RF for Spondy's

[SIIMS]

For those that have been out in practice a while (or whoever)

What has been your longterm experience with the effectiveness of mbb on to RF in patients with unilateral, only axial pain in

1. Degenerative Sondylolisthesis

2. Lytic Spondylolisthesis

Conversely how many have found doing a TFESI due to foraminal stenosis in these patients is effective even in the absence of "true radicular" pain???


Thanks

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[ParaVert]

Talks at ISIS about this. First off, the pars is not innervated by the medial branch. So RF for spondylolysis doesn't work. Degenerative spondy is from the facets falling apart, so MBB should work for that.

I do bilateral TFESIs for spondylolysis because it gets steroid up into the defect which should cool down the axial pain. It works OK, but then again, nothing works great.

 

[SIIMS]

Talks at ISIS about this. First off, the pars is not innervated by the medial branch. So RF for spondylolysis doesn't work. Degenerative spondy is from the facets falling apart, so MBB should work for that.

I do bilateral TFESIs for spondylolysis because it gets steroid up into the defect which should cool down the axial pain. It works OK, but then again, nothing works great.

What is the pars innervated by....Sinovertebral??

Out of curiosity why would you do a TFESI for a pars vs just obliquing out and directly injecting the pars??

Thanks for your reply

 

[ParaVert]

because there's no code for a pars injection and I need to eat. As I said, I get the medicine in the defect

I don't know what imaginary nerve branch innervates the pars. Ask an Australian.

 

[specepic]

I have tried Rf'ing the defect itself (along the back of it), no dice

 

[101N]

because there's no code for a pars injection and I need to eat. As I said, I get the medicine in the defect

I don't know what imaginary nerve branch innervates the pars. Ask an Australian.

The pars is at least partially innervated through the periosteum.

The pars defect as a pain source. A histologic study.
Schneiderman GA, McLain RF, Hambly MF, Nielsen SL.
Source
Northern California Spine and Rehabilitation, Sacramento, USA.
Abstract
STUDY DESIGN:
Tissue from the pars defects of six adult patients with symptomatic spondylolysis and spondylolisthesis was obtained at surgery. A histologic study was conducted to identify and characterize neural elements in this tissue.

OBJECTIVES:
To determine if nociceptive nerve endings were present within the pars defect of patients with symptomatic spondylolysis.

SUMMARY OF BACKGROUND DATA:
The origin of back pain in patients with spondylolysis remains uncertain. The defect in the pars interarticularis has been implicated as a possible pain source.

METHODS:
The soft tissue from the pars defect was obtained at surgery. A modified gold chloride stain was used to prepare the tissue for histologic examination. Tissue blocks were sectioned and studied under light microscopy.

RESULTS:
Neural elements were found in all specimens examined. Free nerve endings believed to have nociceptive function were identified in all specimens. The density of neural elements varied between specimens.

CONCLUSIONS:
The finding of neural elements, including free nerve endings within the pars defect tissue, suggests that the pars defect may be a source of back pain in some patients with symptomatic spondylolysis.

 

[bedrock]

because there's no code for a pars injection and I need to eat. As I said, I get the medicine in the defect

I don't know what imaginary nerve branch innervates the pars. Ask an Australian.

Ive injected the pars before (in a reasonable patient, who wanted to avoid surgery at all costs). Young guy in his 20s. 50% relief for 3-4 months. Coded it as a facet injection and got paid.

 

[PMR 4 MSK]

I've injected a number of pars defects over the years. It's easy to do. I won't comment and CPT codes used, because it's controversial.

Most patients do get relief, but for many, it is short-liived. I have one family with multiple members with L5 pars defects. One got fused at 18 years-old due to injections not lasting. She's actually pain-free now.

The injection is easy, but watch your depth closely.

I've never RF'd it.

 

[Tenesma]

i have injected pars defects - usually with 0.2ml lidocaine - always surprised when it works.. in patients with otherwise normal looking discs and no evidence of listhesis, those patients will actually do well with a pin across the defect by your local spine surgeon - without having to actually fuse levels.

RF for spondylolisthesis works quite well - however, I have noticed that in patients with motion at that level, the effects tend to wear off a lot sooner (ie: only 2-4 months of relief)... in patients with no motion, the relief tends to last a lot longer... intuitively i guess that makes sense.

 

[Mister Mxyzptlk]

I've been underwhelmed by RF for spondy. Injection seems to help for a while.

 

[bedrock]

i have injected pars defects - usually with 0.2ml lidocaine - always surprised when it works.. in patients with otherwise normal looking discs and no evidence of listhesis, those patients will actually do well with a pin across the defect by your local spine surgeon - without having to actually fuse levels.

The difficulty would be in getting them to a spine surgeon who will just put a pin across it and not fuse the entire level.

 

[Tenesma]

bedrock: completely agree.... finding a good surgeon is tough, and it really depends on their exposure during fellowship, cause once they are out of fellowship they are unwilling to try/learn new things...

 

[melancholy]

The pars is at least partially innervated through the periosteum.

The pars defect as a pain source. A histologic study.
Schneiderman GA, McLain RF, Hambly MF, Nielsen SL.
Source
Northern California Spine and Rehabilitation, Sacramento, USA.
Abstract
STUDY DESIGN:
Tissue from the pars defects of six adult patients with symptomatic spondylolysis and spondylolisthesis was obtained at surgery. A histologic study was conducted to identify and characterize neural elements in this tissue.

OBJECTIVES:
To determine if nociceptive nerve endings were present within the pars defect of patients with symptomatic spondylolysis.

SUMMARY OF BACKGROUND DATA:
The origin of back pain in patients with spondylolysis remains uncertain. The defect in the pars interarticularis has been implicated as a possible pain source.

METHODS:
The soft tissue from the pars defect was obtained at surgery. A modified gold chloride stain was used to prepare the tissue for histologic examination. Tissue blocks were sectioned and studied under light microscopy.

RESULTS:
Neural elements were found in all specimens examined. Free nerve endings believed to have nociceptive function were identified in all specimens. The density of neural elements varied between specimens.

CONCLUSIONS:
The finding of neural elements, including free nerve endings within the pars defect tissue, suggests that the pars defect may be a source of back pain in some patients with symptomatic spondylolysis.

Spine (Phila Pa 1976). 2008 Mar 15;33(6):687-93. doi: 10.1097/BRS.0b013e3181669548.
Relationship between the histological findings of spondylolytic tissue, instability of the loose lamina, and low back pain.
Miyauchi A1, Baba I, Sumida T, Manabe H, Hayashi Y, Ochi M.
Author information

• 1Department of Orthopaedic Surgery, Hiroshima City Asa Hospital, Hiroshima, Japan. [email protected]

Abstract
STUDY DESIGN:
We investigated the histomorphological features of the tissue occupying the spondylolytic defect (spondylolytic tissue), which was similar to ligament, and then graded the complete enthesis structure and the density of the fibrous portion. The relationships between the features,instability of the loose lamina against the affected vertebra, and the severity of low back pain were studied.

OBJECTIVE:
To elucidate the histomorphological features of spondylolytic tissue and the associations between the features, instability of the looselamina, and low back pain.

SUMMARY OF BACKGROUND DATA:
Spondylolysis is thought to be caused primarily by a fatigue fracture and spondylolytic tissue has been recognized as being a fibrocartilaginous mass. Recently, innervation of the spondylolytic tissue was reported to be one of the sources of low back pain.

METHODS:
The spondylolytic tissue from 17 patients who underwent microscopic decompression of the pars defect was observed for histology including hematoxylin and eosin, elastica van Gieson, and immunohistochemical staining for S100 protein. Instability of the loose lamina against the affected vertebra was evaluated by flexion/extension radiographs.

RESULTS:
The spondylolytic tissue had a ligamentous structure without innervation. The histomorphological findings, instability of the loose lamina, and low back pain had no relationship to one another.

CONCLUSION:
Spondylolysis is a pseudarthorosis of the pars interarticularis and the spondylolytic tissue tends to develop noninnervated ligament-like tissue with an enthesis structure. The histomorphological features, instability of the loose lamina, and low back pain have no relationship to one another.

 

[Ligament]

Spine (Phila Pa 1976). 2008 Mar 15;33(6):687-93. doi: 10.1097/BRS.0b013e3181669548.
Relationship between the histological findings of spondylolytic tissue, instability of the loose lamina, and low back pain.
Miyauchi A1, Baba I, Sumida T, Manabe H, Hayashi Y, Ochi M.
Author information

• 1Department of Orthopaedic Surgery, Hiroshima City Asa Hospital, Hiroshima, Japan. [email protected]

Abstract
STUDY DESIGN:
We investigated the histomorphological features of the tissue occupying the spondylolytic defect (spondylolytic tissue), which was similar to ligament, and then graded the complete enthesis structure and the density of the fibrous portion. The relationships between the features,instability of the loose lamina against the affected vertebra, and the severity of low back pain were studied.

OBJECTIVE:
To elucidate the histomorphological features of spondylolytic tissue and the associations between the features, instability of the looselamina, and low back pain.

SUMMARY OF BACKGROUND DATA:
Spondylolysis is thought to be caused primarily by a fatigue fracture and spondylolytic tissue has been recognized as being a fibrocartilaginous mass. Recently, innervation of the spondylolytic tissue was reported to be one of the sources of low back pain.

METHODS:
The spondylolytic tissue from 17 patients who underwent microscopic decompression of the pars defect was observed for histology including hematoxylin and eosin, elastica van Gieson, and immunohistochemical staining for S100 protein. Instability of the loose lamina against the affected vertebra was evaluated by flexion/extension radiographs.

RESULTS:
The spondylolytic tissue had a ligamentous structure without innervation. The histomorphological findings, instability of the loose lamina, and low back pain had no relationship to one another.

CONCLUSION:
Spondylolysis is a pseudarthorosis of the pars interarticularis and the spondylolytic tissue tends to develop noninnervated ligament-like tissue with an enthesis structure. The histomorphological features, instability of the loose lamina, and low back pain have no relationship to one another.

this contradicts the study posted earlier