Comments a recent paper About facet joint blocks
Michael Gofeld, MD, Sandee J. Bristow, MD, and Sheila Chiu, DO
Use of ultra sound in pain management is rapidly evolving and the physicians interest in using these techniques are growing very fast.. There are several procedures in pain medicine where ultrasound has advantage over standard fluoroscopy. Eg is peripheral nerves, soft tissues where real time needle movement is needed. Some of the difficult ultrasound blocks can also be done safely with out fluoroscopy in the experienced operator’s hand. Eg are Zygophyseal joint injections and Coeliac plexus block. Currently the Joint Committee (ASRA,ESRA and AAFPS) recommendations for education and training in USPM states the core skills needed for a pain physician to be proficient in this technique. This article was very interesting as currently, the evidence for US in pain medicine is limited. There aren’t many randomized controlled trials in this field. Even though it is a single centre cadaver study, it illustrates the point that the US technique is comparable to fluoroscopy in obtaining anatomical target positioning of the needle in more than 88%. It was performed on 5 cadavers. So translating that to clinical practice may not be the same. The most common difficulty doing facet joint injection under ultra sound are obesity and severity of degeneration in the joints. But it is a very useful tool especially when fluoroscopy is contra indicated. Eg- pregnancy. During the learning curve, one can use fluoroscopy as a second confirmatory test. The article clearly illustrates the feasibility and accuracy of US in facet joint injection. Hopefully, more quality studies will come out to produce the evidence to support this hypothesis.
Dr Athmaja Thottungal
MBBS, FRCA, FFPMRCA,EDRA
(Pain and Regional anaesthesia specialist)
Kent Centre for Pain Medicine,
Kent and Canterbury Hospital,Canterbury, UK.
Currently working as a Consultant with special interest in:
1.Ultrasound guided chronic pain blocks , neuromodulation and pelvic pain
2. Regional anaesthesia for upper limb and breast surgery.
3. Teaching ultra sound guided regional anaesthesia techniques for acute and chronic pain management. Uses interactive practical approach to teaching.
-Immediate past Secretary of LSORA and currently Core Committee member leading ultra sound course in pain management .
-Teaches at various ultra sound guided regional anaesthesia and chronic pain courses
Education-After graduating from India in1996, I had training in A&E, paediatric surgery, and Obstetrics & Gynecology. My personal experience with poor pain management changed my carrier to anaesthetics and eventually to pain management.
-Trained at Kings College, London along with associated hospitals in anaesthetics.
-Did Pain fellowship at Guys and St Thomas hospital, London.
-The regional fellowship was done at Guys and St Thomas hospital followed by European diploma in Regional Anaesthesia.
ATHMAJA THOTTUNGAL MD
Interview with the expert
1- Do you think we can perform a lumbar z-joint block with ultrasound guidance, without fluoroscopy, in safety?
Yes, we can perform the blocks safely provided that- the operator is experienced in using ultrasound techniques and the patient adverse factors like obesity or anatomical abnormalities are not there. Otherwise it poses similar risk as fluoroscopy technique.
2- Share with us your opinion about these two techniques for facet joint blocks: a) Radiofrequency and b) Esteroid + local anesthetic injections.
In my practice, I always offer my patients a steroid+ local anaesthetic block for low back ache of facet origin as a first line. If it is confirmed by > 50% pain relief lasting for more than three months, a diagnostic median branch block will be done. If the patient gets good pain relief (>50% pain reduction) after a diagnostic medial branch block , radiofrequency denervation of facet joint is offered.
3- Which kind of doctors perform the most of the facet joint blocks in UK? Neurosurgeons? Anesthetists? Other ones?
Mostly done by Pain physicians. Among surgical people, spinal surgeons/ orthopaeditians perform most of the facet joint blocks.
Kent Centre for Pain Medicine,
Kent and Canterbury Hospital, Canterbury, UK