Literature Support Z-Joint Injections
AJR Am J Roentgenol. 2006 May;186(5):1228-33.
Therapeutic efficacy of facet joint blocks.
Gorbach C, Schmid MR, Elfering A, Hodler J, Boos N.
Center for Spinal Surgery, University of Zurich, University Hospital Balgrist,
Zurich, Switzerland.
OBJECTIVE: The objective of our study was to investigate outcome predictors of
short- and medium-term therapeutic efficacy of facet joint blocks. MATERIALS AND
METHODS: Forty-two patients with chronic lower back pain who were undergoing
facet joint blocks at one (n = 29) or two (n = 13) levels were analyzed. All
patients underwent MRI or CT of the lumbar spine within 5 months before the
facet joint blocks. The facet joint blocks were performed under fluoroscopic
guidance. A small amount (< 0.3 mL) of iodinated contrast agent, 0.5 mL of local
anesthetics and 0.5 mL of steroids, were injected. The initial pain response was
prospectively assessed using a visual analogue scale. Additional data, including
short-term effect (> 1 week) and medium-term effect (> 3 months), were collected
by a structured telephone interview. CT and MRI were reviewed with regard to the
extent of facet joint abnormalities. Multiple logistic regression analyses were
conducted to identify outcome predictor for efficacy of facet joint blocks.
RESULTS: A positive immediate effect was seen in 31 patients (74%). A positive
medium-term effect was found in 14 patients (33%). Pain alleviated by motion (p
= 0.035) and the absence of joint-blocking sensation (p = 0.042) predicted pain
relief. However, the extent of facet joint osteoarthritis on MRI and CT was not
a significant predictor for outcome (p = 0.57-0.95). CONCLUSION: Facet joint
blocks appear to have a beneficial medium-term effect in one third of patients
with chronic lower back pain and may therefore be a reasonable adjunct to
nonoperative treatment. However, outcome appears to depend on clinical, not on
morphologic, imaging findings.
J Vasc Interv Radiol. 2005 Nov;16(11):1493-8.
Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular
pain in the lumbar spine.
Fuchs S, Erbe T, Fischer HL, Tibesku CO.
Department of Orthopaedics, University Hospital Munster, Albert-Schweitzer-Str.
33, D-48129, Munster, Germany. fuchssu@uni-muenster.de
PURPOSE: To investigate the efficacy and safety of intraarticular sodium
hyaluronate (SH) compared with intraarticular glucocorticoids (triamcinolone
acetonide; TA) in the treatment of chronic nonradicular lumbar pain. MATERIALS
AND METHODS: Sixty patients were included in this randomized, controlled,
blind-observer clinical study and randomly assigned to two groups to receive 10
mg SH or 10 mg TA per facet joint. The facet joints on both sides at levels
S1-L5, L5-L4, and L4-L3 were treated once per week under computed tomographic
guidance. The study visits were timed to permit assessment of the immediate
effect as well as possible carryover effects at 3 and 6 months after completion
of treatment. Changes in pain were assessed with a visual analog scale (VAS) and
changes in function and quality of life were assessed by the Roland Morris
Questionnaire (RMQ), the Oswestry Disability Questionnaire (ODQ), the Low Back
Outcome Score (LBOS), and the Short Form 36 (SF-36) questionnaire. RESULTS:
Patients reported lasting pain relief, better function, and improved quality of
life with both treatments. Mann-Whitney analyses of the patient questionnaires
(RMQ, ODQ, and LBOS) very consistently showed that SH is not inferior to TA. In
addition, the efficacy of SH was largely comparable with that of TA on the VAS
and SF-36. No adverse effects were reported after administration of the test
products. The intraarticular treatment of facet joints (levels S1-L5, L5-L4, and
L4-L3) with SH in patients with chronic nonradicular pain in the lumbar spine
resulted in a marked reduction in pain with improved function and better quality
of life, which was at least equal to the effect of a course of TA injections.
SH-treated patients showed greater benefits in the long term. CONCLUSION:
Intraarticular SH is a very promising new option for the treatment of patients
with chronic nonradicular lumbar symptoms.
Harefuah. 2004 May;143(5):339-41, 391. [Relief of chronic cervical pain after selective blockade of
zygapophyseal joint] [Article in Hebrew] Folman Y, Livshitz A, Shabat S, Gepstein R. Department of
Orthopaedic Surgery, Hillel Yaffe Medical Center, Hadera, Israel. Osteoarthrosis of the zygapophyseal
joint (Z-joint) is a potential cause of chronic cervical pain. The diagnosis of thirty patients, with pain of more
than 12 months duration and with no history of trauma, was confirmed with intra-articular fluoroscopy-guided
infiltration of anesthetic. The patients were subsequently treated with intra-articular
corticosteroids (Depo-Medrol 40 mg). Visual Analogue Scale was used for evaluation purposes. The mean
time for relapse of 50 percent of the pre-injection level of pain was 12.47 +/- 1.89 weeks, significantly longer
than 3 days as reported in patients similarly treated following whiplash neck injury. At this point
selective blockade of Z-joints may be offered as an adjunct for diagnostic and therapeutic purposes for
patients with chronic neck pain due to facet osteoarthrosis in the ambulatory setup.
Am J Phys Med Rehabil. 2001 Mar;80(3):182-8. Therapeutic zygapophyseal joint injections for headaches
emanating from the C2-3 joint. Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Yang ST, Meyer AM.
Department of Rehabilitation Medicine, Hospital of the University of Pennsylvania, Philadelphia
19104, USA. OBJECTIVE: To report our experience using fluoroscopically guided therapeutic intra-articular
C2-3 zygapophyseal joint injections in patients with chronic headaches after a whiplash event. DESIGN:
Restrospective study (n = 18 patients) with independent clinical review. Each patient experienced
persistent daily headache symptoms which failed to improve after at least 3 mo of physical therapy, activity
restriction, and the use of oral analgesics. Each patient demonstrated initially a positive response to a
diagnostic intra-articular C2-3 joint injection. Data collection and analysis were performed by an
independent clinical reviewer. Outcome measures included headache frequency, medication usage,
symptom response to medication, and employment status. RESULTS: Patients' symptom duration before
diagnostic injection averaged 34 mo. Follow-up data collection transpired at an average of 19 mo after
the final therapeutic injection. In 61% of patients, fewer than three headaches were experienced each week;
these headaches were relieved with the use of oral analgesics. CONCLUSIONS: Although the inherent
limitations of this study preclude a definitive statement regarding the efficacy of C2-3 injections,
these initial findings suggest that therapeutic intra-articular zygapophyseal joint injections are effective in the
treatment of headaches emanating from the C2-3 joint after a whiplash event. Future controlled, prospective
studies are necessary to clarify the role of such injections in this challenging patient population
Reg Anesth. 1993 Nov-Dec;18(6):343-50. Medial branch blocks are specific for the diagnosis of cervical
zygapophyseal joint pain. Barnsley L, Bogduk N. Cervical Spine Research Unit, University of Newcastle,
Waratah, New South Wales, Australia. BACKGROUND AND OBJECTIVES. To determine the
specificity of cervical medial branch blocks for the diagnosis of cervical zygapophyseal joint pain by
ascertaining the disposition of the local anesthetic after injection of the medial branches of the cervical
dorsal rami. METHODS. Sixteen consecutive patients with chronic neck pain from motor vehicle accidents
underwent cervical medial branch blocks. A 22-gauge, 90-mm spinal needle was placed onto the target nerve
under image-intensifier guidance. Immediately after each target nerve had been infiltrated with 0.5 ml of local
anesthetic, 0.5 ml of contrast medium was injected to map the spread of injectate.
Radiographs were recorded to document the pattern of spread. RESULTS. Twenty-five injections of local
anesthetic and contrast medium were performed. Contrast medium dispersed in characteristic patterns at
all vertebral levels and always incorporated at least 5 mm of the perceived course of the target
nerve. There was never any spread to the ventral ramus, beyond the medial fibers of semispinalis capitis or
to the adjacent medial branches. No other single structure was consistently within the field of the contrast.
Eleven patients obtained complete or definite relief of their pain, which could only be attributed
to anesthetization of the zygapophyseal joint innervated by the nerves blocked. CONCLUSIONS. Local
anesthetic blocks of the cervical medial branches are a specific test for the diagnosis of cervical
zygapophyseal joint pain. The local anesthetic always reaches the target nerve and does not affect any other
diagnostically important structures.
AJR Am J Roentgenol. 2006 May;186(5):1228-33.
Therapeutic efficacy of facet joint blocks.
Gorbach C, Schmid MR, Elfering A, Hodler J, Boos N.
Center for Spinal Surgery, University of Zurich, University Hospital Balgrist,
Zurich, Switzerland.
OBJECTIVE: The objective of our study was to investigate outcome predictors of
short- and medium-term therapeutic efficacy of facet joint blocks. MATERIALS AND
METHODS: Forty-two patients with chronic lower back pain who were undergoing
facet joint blocks at one (n = 29) or two (n = 13) levels were analyzed. All
patients underwent MRI or CT of the lumbar spine within 5 months before the
facet joint blocks. The facet joint blocks were performed under fluoroscopic
guidance. A small amount (< 0.3 mL) of iodinated contrast agent, 0.5 mL of local
anesthetics and 0.5 mL of steroids, were injected. The initial pain response was
prospectively assessed using a visual analogue scale. Additional data, including
short-term effect (> 1 week) and medium-term effect (> 3 months), were collected
by a structured telephone interview. CT and MRI were reviewed with regard to the
extent of facet joint abnormalities. Multiple logistic regression analyses were
conducted to identify outcome predictor for efficacy of facet joint blocks.
RESULTS: A positive immediate effect was seen in 31 patients (74%). A positive
medium-term effect was found in 14 patients (33%). Pain alleviated by motion (p
= 0.035) and the absence of joint-blocking sensation (p = 0.042) predicted pain
relief. However, the extent of facet joint osteoarthritis on MRI and CT was not
a significant predictor for outcome (p = 0.57-0.95). CONCLUSION: Facet joint
blocks appear to have a beneficial medium-term effect in one third of patients
with chronic lower back pain and may therefore be a reasonable adjunct to
nonoperative treatment. However, outcome appears to depend on clinical, not on
morphologic, imaging findings.
J Vasc Interv Radiol. 2005 Nov;16(11):1493-8.
Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular
pain in the lumbar spine.
Fuchs S, Erbe T, Fischer HL, Tibesku CO.
Department of Orthopaedics, University Hospital Munster, Albert-Schweitzer-Str.
33, D-48129, Munster, Germany. fuchssu@uni-muenster.de
PURPOSE: To investigate the efficacy and safety of intraarticular sodium
hyaluronate (SH) compared with intraarticular glucocorticoids (triamcinolone
acetonide; TA) in the treatment of chronic nonradicular lumbar pain. MATERIALS
AND METHODS: Sixty patients were included in this randomized, controlled,
blind-observer clinical study and randomly assigned to two groups to receive 10
mg SH or 10 mg TA per facet joint. The facet joints on both sides at levels
S1-L5, L5-L4, and L4-L3 were treated once per week under computed tomographic
guidance. The study visits were timed to permit assessment of the immediate
effect as well as possible carryover effects at 3 and 6 months after completion
of treatment. Changes in pain were assessed with a visual analog scale (VAS) and
changes in function and quality of life were assessed by the Roland Morris
Questionnaire (RMQ), the Oswestry Disability Questionnaire (ODQ), the Low Back
Outcome Score (LBOS), and the Short Form 36 (SF-36) questionnaire. RESULTS:
Patients reported lasting pain relief, better function, and improved quality of
life with both treatments. Mann-Whitney analyses of the patient questionnaires
(RMQ, ODQ, and LBOS) very consistently showed that SH is not inferior to TA. In
addition, the efficacy of SH was largely comparable with that of TA on the VAS
and SF-36. No adverse effects were reported after administration of the test
products. The intraarticular treatment of facet joints (levels S1-L5, L5-L4, and
L4-L3) with SH in patients with chronic nonradicular pain in the lumbar spine
resulted in a marked reduction in pain with improved function and better quality
of life, which was at least equal to the effect of a course of TA injections.
SH-treated patients showed greater benefits in the long term. CONCLUSION:
Intraarticular SH is a very promising new option for the treatment of patients
with chronic nonradicular lumbar symptoms.
Harefuah. 2004 May;143(5):339-41, 391. [Relief of chronic cervical pain after selective blockade of
zygapophyseal joint] [Article in Hebrew] Folman Y, Livshitz A, Shabat S, Gepstein R. Department of
Orthopaedic Surgery, Hillel Yaffe Medical Center, Hadera, Israel. Osteoarthrosis of the zygapophyseal
joint (Z-joint) is a potential cause of chronic cervical pain. The diagnosis of thirty patients, with pain of more
than 12 months duration and with no history of trauma, was confirmed with intra-articular fluoroscopy-guided
infiltration of anesthetic. The patients were subsequently treated with intra-articular
corticosteroids (Depo-Medrol 40 mg). Visual Analogue Scale was used for evaluation purposes. The mean
time for relapse of 50 percent of the pre-injection level of pain was 12.47 +/- 1.89 weeks, significantly longer
than 3 days as reported in patients similarly treated following whiplash neck injury. At this point
selective blockade of Z-joints may be offered as an adjunct for diagnostic and therapeutic purposes for
patients with chronic neck pain due to facet osteoarthrosis in the ambulatory setup.
Am J Phys Med Rehabil. 2001 Mar;80(3):182-8. Therapeutic zygapophyseal joint injections for headaches
emanating from the C2-3 joint. Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Yang ST, Meyer AM.
Department of Rehabilitation Medicine, Hospital of the University of Pennsylvania, Philadelphia
19104, USA. OBJECTIVE: To report our experience using fluoroscopically guided therapeutic intra-articular
C2-3 zygapophyseal joint injections in patients with chronic headaches after a whiplash event. DESIGN:
Restrospective study (n = 18 patients) with independent clinical review. Each patient experienced
persistent daily headache symptoms which failed to improve after at least 3 mo of physical therapy, activity
restriction, and the use of oral analgesics. Each patient demonstrated initially a positive response to a
diagnostic intra-articular C2-3 joint injection. Data collection and analysis were performed by an
independent clinical reviewer. Outcome measures included headache frequency, medication usage,
symptom response to medication, and employment status. RESULTS: Patients' symptom duration before
diagnostic injection averaged 34 mo. Follow-up data collection transpired at an average of 19 mo after
the final therapeutic injection. In 61% of patients, fewer than three headaches were experienced each week;
these headaches were relieved with the use of oral analgesics. CONCLUSIONS: Although the inherent
limitations of this study preclude a definitive statement regarding the efficacy of C2-3 injections,
these initial findings suggest that therapeutic intra-articular zygapophyseal joint injections are effective in the
treatment of headaches emanating from the C2-3 joint after a whiplash event. Future controlled, prospective
studies are necessary to clarify the role of such injections in this challenging patient population
Reg Anesth. 1993 Nov-Dec;18(6):343-50. Medial branch blocks are specific for the diagnosis of cervical
zygapophyseal joint pain. Barnsley L, Bogduk N. Cervical Spine Research Unit, University of Newcastle,
Waratah, New South Wales, Australia. BACKGROUND AND OBJECTIVES. To determine the
specificity of cervical medial branch blocks for the diagnosis of cervical zygapophyseal joint pain by
ascertaining the disposition of the local anesthetic after injection of the medial branches of the cervical
dorsal rami. METHODS. Sixteen consecutive patients with chronic neck pain from motor vehicle accidents
underwent cervical medial branch blocks. A 22-gauge, 90-mm spinal needle was placed onto the target nerve
under image-intensifier guidance. Immediately after each target nerve had been infiltrated with 0.5 ml of local
anesthetic, 0.5 ml of contrast medium was injected to map the spread of injectate.
Radiographs were recorded to document the pattern of spread. RESULTS. Twenty-five injections of local
anesthetic and contrast medium were performed. Contrast medium dispersed in characteristic patterns at
all vertebral levels and always incorporated at least 5 mm of the perceived course of the target
nerve. There was never any spread to the ventral ramus, beyond the medial fibers of semispinalis capitis or
to the adjacent medial branches. No other single structure was consistently within the field of the contrast.
Eleven patients obtained complete or definite relief of their pain, which could only be attributed
to anesthetization of the zygapophyseal joint innervated by the nerves blocked. CONCLUSIONS. Local
anesthetic blocks of the cervical medial branches are a specific test for the diagnosis of cervical
zygapophyseal joint pain. The local anesthetic always reaches the target nerve and does not affect any other
diagnostically important structures.
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