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of Anaesthesiology, NICVD, Dhaka, Bangladesh, 3Indian chapter of World Institute of Pain, 4K K Health
Care Centre, Gurgaon, Haryana, India, 5HCG Medisurge Hospitals, Navrangpura, Gujrat, India,
6Department of Anaesthesiology, Ibrahim Medical College and BIRDEM, Dhaka, Bangladesh
.
Journal of the Bangladesh Society of Anaesthesiologists Vol. 24, No. 1, January 2011
injections. These injections targeted facet joints SIJ as a source of pain, controlled intra-articular
via medial branch blocks, intervertebral discs via injections are the only available means of
provocation discography, and sacroiliac joints (SIJs) identifying this site as causing such discomfort.15,16
via intra-articular injections. They concluded that Because innervation of the SIJ is poorly defined
the facet joint contributed to chronic LBP in 40% and most likely complex, pain emanating from here
of the population, the intervertebral disc in 26%, cannot be diagnosed using nerve blocks. Intra-
and the SIJ in 27%. Anecdotal experience among articular injection of a local anesthetic (e.g.
physicians at Advanced Pain Consultants PA, in lidocaine or bupivacaine hydrochloride) into the
Voorhees, NJ, indicates that the intervertebral disc SIJ is the technique of choice used to prove or
is the more frequent significant source of chronic disprove that it is the etiologic factor.
LBP than are lumbar facet joints.
Discogenic Pain
Facet Joint Pain Provocation discography involves injection of
Osteoarthritis and trauma are among the most contrast medium into the disc nucleus to define
common conditions leading to pain emanating from its morphology; this increase in intradiscal pressure
facet joints. The primary symptom of pain allows simultaneous evaluation of the patient’s
emanating from this site is that of LBP. By response to pain reproduction. Therefore,
injecting a solution of 10% hypertonic saline provocation discography can determine if this
solution in the region of the facet joints, Hirsch anatomic location is a pain source. It is based on
and colleagues12 demonstrated that pain can be the concept that if a particular disc is the source of
created in the upper back and thigh regions. Pain pain, stressing it should result in reproduction of
frequently is also referred into the groin, buttocks, that pain. Furthermore, if the disc is not the source
hip, or lateral and posterior thigh regions (or a of pain, then when stressed, it should either not
combination of these sites). Pain is often described cause pain or it may produce pain that is atypical
as a “deep, dull ache” and may be either unilateral (disconcordant) of the underlying pain. Immediately
or bilateral. On physical examination, there may following provocation discography, computed
frequently be increased pain with extension, tomography (CT) scanning is done to obtain a static
tenderness to palpation over the affected joints, axial view of the intervertebral disc to evaluate
and normal findings on neurologic examination. the degree of annular disruption. Sachs et al17
Electrical stimulation of the medial branch nerves developed the Dallas discogram scale, which grades
has also assisted in identifying referral pain disruption of the annulus on a four-point scale. A
patterns.13 normal nucleogram, one in which contrast is
entirely contained within the nucleus, is considered
Facet joint injections or medial branch nerve
a grade 0 disc. Grades 1 to 3 describe extension of
blocks are primarily diagnostic tools. An intra-
the contrast medium to the inner third, middle
articular facet injection usually includes use of a
third, and outer third of the annulus fibrosis,
steroid such as methylprednisolone, which
respectively. Examples include a posterior radial
theoretically reduces inflammation within the
fissure at L4–5 with contrast extravasating into
joint, thereby potentially reducing pain. However,
the anterior epidural space and a grade 3
injecting steroid into the facet joint does not posterolateral annular disruption on the
usually provide lasting relief. Dreyfuss et al14 have postdiscography CT scan.
demonstrated that clinically significant and
prolonged relief from back pain can be achieved Ozone disc nucleolysis and epidural steroid
with radiofrequency neurotomy of the lumbar Outcome studies of lumber disc surgeries
medial branches. Patients’ pain must be carefully document a success rate between 49% to 95%.18
diagnosed with controlled diagnostic blocks of the Reasons for this failure are: 1) dural fibrosis, 2)
lumbar medial branches. arachnoidal adhesions, 3)muscle & fascial fibrosis
4) mechanical instability resulting from the partial
Sacroiliac Joint Pain removal of bony and ligamentous structures
There is no scientific evidence that history or required for surgical exposure and decompression
physical examination can accurately identify the leading to facet & sacro-iliac joint dysfunctions, 5)
24
Interventional pain management procedure for treating low back pain K. Sardar et al
25
Journal of the Bangladesh Society of Anaesthesiologists Vol. 24, No. 1, January 2011
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