Transcript 23.1 Dorsoventral patterning by TGF

Facet Joint Injuries
Mark H. Dean, D.O.
Osteopathic Pain Management
Facet Joint Injuries
• 55-60% of neck pain after
whiplash is due to facet injury
• Results in a referred pain
pattern distribution called
“Sclerotomes”
• Adjacent sclerotomes have
significant overlap
• Makes diagnosis based on
clinical findings alone difficult
Stage 1 Facet Injury
z Acute injury of normal
joint
z Results in damage to the
medial branch of the
facet nerve
z When a ligament is
damaged, nerve fibers of
the facet capsule are also
injured
Stage 1 Facet Injury
z 3 grades of capsular
ligament injury:
y Grade 1- stretch
y Grade 2- stretch and
partial tear
y Grade 3 total tear
Stage 1 Facet Injury
z Damage to nerve fibers
cause the nerve to “die
back” within the myelin
sheath for 2-3 cm.
z Result of ligament injury
y inflammation at the joint
y stiffness and local pain
lasting for several days to
weeks
Stage 2 Facet Injury
6 weeks – 6 months later
z Abnormal, nonmyelinated c-nerve
fibers “re-grow” through
the broken tips of the
myelin sheath into the
damaged joint capsule
Stage 2 Facet Injury
z Non-myelinated cnerve fibers are
highly sensitive to
stretch and pressure.
z Cause locally attached
muscles and fascia to
contract when they
are irritated or
stretched.
Stage 3 Facet Injury
18 months or later
z Joint capsule
becomes encased in
abnormal nerve fibers
z Results in regional
stiffness and
reproducible radiating
pain patterns known
as sclerotomal
patterns
Sclerotomal Pain Patterns
Stage 3 Facet Injury
18 months – 5 years
z Arthritic changes are
associated but not
always present with
joints that have been
injured for greater
than 18 months - 5
years
Re-injury of Stage 3 Facet Injury
z Acute re-injury of a joint
results in radiating
sclerotomal pain patterns
z The pain typically
“appears” to be more
severe than the level
expected from the injury
(Maybe a minor incident).
Stage 1 Facet Injury
Stage 2 Facet Injury
Stage 3 Facet Injury
Diagnosis
z History-History-History
Previous injuries
Description of sclerotomal pain patterns
History of manipulative therapy on an ongoing basis
Multiple specialist history
Able to reproduce pain by specific position or actions
Chronic NSAID, Steroid or narcotic use for pain that
is non cancerous.
y Develop depression and myofascial pain syndromes
y
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y
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y
Diagnosis
z Physical exam
y Neurologically intact i.e. (reflexes, pinprick and
vibratory sensation, muscle strength, straight leg
test, etc.)
y MRI: may have disk disease however does not fit
pain pattern picture
y Plain film X-rays: no obvious fractures
y Muscle texture
x Boggy and painful in acute (stage 1)
x Rope like and painful in chronic (stage 2-3)
x Limited range of Motion (short term in stage 1 and long
term I stage 2-3)
Diagnosis
z X-ray cinematography of the spine and joints.
y Pinpoints joints that have gapping injuries and allows
for accurate treatment without years of missed
diagnosis and unnecessary treatment
y Reduces the error rate of plain film x-rays by 15%.
(plain film x-rays have a 20-25% error rate)
y Radiation level is the same or less than plain films
studies depending on the study completed
Indications
z Bulging, protruded, prolapsed or herniated discs without free
fragment and are not surgical candidates
z Frozen or fixated articulations
z Epidural / Spinal Nerve Root Adhesions
z Failed low back surgery
z Compression syndromes with or without radiculopathies caused
from adhesion formation, but not associated with osteophyic
entrapment
z Restricted motion, which causes pain and apprehension from the
patient
z Unresponsive to manipulation and adjustment when they are the
therapy of choice
Indications, cont’d
z Unresponsive pain, which interferes with the function of daily life
and sleep patterns, but which falls within the parameters for
manipulative treatment
z Unresponsive muscle contraction, which is preventing normal daily
activities and function
z Post-traumatic syndrome injuries from acceleration/deceleration or
deceleration/acceleration types of injuries, which result in painful
exacerbation of chronic fixations
z Chronic recurrent neuromusculoskeletal dysfunction syndromes,
which result in a regular periodic treatment series, that are always
exacerbations of the same condition
z Neuromusculoskeletal conditions that are not surgical candidates
but have reached MMI especially with occupational injuries
Contraindications
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Any form of malignancy
Metastatic bone disease
TB of bone
Acute bone fractures
Direct manipulation of old compression fractures
Acute inflammatory arthritis
Acute inflammatory gout
Syphilitic articular or periarticular lesion
Contraindications, cont’d
z Gonorrheal spinal arthritis
z Advanced osteoporosis
z Evidence of cord or caudal compression by tumor or
disc herniation beyond 5mm
z Osteomyelitis
z Widespread staph/strep infection
z Sign/symptom of aneurysm
z Unstable apondylosis
z Active Hepatitis B or C
Treatment
z Stage 1
y Physical therapy and manual therapies are critical to
prevent abnormal nerve fiber formation
y Cinematography Imaging studies as soon as initial
stiffness and pain has resolved to document injury
y If sclerotomal pain patterns start developing then
consider treatment for stage 2 or 3 injury
y Avoid long term NSAIDS and steroid for pain. They
result in the development of C-nerve fiber.
Treatment
z Stage 2 - 3
y Manual therapy and physical therapy 4-6 weeks.
y Cinematography Imaging studies to document injury
y If not resolved completely then:
x Interventional pain management of the affected joints
x Spinal Manipulation under general anesthesia with
interventional pain management if needed
x Both followed with 4-6 weeks of intensive physical and
manual therapy
x Avoid long term use of NSAIDS and steroids (short term ok –
several days)
x Narcotics for short period of time for post procedure pain
only
Treatment
z Stage 3
y Cinematography Imaging studies as soon as initial stiffness and
pain has resolved to document injury
y Interventional pain management of the affected joints in a
series (steroid may be needed initially due to pain,
radiofrequency rhizotomy or micro-rhizotomy series for long
term resolution)
y Spinal manipulation under anesthesia if unable to tolerate
therapies
y Followed with 4-6 weeks of intensive physical and manual
therapy
y Avoid long term use of NSAIDS and steroids (short term ok –
several days)
y Narcotics for short period of time for post procedure pain only
Treatment
z Interventional pain management procedures:
z Facet injections- medial branch block
y Anesthetic-steroid combinations- short term improvement only
good to reduce immediate pain (stage 1 or stage 3B)
z Radiofrequency Rhizotomies of facet nerve
y Better longer term results repeated every 4-6 months for years
(Stage 2 or 3A-B)
z Chemical Micro-Rhizotomy of the facet capsule nerves
y Better long term results. Repeated 2-4 times per joint several
weeks apart to treat the un-mylenated C-nerve fibers that are
the source of pain. Generally, the result is permanent after
completion of treatment (Stage 2 or 3A-B)
Treatment
z Spinal Manipulation under General
Anesthesia:
y Osteopathic procedure used in stage 2-3
injuries that require “deeper” stretching of
affected joints to manually breakup the
abnormal nerve fibers and scar tissue that
forms around stage 2-3 injuries.
y Performed in surgical center or hospital only
y Can be used to reduce herniated disks of the
spine as well.
Indications and Limitations of Coverage and/or Medical Necessity:
“ Because of refinements in manipulative medicine techniques and
improvements in physical therapy modalities, this procedure should only be
performed on select patients who have failed to respond to conservative
therapy.”
Scott Haldeman, M.D. in AAOS 2003, in the most recent RCT, “Medication –
Assisted Manipulation for Low Back Pain” Department of Neurology,
University of California, Irvine reported that:
“Medication-assisted manipulation offers patients increased improvement in
low back pain and disabilirt when compared to usual chiropractic care.”
Published in THE SPINE JOURNAL in 2002, the authors, Frank Kohlbeck, DC
and Scott Haldeman, DC, MD, PhD, performed a literature review of MUA
(49 published articles) and concluded the following:
“Medicine-assisted spinal manipulation therapies have a relatively long
history of clinical use and have been reported in the literature for over 70
years. If a clinician recommends MUA it would be difficult to deny the use
of medication-assisted manipulation or fail to reimburse for it.”
z Daniel West et al reported in a 1998 study of 177 patients that
68.6% of patients out of work returned to unrestricted work
activities after a series of three consecutive MUA procedures at 6
months post MUA, that 58.4% of he MUA patients receiving
medications prior to the procedure required no prescription
medication post procedure and finally that 60.1% of patients with
lumbar pain resolved post MUA series of procedures.
z Samuel Turek, M.D., orthopedic surgeon, reports in his textbook,
Principles and Applications of Orthopedics, that “good to
excellent results” can be expected in 50% of patients with acute
herniated nucleus pulposus with manipulation under anesthesia.
z Thomas Dorman, M.D., orthopedist, recommends in his textbook,
Diagnostic Techniques in Orthopedic Medicine, manipulation
under anesthesia when the patient has failed at conservative in
office care.
z Robert Mensor, M.D., orthopedic surgeon, conducted a large clinical
trial of over 600 patients with EMG verified radiculopathy and found
that 83% responded well to manipulation under anesthesia.
z These findings were verified by Donald Chrisman, M.D., orthopedic
surgeon, reporting that 51% of patients with unrelieved symptoms
after conservative care had good to excellent results even three
years after MUA.
z Bradford and Siehl reported on 723 MUA patients, the largest trial
conducted on MUA procedures, and found that 71% had good
results (normal activity, relatively symptom free) and that 25.3%
had fair results (improvement, return to relatively normal activity
with some residual symptoms) and that flexibility, elasticity and
range of motion can be restored to patients with chronic back pain.
z Paul Kuo, M.D., Professor of Orthopedic Surgery, reported his
clinical investigation in 1986 of 517 patients treated with MUA with
83.9% of the cases responding well.
z Further research is ongoing. Well designed prospective controlled
clinical trials are being conducted to evaluate the clinical and cost
effectiveness of MUA procedures in selected patient populations.
z It is important to note that to date there has been no clinical trial
that demonstrates MUA to be ineffective in an appropriately
selected patient population. Clinical outcome assessments from
these and previous studies will further delineate the parameters
and the patient population within which MUA can be anticipated to
be most effective.