Download PDF
Die Wirbelsäule 2020; 04(03): 182-192
DOI: 10.1055/a-0968-9222
Übersicht

Infiltrationen und Radiofrequenztherapie der lumbalen und zervikalen Facettengelenke und der Iliosakralgelenke: Überblick, Evidenz und Ergebnisse

Infiltrations and radiofrequency treatments of lumbar and cervical zygapophyseal joints and the iliosacral joints: Overview, evidence and results
K. Wiechert
1   Wirbelsäulenzentrum, Schön Klinik München-Harlaching
,
A. Redder
2   Wirbelsäulenzentrum, Orthopädische Fachkliniken der Hessing Stiftung, Augsburg
,
J. Lohmann
3   Klinik für Spinale Chirurgie, Schön Klinik Hamburg-Eilbek
› Author Affiliations
› Further Information
    Permissions and Reprints

Zusammenfassung

Einleitung Infiltrationen der Facettengelenke der HWS und LWS als auch der Iliosakralgelenke sind weltweit verbreitet und lang etabliert. Techniken, basierend auf röntgengestützter als auch sonografischer Bildgebung, stellen den Standard dar. Bez. der Indikationsstellung und der Ergebnisse sind die diagnostischen Infiltrationen von den therapeutischen Indikationen klar zu unterscheiden.

Diagnostische Infiltrationen Die diagnostischen Infiltrationen kommen im Rahmen einer funktionellen Diagnostik zum Einsatz, um eine arthrogene Schmerzursache zu sichern. Hier sind Ramus medialis Infiltrationen und intraartikuläre Infiltrationen in Ihrer Aussagekraft identisch anzusehen. Um die Rate falsch positiver Befunde zu reduzieren, sind serielle Infiltrationsprotokolle mit unterschiedlich lang wirksamen Lokalanästhetika bzw. Placebo zu bevorzugen. Die Evidenz der Studienlage ist überschaubar, da das Ausmaß der Schmerzreduktion das entscheidende Outcome-Kriterium darstellt und Schmerz per se multifaktoriell ist. Lumbale und zervikale Facettengelenksinfiltrationen zeigen unterschiedliche Raten falsch-positiver Befunde.

Therapeutische Infiltration Bei gesichert arthrogenem Schmerz können leitliniengerecht Facettengelenks- und Iliosakralgelenksinfiltrationen durchgeführt werden. Die Evidenz ist hierbei bei methodisch schwacher Studienlage allgemein mittel bis schlecht, insbesondere in Bezug auf langfristige Ergebnisse.

Radiofrequenztherapie Die Radiofrequenztherapie stellt ein etabliertes Verfahren bei vertebragenen Gelenkschmerzen dar. Hier ist vorab eine gesicherte Diagnose für die Indikationsstellung unabdingbar. Es gibt unterschiedliche Behandlungstechniken. Aufgrund methodischer Probleme und einer Vielzahl von Durchführungstechniken und Begleitpathologien ist die Studienlage auch hier schwach.

Abstract

Interventional therapies for facet joint pain of the lumbar and cervical spine as well as the iliosacral joints have been globally established for many years. Image guided techniques using xray or ultrasound modality are standardized. Indications for the interventions can be categorized in diagnostic testing and therapeutic injections.

Diagnostic injections Diagnostic injections are employed in the context of defining arthrogenic spinal pain sources. Medial branch blocks and intraarticular injections are found to be equally as effective. Serial injection protocols with different local anaesthetic agents should be employed to reduce the rate of false positive findings. Lumbar and cervical facet joint injections do have different rates of false positive findings. Scientific evidence, however, is moderate in many cases due to methodological reasons and the key aspects that the key outcome measure of the studies is the amount of pain reduction. This concept lacks a gold standard because of the multifactorial aspects of pain in general.

Therapeutic injections In cases of proven arthrogenic spinal pain, guidelines explicitly mention facet joint and iliosacral joint injections as a possible treatment modality. Long term evidence for subacute and chronic pain is poor.

Radiofrequency denervations Radiofrequency constitutes an established method of treating arthrogenic pain. There are a number of published standardized techniques. Evidence is moderate at best for mid and longterm outcome due to comparable methodological issues, limiting comparability in metanalytic studies.

Schlüsselwörter

Facettengelenke - Diagnostische Infiltration - Therapeutische Infiltration - Radiofrequenztherapie

Keywords

Facet joints - diagnostic injections - therapeutic injections - radiofrequency


Publication History

Article published online:
13 August 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 

  • Literatur

  • 1 Goldthwait JE. The lumbosacral articulation: an explanation of many causes of lumbago, sciatica, and paraplegia. Boston Med Surg J 1911; 164: 356-372
    CrossrefGoogle Scholar
  • 2 Schütz U, Cakir B, Dreinhöfer K. et al. Diagnostic Value of Lumbar Facet Joint Injection: A Prospective Triple Cross-Over Study. PLoS ONE 2011; e27991 DOI: 10.1371/journal.pone.0027991.
    CrossrefPubMedGoogle Scholar
  • 3 Ghormley RK. Low-back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA 1933; 101: 1773-1777
    CrossrefGoogle Scholar
  • 4 Mooney V, Robertson J. The facet syndrome. Clin Orthop 1976; 115: 149-156
    Google Scholar
  • 5 Dt. Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). S2k Leitline Spezifischer Kreuzschmerz. AWMF Registernr. 033-051(Dezember 2017). Im Internet (Stand Dezember 2019): https://www.awmf.org/uploads/tx_szleitlinien/033-051l_S2k_Spezifischer_Kreuzschmerz_2018-02.pdf
    Google Scholar
  • 6 Wiechert K. Stellenwert bildwandlergestützter Infiltrationen bei der Diagnostik degenerativer Wirbelsäulenerkrankungen. Nervenheilkunde 2018; 36: 369-374 DOI: 10.1055/s-0038-1627020.
    Article in Thieme ConnectGoogle Scholar
  • 7 Palmer WE. Spinal Injections for Pain Management. Radiology 2016; 281: 669-688 DOI: 10.1148/radiol.2016152055.
    CrossrefPubMedGoogle Scholar
  • 8 Weidle PA, Weidle J, Schultheis BC. Sonografie-gesteuerte Iliosakral- und Facettengelenkinjektionen. OUP 2016; 4: 210-215 DOI: 10.3238/oup.2016.0210–0215.
    CrossrefGoogle Scholar
  • 9 Himes N, Chansakul T, Lee T. Magnetic Resonance Imaging–Guided Spine Interventions. Magn Reson Imaging Clin N Am 2015; 23: 523-532 DOI: 10.1016/j.mric.2015.05.007.
    CrossrefPubMedGoogle Scholar
  • 10 Bogduk N. (eds.) Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd edition. San Francisco: Spine Intervention Society; 2013
    Google Scholar
  • 11 Bamberger HG, Roth H, Hau W. et al. Katzenmeier BGB § 630e Rn. 41–48. Aufklärungspflichten. BeckOK. 53 Ed. 2020
    Google Scholar
  • 12 Hien NM. Sonografiegesteuerte Injektionen an der Wirbelsäule. Darstellung der Regionen und praktisches Vorgehen. OUP 2018; 7: 019-023 DOI: 10/3238/oup2018.0019-0023.
    CrossrefGoogle Scholar
  • 13 Peh WCG. Image-guided facet joint injection. Biomed Imaging Interv J 2011; 7: e4
    CrossrefPubMedGoogle Scholar
  • 14 Brinjikji W. et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015; 36: 811-816
    CrossrefPubMedGoogle Scholar
  • 15 Kalichman L. et al. Computed tomography-evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. Spine J 2010; 10: 200-208
    CrossrefPubMedGoogle Scholar
  • 16 Schwarzer AC. et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?. Spine (Phila Pa 1976) 1994; 19: 1132-1137
    CrossrefPubMedGoogle Scholar
  • 17 Manchikanti L. et al. Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician 1999; 2: 59-64
    CrossrefPubMedGoogle Scholar
  • 18 Manchikanti L. et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord 2004; 5: 15
    CrossrefPubMedGoogle Scholar
  • 19 Manchukonda R. et al. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech 2007; 20: 539-545
    CrossrefPubMedGoogle Scholar
  • 20 Schwarzer AC. et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994; 58: 195-200
    CrossrefPubMedGoogle Scholar
  • 21 Manchikanti L. et al. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain 2000; 4: 337-344
    CrossrefPubMedGoogle Scholar
  • 22 Dreyfuss PH, Dreyer SJ, Herring SA. Lumbar zygapophysial (facet) joint injections. Spine 1995; 20: 2040-2047
    CrossrefPubMedGoogle Scholar
  • 23 Birkenmaier C. et al. Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenervation of lumbar facet joints. Reg Anesth Pain Med 2007; 32: 27-33
    CrossrefPubMedGoogle Scholar
  • 24 Cohen SP, Huang JH, Brummett C. Facet joint pain--advances in patient selection and treatment. Nat Rev Rheumatol 2013; 9: 101-116
    CrossrefPubMedGoogle Scholar
  • 25 van Wijk RM. et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain 2005; 21: 335-344
    CrossrefPubMedGoogle Scholar
  • 26 Curatolo M, Bogduk N. Diagnostic blocks for chronic pain. Scand J Pain 2010; 1: 186-192
    CrossrefPubMedGoogle Scholar
  • 27 Manchikanti L. et al. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician 2007; 10: 425-440
    CrossrefPubMedGoogle Scholar
  • 28 Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976) 1990; 15: 453-457
    CrossrefPubMedGoogle Scholar
  • 29 Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation. Spine (Phila Pa 1976) 1990; 15: 458-461
    CrossrefPubMedGoogle Scholar
  • 30 Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med 2007; 8: 344-353
    CrossrefPubMedGoogle Scholar
  • 31 Falco FJ. et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician 2012; 15: E839-E868
    CrossrefPubMedGoogle Scholar
  • 32 Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophyseal joint blocks for chronic cervical pain. Med J Aust 2001; 174: 174-176
    CrossrefPubMedGoogle Scholar
  • 33 Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain 1993; 55: 99-106
    CrossrefPubMedGoogle Scholar
  • 34 Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain 1995; 11: 208-213
    CrossrefPubMedGoogle Scholar
  • 35 Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther 2008; 16: 142-152
    CrossrefPubMedGoogle Scholar
  • 36 Rosenberg JM, Quint TJ, de Rosayro AM. Computerized tomographic llocalization of clinically-guided sacroiliac joint injections. Clin J Pain 2000; 16: 18-21
    CrossrefPubMedGoogle Scholar
  • 37 Kennedy DJ. et al. Fluoroscopically Guided Diagnostic and Therapeutic Intra-Articular Sacroiliac Joint Injections: A Systematic Review. Pain Med 2015; 16: 1500-1518
    CrossrefPubMedGoogle Scholar
  • 38 Maigne JY, Planchon CA. Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks. Eur Spine J 2005; 14: 654-658
    CrossrefPubMedGoogle Scholar
  • 39 King W. et al. Diagnosis and treatment of posterior sacroiliac complex pain: a systematic review with comprehensive analysis of the published data. Pain Med 2015; 16: 257-265
    CrossrefPubMedGoogle Scholar
  • 40 Hildebrandt J. Relevanz von Nervenblockaden bei der Diagnose und Therapie von Rückenschmerzen. Schmerz 2001; 15: 474-483
    CrossrefPubMedGoogle Scholar
  • 41 Theodoridis T, Krämer J. Injektionstechniken an der Wirbelsäule – Manual und Atlas. 3. Aufl. Stuttgart: Thieme; 2017
    Google Scholar
  • 42 Boswell MV, Colson JD, Sehgal N. et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10: 229-253
    CrossrefPubMedGoogle Scholar
  • 43 Fritz J, Niemeyer T, Clasen S. et al. Management of chronic low back pain: rationales, principles, and targets of imaging-guided spinal injections. Radiographics. Radiological Society of North America 2007; 27: 1751-1771
    Google Scholar
  • 44 Luukkainen RK, Wennerstrand PV, Kautiainen HH. et al. Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacro-iliac joint. Clin Exp Rheumatol 2002; 20: 52-54
    PubMedGoogle Scholar
  • 45 Leggett LE, Soril LJJ, Lorenzetti DL. et al. Radiofrequency ablation for chronic low back pain: A systematic review of randomized controlled trials. Pain Res Manag 2014; 19: e146-e153
    CrossrefPubMedGoogle Scholar
  • 46 Palea O, Andar HM, Lugo R. et al. Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule. Cureus 2018; 10: e2322 DOI: 10.7759/cureus.2322.
    CrossrefPubMedGoogle Scholar
  • 47 Lee CH, Chung CK, Kim CH. The Efficacy of Conventional Radiofrequency Denervation in Patients with Chronic Low Back Pain Originating from the Facet Joints: A Meta-analysis of Randomized Controlled Trials. Spine J 2017; S41-S88 DOI: doi.org/10.1016/j.spinee.2017.07.103.
    CrossrefGoogle Scholar
  • 48 Ferrante FM, King LF, Roche EA. et al. Radiofrequency sacroiliac joint denervation for sacroiliac syndrome. Reg Anesth Pain Med 2001; 26: 137-142
    CrossrefPubMedGoogle Scholar
  • 49 Buijs EJ, Kamphuis ET, Groen GJ. Radiofrequency treatment of sacroiliacal joint-related pain aimed at the first three sacral dorsal rami: a minimal approach. Pain Clinic 2004; 16: 139-146
    CrossrefGoogle Scholar
  • 50 Burnham RS, Yasui Y. An alternate method of radiofrequency neurotomy of the sacroiliac joint: a pilot study oft he effect on pain, function, and satisfaction. Reg Anesth Pain Med 2007; 32: 12-19
    PubMedGoogle Scholar
  • 51 Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis and treatment. Anesth Analog 2005; 101: 1440-1453
    CrossrefPubMedGoogle Scholar
  • 52 Cosman Jr. ER, Gonzalez CD. Bipolar Radiofrequency Lesion Geometry: Implications for Palisade Treatment of Sacroiliac Joint Pain. Pain Practice 2011; 1: 3-22
    CrossrefPubMedGoogle Scholar
  • 53 Rupert MP, Lee M, Manchikanti L. et al. Evaluation of Sacroiliac Joint Interventions: A Systematic Appraisal of the Literature. Pain Physician 2009; 12: 399-418
    CrossrefPubMedGoogle Scholar
  • 54 Yun DH. et al. Efficacy of ultrasonography-guided injections in patients with facet syndrome of the low lumbar spine. Ann Rehabil Med 2012; 36: 66-71
    CrossrefPubMedGoogle Scholar
  • 55 Gofeld M, Bristow SJ, Chiu S. Ultrasound-guided injection of lumbar zygapophyseal joints: an anatomic study with fluoroscopy validation. Reg Anesth Pain Med 2012; 37: 228-231
    CrossrefPubMedGoogle Scholar
  • 56 Wu T. et al. Effectiveness of Ultrasound-Guided Versus Fluoroscopy or Computed Tomography Scanning Guidance in Lumbar Facet Joint Injections in Adults With Facet Joint Syndrome: A Meta-Analysis of Controlled Trials. Arch Phys Med Rehabil 2016; 97: 1558-1563
    CrossrefPubMedGoogle Scholar