，长期 > 6个月）。次要结果指标是功能状态、心理状态的改善、重返工作岗位以及阿片类药物摄入量的减少。
本评估共评估了21项符合适当纳入标准的随机对照试验。共评估了5项观察性研究。在腰椎，就长期有效性而言，射频神经切断术和腰椎小关节神经阻滞有II级证据，而腰骶关节腔内注射的证据为III级。在颈椎，就长期改善而言，颈椎射频神经切断术和颈椎小关节神经阻滞有II级证据，颈椎关节腔内注射有IV级证据。在胸椎，胸椎小关节神经阻滞有II级证据，射频神经切断术有IV级证据用于长期改善。
本系统评价的局限性包括总体上高质量研究匮乏，更具体地说，缺乏与胸椎小关节注射相关的研究。
基于目前对脊柱小关节疼痛管理的评估，腰椎和颈椎射频神经切断术以及颈椎、胸椎和腰椎的治疗性小关节神经阻滞在长期改善方面的证据为II级；腰椎关节腔内注射为III级；颈椎关节腔内注射和胸椎射频神经切断术为IV级。
