Abstract
Introduction
The problem of diagnostics and treatment of pain syndromes caused by degenerative processes of lumbar spine remains actual because of a high prevalence of these diseases and diagnostic difficulties in determining the source of pain especially in case of noncompressive pain syndromes. It was reported that in the majority of the cases, pain syndromes associated with degeneration of lumbar spine are noncompressive forming approximately 80% whereas those with nerve root compression account for only up to 20%. Different studies support the statement that in the majority of cases, the approach from the position of reductionism is applicable in case of pain syndromes associated with lumbar spine degeneration, however, a precise diagnostic of the main source of pain is required to apply highly specific minimal invasive modalities. It is a well-known fact that diagnostic methods have a limited accuracy regarding the ability to determine the source of pain in case of noncompressive pain syndromes, and in terms of this issue the evaluation of relative contribution of different structures in low back pain (LBP) could be helpful to develop a rational diagnostic algorithm.
The objective of this study is to evaluate a relative contribution of various structures in LBP in case of degenerative diseases of lumbar spine.
Materials and Methods
This is a prospective nonrandomized study of 83 consecutive patients presenting LBP with or without sciatica at least during 6 months. In all cases, there was no evidence of nerve root compression according to the results of clinical examination and neurovisualization. All patients were resistant to the repeated courses of conservative therapy including various types of blocks. All patients were given neurological examination, examination applying visual analogue scale (the result is VAS score) and Oswestry disability questionnaire (the result is Oswestry disability index—ODI). MRI imaging was applied in all cases. To confirm the discogenic origin of pain, a provocative discography was applied under the control of the fluoroscopy, the diagnostic criterion was the reproduction of concordant pain. To confirm the contribution if facet joints or sacroiliac joints in LBP, a repeated diagnostic blocks with various anesthetics, were applied under the guidance of the fluoroscopy, the diagnostic criterion was at least 50% pain intensity relief (VAS score) during the anesthetic action.
Patients were treated with nucleoplasty when discogenic origin of pain was confirmed by the results of discography. Using ablation and coagulation mode six channels were created within the disk. Radiofrequency denervation was applied in cases of facet joints blocks positive results. Chemical denervation with ethyl alcohol was applied in cases, when evidence of sacroiliac joint pain was provided by the results of diagnostic blocks.
The criterion of clinically significant treatment results was at least 50% VAS score decrease and 40% decrease in ODI score after intervention was applied.1 Patients with significant biomechanical impairments who showed unsatisfactory results after interventional pain management underwent transpedicular fixation and interbody fusion.
The conclusion concerning the prevalence of different pain sources was based on the estimated rate of clinically significant results after the applied interventions.
Results
According to the results of different interventions application, the rate of facet joint pain was accounted up to 51.2% with 95% CI (39.4 to 61.8%), the rate of discogenic pain formed 16.9% with 95% CI (9.5–26.7%), sacroiliac joint pain came to 7.2% with 95% CI (2.7–15.1%). In 8.4% cases, the source of pain was not determined. In the minority of cases the approach from the position of reductionism was ineffective because of the agglomeration of different factors including biomechanical impairments, those cases formed 16.3% with 95% CI (9.8–27.0%); further stabilization of segment with pedicle screws and interbody fusion resulted in a clinically significant pain relief.
Conclusion
The results of our study show that approach from the position of reductionism is effective in the majority of cases of chronic noncompressive pain syndromes presentation, associated with lumbar spine degenerative processes. In other words, main source of pain can be identified, justifying the application of the specific interventional pain management as the first stage of surgical treatment. The results of our study shows the domination of facet joints in structure of LBP causes, and according to the results of 95% CI estimation, the difference in rate of two most frequent types of pain—facet joint pain and discogenic pain is considerable. Diagnostic algorithm should be adjusted to the probability of different pain sources detection to diminish a number of the applied invasive diagnostic manipulations. The reason to focus on the facet joints pathology evaluation in case of chronic noncompressive pain syndromes is not only because of the higher probability to evaluate this source of pain but also because of the relatively higher efficacy and safety of diagnostic tools applied to determine this source of pain in comparison to those applied to verify the discogenic pain.
Yes
None declared
Manchikanti L, Derby R, Benyamin RM, Helm S, Hirsch JA. A systematic review of mechanical lumbar disk decompression with nucleoplasty. Pain Physician 2009;12:561–572