Cryoneurolysis for the treatment of lumbar zygoapophyseal joint pain
Manuel Cunha e Sa
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Sanjay Behari
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S. Behari Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute
, Lucknow, UP,
India
1
) Department of Neurosurgery, Hospital Garcia de Orta
, Almada 2800,
Portugal
1. The universality of the problem afflicting populations across various ages, occupations and countries. 2. The enormous burden it imposes both in terms of patient suffering and medical costs. 3. The multitude of existing mechanisms that may be responsible that often require differing treatment strategies. 4. All potential pain sources may not manifest individually but in a complex and often tandem fashion, which makes their exact identification even more elusive. 5. Pain perception itself is a complex domain greatly influenced by one's personality and various psychological factors, such as anxiety and depression. 6. None of the strategies works to take care of the lowerback pain in its entirety.
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Zygaphophyseal or facet joint pain is an important and
yet often missed entity in the spectrum of lower-back pain.
The condition is likely to be missed due to many factors.
With modern multiplaner imaging techniques like contrast
enhanced magnetic resonance imaging and computed
tomographic scanning, there is an increasing preoccupation
to diagnose a prolapsed or degenerated intervertebral disc
or osteophytosis. There is, unfortunately, no unequivocal
test to diagnose facet joint pathology, even when special
emphasis is placed on concentrating on its focused and
enlarged images in various sequences. The manifestation of
facet joint pain closely resembles that of lumbar
radiculopathy related to disc degeneration and prolapse. Unless facet
joint arthropathy is suspected and tenderness of the lumbar
facet joint specifically sought for on clinical examination,
the entity is often missed. This is more likely in the
subgroups of middle-aged women with multiple joint pains
and associated facet arthropathy, and in middle-aged and
elderly patients with borderline thecal compression and
foraminal stenosis with degenerative disc disease or
prolapse.
Knoeler and co-workers have done a yeoman service in
focusing attention on the zygapophyseal joint as a specific
generator of lower-back pain and the stellar role minimally
invasive techniques play in effectively treating it. In a
retrospective series, the authors have reported their
experience in 91 of their patients having undergone 117
cryoneurolysis procedures for the treatment of pain
attributable to the facet joint. This they did by utilizing the
technique of thermal denervation of the facet to obtain pain
relief. The level of evidence for the efficacy of denervation
procedures for lumbar medial branch nerves either by
radiofrequency or cryoneurolysis has been found to be
moderate for short and long-term pain relief [1]. Perhaps, as
opposed to the commoner techniques of chemical
rhizotomy and radiofrequency thermocoagulation, where there is
an inherent danger of the spread of chemical or heat
respectively to the functional nerve roots in close proximity,
cryotherapy has the advantage of being a safer alternative.
The scientific temper of the study is commendable and
may serve as a baseline study for further research in this
area. All evidence of nerve root impingement was ruled out
systematically in the imaging studies obtained. Prior to
proceeding with the actual facet joint denervation, there
was a diligent establishment of the source of pain by
ensuring its temporary relief with two diagnostic blocks.
Psychological profiling of patients was undertaken and
those who were depressed were identified. The patient
population where facet joint cryotherapy constituted a
seminal procedure was compared with that where the
procedure was performed after other interventions had
already failed. Thus, those patients in whom this procedure
was not likely to meet the expected goals could be
identified.
The enthusiasm for adopting the results of the study in
clinical practice, however, should be tempered, bearing in
mind its inevitable shortcomings. No appreciation of the
morphologic changes affecting the facet joints and the
remaining components of the spinal unit is included. There
is no mention of any functional studies that are possible and
all imaging was probably obtained in the recumbent
position. Without a control group, a recurring thought that
incessantly prevails is that the placebo effect of the
procedure may have been, to some extent, responsible for
the good results achieved. In spite of the limited benefit
extracted from facet joint cryotherapy in patients who were
psychologically affected and those with persisting
lowerback pain despite the recurrent use of both percutaneous
and open techniques, the authors still persisted in
recommending the use of this procedure in these subgroups. An
inevitable conclusion derived from the fact that there was
no statistically significant difference in the pre- and
postinterventional pain rating between patients with and (...truncated)