Joint Injections

OBJECTIVE The goal of this study was to use computed tomographic (CT) scanning to localize clinically guided sacroiliac (SI) joint injections and identify other structures affected by this procedure. DESIGN A prospective, double-blind, correlational outcome study design was used. Injection of 39 SI joints with a mixture of bupivacaine (0.25%), methylprednisolone (40 mg), and iohexol (Omnipaque; 180 mg/dl) using a clinically guided technique, (i.e., no image guidance) was performed. Patients had CT scans obtained both immediately after needle placement and after contrast injection. Neither the patients nor their clinicians were aware of the CT findings at the time of injection. SETTING Academic multidisciplinary pain center. PATIENTS Patients with SI disease by clinical criteria. RESULTS Intra-articular injection was accomplished in 8 of 37 (22%) patients. Injected material was identified within 1 cm of the joint 68% of the time. Epidural (spinal canal) injected material was seen 24% of the time. CONCLUSIONS The low rate of intra-articular injection seen with this clinically-guided technique suggests restraint in its use for injection therapy. Some image guidance (e.g., fluoroscopy, CT) is probably necessary to reliably inject the SI joint. Perhaps in clinical settings, where image guidance is not readily available, a clinically-guided technique could initially be tried in patients at low risk for complications from such injections. This study also provides an anatomic explanation for the occasional weakness observed after SI joint injection.

BACKGROUND A 2-year review of literature from October 2004 to December 2006 was completed to update current scientific evidence on diagnostic utility of facet joint injections. Diagnostic injections are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. There is no physical examination technique, laboratory test, or imaging modality that can precisely identify the spinal structure causing pain, distinguish the culprit from a variety of potential targets, and predict response to a therapeutic intervention. Zygapophysial joint injections, commonly called facet injections (intraarticular joint injections and medial branch blocks) are local anesthetic injections of the facet joint or its nerve supply. These are diagnostic procedures used to determine if pain is arising from facet joints, distinguish painful from nonpainful joints and prognosticate response to therapeutic facet joint interventions. Diagnostic injections must meet the cardinal features of a diagnostic test i.e., accuracy, safety, and reproducibility. Accuracy is based on comparison with a "gold standard" to confirm presence or absence of a disease. There is, however, no available gold standard to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. OBJECTIVES Evaluate and update available evidence (2004 to 2006) relating to clinical utility of facet joint injections (intraarticular and medial branch blocks) in diagnosing chronic spinal pain of facet joint origin. STUDY DESIGN Review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing facet joint pain according to Agency for Healthcare Research and Quality (AHRQ) and Quality Assessment Studies of Diagnostic Accuracy (QUADAS) criteria. The level of evidence was classified as conclusive (Level I), strong (Level II), moderate (Level III), or limited (Level IV). METHODS Computerized database search (2004 to 2006) of PUBMED, EMBASE, CINAHL, and Web of Knowledge was conducted to identify studies on facet joint pain and diagnostic interventions. Abstracts, reviews, book chapters, case reports, studies based on single blocks or blocks without radiologic control, and studies describing techniques were excluded. Prospective studies were given priority over retrospective studies. RESULTS There is no change in the strength of evidence for facet joint diagnostic injections. There is strong evidence for controlled comparative local anesthetic facet joint injections or medial branch blocks in the diagnosis of neck and low back pain and moderate evidence in the diagnosis of pain arising from thoracic facet joints. CONCLUSION The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.

The lumbar zygapophysial joints are a potential cause of back and lower extremity pain. Absolute diagnosis of lumbar zygapophysial joint-mediated pain is based on selective analgesic injections of these joints or their nerve supply. The therapeutic role of zygapophysial joint injections is controversial. This contemporary concepts paper reviews the anatomy, mechanics, pathology, and diagnosis of this condition. A critical review of previous studies assessing the role of diagnostic and potentially therapeutic zygapophysial joint injection procedures is presented. The need for future studies is addressed, and current recommendations for the role of zygapophysial joint injection procedures based on this critical scientific review are provided.

The authors performed fluoroscopy-guided sacroiliac (SI) joint injections. With the patient prone and the x-ray tube perpendicular to the fluoroscopic table, the skin was marked over the distal 1 cm of the SI joint. With the tube angled 20 degrees - 25 degrees cephalad, a 22-gauge needle was inserted at the skin mark and advanced perpendicular to the fluoroscopic table toward the posterior joint. Nonionic contrast material was injected to confirm the intraarticular position of the needle. Of 31 SI joint injections, 30 (97%) were intraarticular. Mean procedure time was 108 seconds. This technique is safe, rapid, and reproducible.

Objective. To investigate the feasibility and effectiveness of sonographic guidance for therapeutic intra‐articular sacroiliac joint injections in patients with sacroiliitis. Methods. Thirty‐four consecutive patients with sacroiliitis were enrolled in this study. The synovial portions of 60 sacroiliac joints received injections under sonographic guidance. For treatment, a mixture of a corticosteroid and a local anesthetic was injected intra‐articularly. Fluoroscopic spot images were obtained to assess the accuracy of the sonographically guided technique. Results. Of the 60 sonographically guided injections, 46 (76.7%) were successful (i.e., intra‐articular), and 14 (23.3%) were missed. The successful intra‐articular injection rate was 60% in the first 30 injections, and it gradually improved, reaching 93.5% in the last 30 injections. The mean procedure time was 9 minutes. Conclusions. Our initial experience suggests that sonographically guided therapeutic injections to sacroiliac joints could be valuable alternatives to other guidance modalities in patients with sacroiliitis. In the hands of experienced radiologists, this technique is safe, rapid, and reproducible.

This study evaluates the specificity of facet joint injections in diagnosing symptomatic facet joint pain. Fifty-four patients had 143 facet joint injections performed in a prospective study. Pain provocation and pain relief were used to confirm the diagnosis. All patients had symptoms and signs considered suggestive of facet joint pain. Less than 1.5 ml of bupivacaine was injected into each joint to prevent extravasation. Only nine patients (16.7%) had the diagnosis confirmed, significantly lower than most published results. An anatomic study performed suggests that extravasation into the epidural space occurs following rupture of the joint capsule. This provides an explanation by which good therapeutic results can be obtained if large volumes of therapeutic agent are used.

We conducted this study to develop an ultrasound-guided approach for facet joint injections of the lumbar spine. Five zygapophyseal joints (L1-S1) on each side of 5 embalmed cadavers were examined by ultrasound for a total of 50 examinations. The joint space was demonstrated under ultrasound guidance. The midpoint of the joint space, defined as the middle of its cranio-caudal extension on its dorsal surface, was taken as a reference point, and its position was computed from its depth and lateral distance from the spinous process. Forty-two of 50 approaches could be clearly visualized. Subsequently, these distances were compared to those obtained by computed tomography (CT). To assess the efficacy of ultrasound in the needle placement, all lumbar facet joints were approached in one embalmed cadaver. The exact placement of the needle tips was again evaluated by CT. Ultrasound and CT measurements showed the same mean depth and lateral distance to the reference point, 3.15 ± 0.5 cm and 1.9 ± 0.6 cm, respectively. Pearson’s coefficient of correlation was 0.86 (P < 0.0001) between ultrasound and CT. All 10 needle tips were within the joint space during simulated facet joint injections. We conclude that ultrasound guidance might be a useful adjunct for facet joint injections in the lumbar spine.

Background: The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups. Methods: Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV). Results: A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone. Conclusion: This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone.

BACKGROUND Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources, overlapping clinical features, and nonspecific radiologic findings. Diagnostic injection techniques are employed to isolate the source(s) of pain. Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply. Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test (i.e., accuracy, safety and reproducibility). Accuracy must be compared with a "gold" or criterion standard that can confirm presence or absence of a disease. There is, however, no available gold standard, such as biopsy, to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. OBJECTIVES To evaluate accuracy, safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin. STUDY DESIGN A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints. METHODS Relevant literature on diagnostic facet injections was identified through database searches. Excluded were abstracts, reviews, book chapters, case reports and studies based on single blocks or blocks without radiologic control. Prospective studies with placebo control, or controlled comparative local anesthetic blocks, were given priority over retrospective studies. Each study was graded using AHRQ and QUADAS criteria. The level of evidence was classified as conclusive, strong, moderate, limited, or inconclusive. RESULTS Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain. There was moderate evidence in the diagnosis of pain arising from thoracic facet joints. CONCLUSION The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves (medial branch or dorsal ramus) are reproducible, reasonably accurate, and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.

OBJECTIVE To assess the validity of fluoroscopically guided diagnostic intra-articular injections of local anesthetic and effectiveness of intra-articular steroid injections in treating sacroiliac joint (SIJ) pain. DESIGN Systematic review. INTERVENTIONS Ten reviewers independently assessed 45 publications on diagnostic validity or effectiveness of fluoroscopically guided intra-articular SIJ injections. OUTCOME MEASURES For diagnostic injections, the primary outcome was validity; for therapeutic injections, analgesia. Secondary outcomes were also described. RESULTS Of 45 articles reviewed, 39 yielded diagnostic data on physical exam findings, provocation tests, and SIJ injections for diagnosing SIJ pain, and 15 addressed therapeutic effectiveness. When confirmed by comparative local anesthetic blocks with a high degree of pain relief, no single physical exam maneuver predicts response to diagnostic injections. When at least three physical exam findings are present, sensitivity, and specificity increases significantly. The prevalence of SIJ pain is likely 20-30% among patients that have suspected SIJ pain based on history and physical examination. This estimate may be higher in certain subgroups such as the elderly and fusion patients. Two randomized controlled trials and multiple observational studies supported the effectiveness of therapeutic sacroiliac joint injections. CONCLUSIONS Based on this literature, it is unclear whether image-guided intra-articular diagnostic injections of local anesthetic predict positive responses to therapeutic agents. The overall quality of evidence is moderate for the effectiveness of therapeutic SIJ injections.