Big disc protrusions gimps facets

I have a patient who had a large disc protrusion. These have been shown to have a good chance of recovery (vs disc bulges which very few with sciatica were better a year later). This patient did not improve until facet levels had been thoroughly needled on side of sciatica. Now it appears that facet problems may be common in such a situation and explain some poor epidural steroid responses

OK, this is not new, but given it was just a poster presentation, it was new to me…

Archives of Physical Medicine and Rehabilitation, Volume 85, Issue 9, September 2004, Page e38

Poster 172
Treatment Using Fluoroscopically Guided Facet Blocks in Patients With Persistence of Back Pain After Large Disk Herniation and Resolution of Radiculopathy.
Jonah Green, MD (NYU, New York, NY); Thomas J. Errico, MD; Jeffrey Spivak, MD; Gerard P. Varlotta, DO, e-mail: Disclosure: J. Green, None; T.J. Errico, None; J. Spivak, None; G.P. Varlotta, None.

Objective: To evaluate the efficacy of facet blocks in treating patients with large herniated disks who even after resolution of their radiculopathy still had complaints of back pain. Design: Case series.

Setting: Outpatient-based sports medicine practice at a major university hospital. Participants: 7 patients with low back pain who presented with radiculopathy and whose magnetic resonance imaging findings were consistent with large herniated disks. Interventions: Each patient was initially treated with oral steroids for radiculopathy. On follow-up visits, each had resolution of the radicular symptoms, but was left with the complaint of back pain. Each subject then underwent fluoroscopically guided facet blocks.

Main Outcome Measures: Patients were asked to chart their back pain on a visual analog scale prior to facet injection and then 1wk and 1mo postinjection. Results: There was marked decrease in pain postinjection seen in all 7 subjects. In addition, pain relief was maintained at 1-mo follow-up visits. Alleviation of back pain also allowed these patients to participate in a physical therapy strengthening program and to maintain their current decreased pain state.

Conclusions: Large herniated disks in the lower lumbar region can cause mechanical changes in the spine. These mechanical changes can create facet syndrome. Even though all study patients had documented herniated disks thought to be the cause of their back pain, the actual source of their pain was the presence of facet syndrome. Treatment of the facet syndrome, as shown in this study, improved their symptoms. Key Words: Disk, herniated; Facet joint; Rehabilitation.

My comments: It is not surprising that neurogenic inflammation would set in on the facet at the same level; the muscle tissues can clearly become woody and edematous as well. Once the period for resorption of the disc had occurred patient continued to have pain low lumbar radiating to buttock. She had had steroid epidural injections done by a pain certified anesthetist but continued to complain of significant problems. There was spasm of the associated quadratus lumborum, psoas, and buttock muscles that responded some to work but the most benefits seemed to occur through needling of the facet areas around L4. She still has some gluteus medius/minimus and piriformis problems which are improving.

This highlights how idiotic it is to expect one modality to solve one’s problems. Epidural steroids were not the answer by themselves but made it possible fo treatments of the facet to be possible. I suspect treatments of the facet were facilitated by the fact psoas and quadratus lumborum spasms had been diminished as well. Yet evidence based medicine would considered none of these measures all that useful and probably not hence worth doing. This slavery to one modelity success has led to an age of dis-reason eloquently described by Johe Saul in his 1992 book called “Voltaire’s Bastards The Dictatorship of Reason in the West“. The need for multidisciplinary treatment for chronic pain to get results has been known since Bonica’s time and people ought to know better.

People who condemn steroid epidurals as ineffective might want to consider that its used makes other modalities working on other issues like facets possible. I welcome any comments on this.

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