Percutaneous radiofrequency facet joint denervation (RFJD) has been used increasingly since being described by Shealy1 for the non-surgical treatment of chronic low back pain. Extensive literature exists on this technique with a number of randomised control studies suggesting efficacy against Placebo2,3. However, the efficacy and reliability of repeat RFJD for chronic back pain is unknown. A prospective study was carried out on a consecutive series of 57 patients undergoing repeat lumbar RFJD between 2004 &
2006. 57 consecutive patients treated by the senior author (OLO) between April 2004–June 2006 were included in a prospective analysis using a visual analogue score (VAS) and the low back outcome score (LBOS). All 57 participants completed a telephone questionnaire at follow up. There were no complications. At a median average follow up of 14 months overall, clinical outcomes demonstrated moderate improvement in the majority of patients with poor rating at LBOS decreasing from 54.3% pre- to 40.3% post-RFJD. The overall degree of satisfaction was 77.2%. The overall median duration of pain relief was 10 months. Our study suggests that repeat RFJD appears to have reliable and satisfactory results when repeated with most patients reporting a high degree of satisfaction and with the clinical outcome similar to the initial procedure.
STUDY DESIGN: A prospective study of 135 subjects with whiplash injury. OBJECTIVES: To identify factors predictive of prolonged disability following whiplash injury. SUMMARY OF BACKGROUND DATA: Although subjects with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision. METHODS: 147 subjects with recent whiplash injury were interviewed for putative risk factors for disability. 135 were re-interviewed 12 months later to assess degree of duration of disability. Bi-variate and multi-variate analyses were undertaken to measure the association between putative risk factors and measures of outcome. RESULTS: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (p<
0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a predictor of outcome. CONCLUSIONS: SF-36 scores for bodily pain and role emotional are useful means of identifying subjects at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimise litigation.
Disc degeneration in the human spine is characterised by progressive fraying and dehydration of the nucleus pulposus associated with formation of clefts within the annulus fibrosus. These have been classified on the basis of autopsy studies into radiating, circumferential and peripheral tears (rim lesions). Outer tears allow neovascularisation of the outer third of the annulus fibrosus and ingrowth of nerve fibres. Correlation with discographic findings had suggested the relevance of peripheral defects in the pathogenesis of discogenic pain. Outer annular tears are likely to be linked to tensile strain onto the collagen fibres and, therefore, may have a mechanical aetiology. In the animal model, peripheral tears of the outer annulus were proven to induce degenerative changes within the inner annulus and the nucleus pulposus. The increased understanding of the role of discrete peripheral defects of the annulus in discogenic pain may support the potential therapeutic effects of thermal treatment using radiofrequency waves and specially designed probes. At present, however, no in vivo studies have been able to demonstrate healing of outer annulus defects and reversibility of mechanical lesions to the intervertebral discs by thermal therapy. While it is highly likely that discrete defects of the outer annulus may be responsible for acute episodes of self-limiting low back pain, it is unclear if annular pathology may be as relevant for chronic disabling back pain. Recent studies using discography and other semi-invasive techniques have suggested that the main discriminating factors between benign, self limiting and chronic disabling back pain may not be anatomical but psycho-social. The challenge remains, in the 21st Century as in the past, to devise appropriate strategies that may lessen the socio-economic burden of back pain. Surgery, however, is highly unlikely to play a significant role in the future.
Surgery for back pain remains highly controversial in view of the significant complication rate and the low likelihood of a successful clinical outcome. Over the last few years, titanium and carbon fibre interbody implants have been used to stabilise spinal motion segments following sub-total removal of disc tissue. These implants offer the theoretical advantage of immediate stabilisation, avoidance of late collapse and prevention of loss of correction of pre-operative deformity in combination with other types of segmental instrumentation such as pedicle screws. Recent long term studies have suggested the possibility of late loosening, implant migration and recurrence of segmental deformity. A recent prospective long term study of titanium cylindrical implants for lumbar degenerative disc disease has indicated that in the presence of multi-level disease, pre-existing olisthesis and levels proximal to the lumbosacral segment, the use of supplementary pedicle screw fixation is required. It appears, however, that despite improved radiological results, the use of interbody cages may not lead to superior functional outcomes when the surgery is carried out for non-specific low back pain.
