Original ContributionSonoanatomic indices of lumbar facet joints in patients with facetogenic back pain in comparison to healthy subjects☆
Introduction
Low back pain (LBP) is the most common complaints of the patients referred to a pain clinic. The LBP has multiple etiologies and according to the International Organization Pain, pain caused by lumbar facet joint is responsible for 15%-45% of all reported cases. The terminology of facet syndrome was first used in 1933 by Ghormley, which has separated this condition from the other causes of LBP [1], [2]. Among other major etiologies of lumbar pain, intervertebral disc herniation and inflammation of the sacroiliac (SI) joint can be noted [3]. Pain associated with lumbar facet joint is generally localized over the involved joint; however, it may be referred to back and thigh. Due to this latter pattern of spread, it is not uncommon for the facet joint pain to be falsely perceived as radicular pain (pseudoradiculopathy).
Diagnosis of facet joint disease (FJD) is generally made using 4 physical examination components of Revel criteria (standing flexion, returning from standing flexion, standing extension, and the extension rotation test), which describe the pain relief with rest [4]. Dependence on the lack of pain exacerbation by coughing or bending forward has yielded conflicting results [5]. Although both the computerized tomographic (CT) scanning and the magnetic resonance imaging (MRI) provide valuable information on the presence of degenerative joint disease, they lack the ability to make a final diagnosis of FJD. In another study, positron emission tomography scanning was used for diagnosis with a high sensitivity. However, low specificity (lower true-positive rates) and excessive cost of the unit have been limiting factor for its widespread use [6].
Injections of corticosteroids and local anesthetics into the joint or around the medial branch nerves have been used both for treatment and diagnosis of FJD. The use of these blocks to diagnose FJD carries significant rates of false negative due to variation in the anatomical path of the medial branch nerves and false positive due to the block of the other branches of the intervertebral nerves [7]. Performing multiple blocks while increasing its sensitivity and specificity in diagnosis of FJD is both money and time consuming. The use of ultrasound technology has lately become popular among the physicians practicing interventional pain management worldwide. In addition, the ultrasound technology has enabled us to define new sonoanatomic landmarks, which not only can be used in the success of the guided blocks as they may also be applied in diagnosis FJD in patients with LBP.
The main objective of this study was to identify sonoanatomic characteristics that are associated with FJD of the 3 lower lumbar vertebras (L3-L5). By the use of ultrasound, we measured interfacet joint distance (IFJD) as the primary end point and the distance of the facet joints from the skin (DFS) as the secondary end point in patients with established diagnosis of FJD and compared with healthy population. We hypothesized that both IFJD and DFS are decreased in patients with FJD.
Section snippets
Methods
The scientific merit, study design and protocol, ethical conduct, and the forms used for obtaining informed consents were reviewed and approved by the institutional review board of Rasul-e-Akram hospital an affiliate of Iran University of Medical Sciences. Although the study was determined to be noninterventional and observational in nature, special care was taken to assure that the privacy of the participants.
The following are the inclusion and exclusion criteria and definitions: patients
Results
Ten female and 10 male patients with FJD and 40 (19 female and 21 male) HVG were enrolled in this study. The average age of the patients was 44.2 ± 10.2 years old in the FJD, which was similar to the average age of 40.5 ± 9.3 years old in the HVG (P = .190). Both groups were also similar from the anthropometric variables point of view. The average height and weight was both similar between the FJD and HVG groups. The body mass index was 25.4 ± 2.9 kg/m2 in FJD patients that was similar to 24.7 ± 3.5 kg/m2
Discussion
In this study, the distance between lumbar facet joints and the skin and the other facet joints has been measured in both healthy and facetogenic back pain patients. We describe that the interfacet distance is smaller in patients with FJD compared with HVGs as measured by ultrasonic methods. Although there is no difference in the depth of the facet joints between the patients with the FJD and normal subjects, these joints are significantly deeper on the side of inflammation (left) than the
Limitations
One of the major pitfalls of this study is the fact that the diagnosis of facet-mediated pain has been made solely by clinical examination, not confirmed by any imaging such as MRI or x-rays. There are some concerns about the diagnostic value of medial branch block in FDJ. Comparing sonometric measurements with those of MRI would have added information regarding the bias and precision of this imaging modality for each one of the measurements. However, there is enough evidence in the literature
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Conflict of interest: None of the authors has any conflict of interest to report.