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Facet Related Interventions
Who, When and Where
Prof & HOD Dept. of
Anesthesia & Pain, B.H.I.M.S.,
Pain Physician, Lilavati,Raheja, Shushrusha Hospital
Ex.President, IndianSocietyfor Study of Pain,
Executive President, PainManagement and ResearchFoundation
Hobbies-Music, Sports
Web-www.paincure.in
Dr.D.K. Baheti
mailto:[email protected]:[email protected]8/7/2019 Baheti Jt Pain
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Facet Related InterventionsWho, When and Where
Dr.D.K.Baheti MD
Prof & HOD
Dept. Of Anaesthesia and Pain ManagementB.H.I.M.S.,Mumbai-India
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What are the Facet Joint?
Facet joints are located at the posterior (back)aspect of the spine.
Each back bone (vertebra) has four facet joints, anupper and a lower pair.
These joints link the back of the spine together.
They are designed to provide stability and control
motion between the vertebrae.
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Facet Jt. Pain Syndrome (FJPS)?
FJts are prone to injury, deterioration, &inflammation. FJPS can occur anywhere in thespine including the low back.
FJP is usually at the level of the affected facetjoint(s), and is made worse by activities that putpressure on these joints i.e. leaning backwardsand "extending" the lower back or twisting at thewaist.
Occasionally the pain may radiate to other areassuch as the buttocks.
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PAIN DISTRIBUTION
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What causes Facet Jt. Syndrome?-2
Degenerative Disc Disease occurs1-Irritated from trauma, repetitive movements,
arthritic changes
2-The damaged disc looses cushioning effect which
leads to more stress on facet joints , which may resultin degeneration of the facet joint.
3-Poor posture can also cause undue stress on the facetjoints.
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What cause Facet jt. Syndrome?3
The natural inward curve in the lumbar (low back) aredesigned and positioned to handle a certain amount ofstress.
When the natural curve of the lumbar spine is
exaggerated excess stress is placed on the facet joints. Poor body mechanics or how we use our body such as
bending from the back, improper lifting, poor restpositions, and prolonged sitting in poorly designed
chairs can all cause undo stress on the facet joints.
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Facet Joint Pain Syndrome-Diagnosis? Good medical history and a physical examination.
X-rays- AP/LAT/OBLIQUE of the lower back may
help to rule out degenerative changes in the facetjoints or degenerative disc disease.
MRI and CT scans.
Diagnostic blocks
http://backpaininfo.com/backDegenerativeDisc.htmlhttp://backpaininfo.com/backDegenerativeDisc.html8/7/2019 Baheti Jt Pain
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Differential Diagnosis!!!
Herniated disc infllamation
Fracture Torn back muscle
Acute Intra abdominal problem
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SITES OF PAIN
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Symptoms FJPS Persistent joint tenderness
Muscle guarding
Discomfort in leaning forwards/backwards Radiating pain Lumbar- in to buttock and leg
Cervical- Shouldar, front and down arm even fingers
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WHOA 38 year old woman presented withLow Back
Pain with radiation along the Postero-Lateral
aspect of the Left Thigh to just abovethe
knee and also out to the Left Hiplateral aspect.
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Pain
The pain was described as a constant dull ache with asharp stabbing in left paravertebrally and over the SI
joint.
Pain varied between VAS 0.8----7.0: 4.5 mean
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Worse
= Sitting especially in a soft sofa.= Mornings
= Standing still
= Long walks
= Much pain when tired, often in the evenings
after work
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Weight Bearing on
the Left Leg and
pushing with the
Right leg
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Better
When she had got going in the mornings after getting up
Short Walks
Best
Not too Little ___ Not too Much Movement
Stand a Little, Sit a Little, Walk a Little
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Examination
Inspection Para-Vertebral muscle spasm
Palpation Tender Mid-line and Left Paravertebral
Movement Stiff, careful, reduced flexion, pain onextension.
S L R Left 80 C Right 90 C
Reflexes Brisk, Equal both sidesSensory Reduced along Postero-Lateral aspectLeft thigh.
Motor Normal
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Clinical Diagnosis
?
Facet (Z joint) Pain
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Medication
Gabapentin 300mg x 3 Daily
Paracetamol 1 g x 3 Daily
Tramadol 50 100 mg occasionally whenbad
Sertralin (Zoloft) 50 mg Daily (Anti-depressant)
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Previous Treatment Attempts
Physiotherapy, massage, exercise programs, twice a week
4 years -- No Effect.
Acupuncture -- No Effect.
TNS -- No Effect.ESI x 3 -- Minimal Effect.
MRI -- slightly bulging disc
Orthopedic surgeon -- surgery not indicated.
Condition -- variable but stable. Works half time now
after Rehab, been off-sick for 4 years
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Pain Left Gluteal and P/L Left Thigh
Trans Foraminal ESI L5 Left
Fantastic 80% Better 2 Months
Pains gradually back
Now only 10% Better
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Repeat L5 Trans Foraminal ESI
Not as Good -- Shorter Effect
Now Most Pain Both Hips Laterally andParavertebral more on left
BUT Better in the Leg
Pain Still provoked by
Sitting and Extension
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3 Months Later
Back Again, Was Fine 2 Months
Now only 40% Better
Patient mentions that she has
Even More Problems Passing UrineBeen to Urologists and Gynaecologists 4 Years
Did not mention it before as she thought it was notrelevant
Temp. Left foot 1,8C colder than rightPatient admits that Left Foot often Feels Colder
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Medial Branch Blocks
L3 - L4 - L5 - S1 Left
Bupivacaine 5 mg/ml
40 50% Better first 3 hours
50% Better 3 Weeks
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Repeat Medial Branch Blocks L3L4L5S1
Initially 60% better
then 70% better 10 days
But only 20% better at follow-up6 weeks later.
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Re-Examined
Tender Para-vertebral Upper Lumbar
So Medial Branch Blocks L1 L2 L3 Left30 minutes later - 90% Better
BUT
Still Tender Left Para-vertebral Low Lumbar
Medial Branch Blocks L4 L5 S1 Left
Pain free
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Lumbar Sympathetic Block
10 ml of Bupivacaine Injected at Antero-Lataspect lower border L4 Left
Temp Rise 13,6 C Left Big Toe
Passes Urine normally first time in 4 years
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Radio Frequency Lesioning L4 S1
with 40% Improvement
2 Months Later No More Leg Pain, Still cant Sit,Slight Urinary Problems only
Radio Frequency Lesioning L1 L4
3 Months Later 70% BetterLeg Feels Colder and still some Urinary Problems
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Repeat Lumbar Sympathetic Block x 2
Patient Been completely Painfree
Not had ANY Urinary Problems
At 6, 12 and 18 months Follow-up.
Has worked full time last 2 years
Has stopped all medication
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R.F. LUMBAR FACET JOINT
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FACET JOINT INJECTION
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Treatment
Physical therapy (joint mobilization ormanipulation)
Exercise, and education on good spineposture,
Anti-inflammatory medications, Pain medications and activity modification.
Injections (with a steroid) or R.F. to block thepain messages from the nerves
Rarely, surgery is required.
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Treatment-2 Heat (e.g. heat wraps, a hot water bottle, hot
showers) or cold (e.g. cold pad applications)
Changes in daily activities (e.g. shortening oreliminating a long daily commute), and addingfrequent rest breaks
Chiropractic manipulations or osteopathic
manipulations may provide pain relief
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Treatment-3For the neck, a restraining collar maybring temporary
relief, as may also cervical traction. A suitable supportive neck pillow is often
essential and abnormal nighttime flexionpositioning of the neck, such as when using a
pile of pillows, is to be avoided.
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PART OF THE PRESENTATION
COURTESY
DR.S.NATH(SWEDEN)
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