Tran John, Alboog Abdulrahman, Barua Ujjoyinee, Billias Nicole, Loh Eldon
Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Canada.
Department of Physical Medicine and Rehabilitation, Parkwood Institute, London, Canada.
Interv Pain Med. 2024 Aug 19;3(3):100433. doi: 10.1016/j.inpm.2024.100433. eCollection 2024 Sep.
Lumbar medial branch (MB) radiofrequency ablation is a common intervention to treat facetogenic low back pain. The consensus among spine pain interventionalists is that capturing a greater length of the MB correlates with a longer duration of pain relief. Therefore, there has been interest in defining optimal needle angles to achieve parallel cannula placement. Presently, there is inconsistency regarding the optimal caudal needle angles.
The objectives of this study were to: 1) use a dissection-based 3D modelling methodology to quantify optimal caudal needle angles from cadaveric models; and 2) compare optimal cadaver-derived caudal needle angles with real-world patient-derived needle angles.
Eighteen formalin embalmed lumbosacral spine specimens were dissected, digitized, and modelled in 3D. Virtual needles were simulated and placed parallel with the L1-L5 MBs. Cadaver-derived caudal needle angles were measured from the high-fidelity 3D models with optimally placed virtual needles. Lateral fluoroscopic images of patients (n = 200) that received lumbar MB denervation were reviewed to measure patient-derived caudal needle angles (L3-L5 MB levels). Descriptive statistics were used to analyze the cadaver (L1-L5 MB levels) and patient-derived (L3-L5 MB levels) caudal needle angles. The cadaver and patient-derived mean caudal needle angles for L3-L5 MB levels were compared.
There was variability in the cadaver-derived mean caudal needle angles. The lowest mean caudal needle angle was the L1 MB level measured at 41.57 ± 8.56° (range: 27.14° - 53.96°). The highest was the L5 MB level with a mean caudal needle angle of 60.79 ± 8.55° (range: 46.97° - 79.74°). A total of 123 patients were included and 369 caudal needle angles (L3-L5 MB levels) were measured and analyzed. There was variability in the patient-derived mean caudal needle angles. The patient-derived mean caudal needle angles were 29.18 ± 8.77° (range: 11.80° - 61.31°), 33.34 ± 7.23° (range: 16.40° - 54.15°), and 49.08 ± 8.87° (range: 26.45° - 76.95°) for the L3, L4, and L5 MB levels, respectively. There was a significant difference in mean caudal needle angle between cadaver and patient-derived needle angles at the L3, L4, and L5 MB levels.
Analysis of cadaver-derived needle angles versus patient-derived data suggests optimization of lumbar MB denervation requires greater caudal angulation to achieve parallel needle placement. Further research is required to assess the clinical implications.
腰椎内侧支（MB）射频消融术是治疗小关节源性下腰痛的一种常见干预措施。脊柱疼痛介入专家的共识是，消融更长的MB节段与更长的疼痛缓解期相关。因此，人们对确定实现平行套管置入的最佳进针角度很感兴趣。目前，关于最佳尾侧进针角度存在不一致的观点。
本研究的目的是：1）使用基于解剖的三维建模方法，从尸体模型中量化最佳尾侧进针角度；2）将尸体来源的最佳尾侧进针角度与实际患者的进针角度进行比较。
对18个经福尔马林防腐处理的腰骶椎标本进行解剖、数字化处理并建立三维模型。模拟虚拟针并使其与L1-L5的MB平行放置。从具有最佳放置虚拟针的高保真三维模型中测量尸体来源的尾侧进针角度。回顾接受腰椎MB去神经支配的患者（n = 200）的侧位透视图像，以测量患者来源的尾侧进针角度（L3-L5的MB节段）。使用描述性统计分析尸体（L1-L5的MB节段）和患者来源（L3-L5的MB节段）的尾侧进针角度。比较L3-L5的MB节段尸体和患者来源的平均尾侧进针角度。
尸体来源的平均尾侧进针角度存在差异。最低的平均尾侧进针角度是L1的MB节段，为41.57±8.56°（范围：27.14°-53.96°）。最高的是L5的MB节段，平均尾侧进针角度为60.79±8.55°（范围：46.97°-79.74°）。共纳入123例患者，测量并分析了369个尾侧进针角度（L3-L5的MB节段）。患者来源的平均尾侧进针角度存在差异。L3、L4和L5的MB节段患者来源的平均尾侧进针角度分别为29.18±8.77°（范围：11.80°-61.31°）、33.34±7.23°（范围：16.40°-54.15°）和49.08±8.87°（范围：26.45°-76.95°）。L3、L4和L5的MB节段尸体和患者来源的进针角度平均尾侧进针角度存在显著差异。
对尸体来源的进针角度与患者来源数据的分析表明，优化腰椎MB去神经支配需要更大的尾侧角度以实现平行针置入。需要进一步研究以评估其临床意义。
