Cervical facet issues post MVA but nothing on MRI

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bedrock said:
disagree, I think it improves the likelihood of a positive response to MBB/RF if they patient has positive facet provocation maneuvers. I also palpate the facet joints which is often helpful with cervical facet issues, less with lumbar, but I still do it, and helps clarify between myofascial and facet pain, and decide which levels to include.

Also, I know you don't deal with this in the military medicine here in CA, but many commercial insurance companies in CA will deny the MBB or RF if you omit facet loading tests in your physical exam.
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I still facet load and palpate.

But I don't stop doing Dx mbb with negative finding if the story is good.
 
epidural man said:
You should do a study then to prove this. Because every other study has shown this is not realible in the least. In fact, Cohen showed that facet loading has a negative correlation to responding to RF.
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Epidural man is right... some studies show a negative correlation with pain on lumbar extension. And it depends on which criteria you use i.e. Helbig vs. Revel. And what are all you guys talking about wishing there were studies comparing anesthetic to saline mbb's?? There've been a number of studies looking at this. Try google 😉
 
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Timeoutofmind said:
How do you know if you are producing myofascial or facetogenic pain with palpation?
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As lonelobo said, you can't -

Thus why physical exam isn't much help if you have a great story (like whiplash) for facet mediated pain. That is why your idea of an injection (after you have ruled out all other secondary gain issues like 101N says) is great - even in the absence of radiological findings.

Since exam will not help you much to rule out the possibility of facet mediated pain, there real answer comes from a diagnostic injection. the BEST diagnostic injection is blocking the innervation to the structure. Intra-articular injections may serve as a diagnostic injection, but it isn't specific since the volumes used are larger, and there isn't really any consensus on where best needle placement is, or really who knows where that volume of medication goes - and could be blocking muscle pain (back leakage), or epidural spread which is very non-specific. That is why most pain physicians argue for a well placed, very specific (low volume) diagnostic medial branch block.
 
epidural man said:
As lonelobo said, you can't -

Thus why physical exam isn't much help if you have a great story (like whiplash) for facet mediated pain. That is why your idea of an injection (after you have ruled out all other secondary gain issues like 101N says) is great - even in the absence of radiological findings.

Since exam will not help you much to rule out the possibility of facet mediated pain, there real answer comes from a diagnostic injection. the BEST diagnostic injection is blocking the innervation to the structure. Intra-articular injections may serve as a diagnostic injection, but it isn't specific since the volumes used are larger, and there isn't really any consensus on where best needle placement is, or really who knows where that volume of medication goes - and could be blocking muscle pain (back leakage), or epidural spread which is very non-specific. That is why most pain physicians argue for a well placed, very specific (low volume) diagnostic medial branch block.
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I know we are saying that normal mri does not R/o facetogenic pain...but wouldn't u agree that facet disease on MRI helps rule it in?

Doesn't it help u pick which levels to treat?...I mean I just feel like it has to be more sensitive/specific than gestalt from H and P
 
Timeoutofmind said:
I know we are saying that normal mri does not R/o facetogenic pain...but wouldn't u agree that facet disease on MRI helps rule it in?

Doesn't it help u pick which levels to treat?...I mean I just feel like it has to be more sensitive/specific than gestalt from H and P
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A normal MRI does not exist. It is normal to have the set arthropathy and degenerative discs on an MRI as an age-appropriate function of walking upright
 
lobelsteve said:
A normal MRI does not exist. It is normal to have the set arthropathy and degenerative discs on an MRI as an age-appropriate function of walking upright
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Agreed.

My question is though, doesnt it help you rule in facetogenic pain if you have a patient with facet disease on MRI versus if you have the exact same patient/presentation with no facet disease on MRI? And doesnt it help you decide which levels to treat?
 
no.

unless you had a pre-injury MRI, how do you know if these findings did or did not exist prior to injury? findings of facet disease does not correlate with symptomatology. many ppl have facet arthropathy without neck pain.

then again, if you have a pre-injury MRI, why was one done (other than neck pain)?
 
MRI only helps to predict facet mediated pain if the discs are pristine. If axial lbp and pristine discs on imaging, SIS recommends first investigating the facets as the possible cause of pain
 
Ducttape said:
no.

unless you had a pre-injury MRI, how do you know if these findings did or did not exist prior to injury? findings of facet disease does not correlate with symptomatology. many ppl have facet arthropathy without neck pain.

then again, if you have a pre-injury MRI, why was one done (other than neck pain)?
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I should have specified...not talking about an acute injury just facet pain in general.

I just dont know if I buy it...It seems if someone has some huge and gnarly facets with fluid in them on MRI and axial back pain, that this is some type of explanation of their back pain. (I do understand and agree that the reverse is not true...normal MRI does nor preclude facetogenic pain).
 
https://www.ncbi.nlm.nih.gov/pubmed/9209878
The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males.
Savage RA1, Whitehouse GH, Roberts N.
Author information
  • 1Magnetic Resonance and Image Analysis Research Centre, University of Liverpool, UK.
Abstract
The purpose of this study was to undertake a critical review of the potential role of magnetic resonance imaging (MRI) in the evaluation of low back pain (LBP) and to determine if there were differences in the MRI appearances between various occupational groups. The study group, 149 working men (78 aged 20-30 years and 71 aged 31-58 years) from five different occupations (car production workers, ambulance men, office staff, hospital porters and brewery draymen), underwent MRI of the lumbar spine. Thirty-four percent of the subjects had never experienced LBP. Twelve months later, the examination was repeated on 89 men. Age-related differences were seen in the MRI appearances of the lumbar spine. Disc degeneration was most common at L5/S1 and was significantly more prevalent (P < 0.01) in the older age group (52%) than in the younger age group (27%). Although LBP was more prevalent in the older subjects there was no relationship between LBP and disc degeneration. No differences in the MRI appearance of the lumbar spine were observed between the five occupational groups. Overall, 45% had 'abnormal' lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression). There was not a clear relationship between the MRI appearance of the lumbar spine and LBP. Thirty-two percent of asymptomatic subjects had 'abnormal' lumbar spines and 47% of all the subjects who had experienced LBP had 'normal' lumbar spines. During the 12-month follow-up period, 13 subjects experienced LBP for the first time. However, there was no change in the MRI appearances of their lumbar spines that could account for the onset of LBP. Although MRI is an excellent technique for evaluating the lumbar spine, this study shows that it does not provide a suitable pre-employment screening technique capable of identifying those at risk of LBP.
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https://www.ncbi.nlm.nih.gov/pubmed/18923337
(CT study, not MRI, but I included it as a broad discussion in imaging)
Spine (Phila Pa 1976). 2008 Nov 1;33(23):2560-5. doi: 10.1097/BRS.0b013e318184ef95.
Facet joint osteoarthritis and low back pain in the community-based population.
Kalichman L1, Li L, Kim DH, Guermazi A, Berkin V, O'Donnell CJ, Hoffmann U, Cole R, Hunter DJ.
Author information
  • 1Boston University School of Medicine, Boston, MA, USA.
Abstract
STUDY DESIGN:
Cross-sectional study.

OBJECTIVE:
To evaluate the association between lumbar spine facet joint osteoarthritis (FJ OA) identified by multidetector computed tomography (CT) and low back pain (LBP) in the community-based Framingham Heart Study.

SUMMARY OF BACKGROUND DATA:
The association between lumbar FJ OA and LBP remains unclear.

METHODS:
This study was an ancillary project to the Framingham Heart Study. A sample of 3529 participants of the Framingham Heart Study aged 40 to 80 underwent multidetector CT imaging to assess aortic calcification. One hundred eighty-eight individuals were consecutively enrolled in this ancillary study to assess radiographic features associated with LBP. LBP in the preceding 12 months was evaluated using a self-report questionnaire. FJ OA was evaluated on CT scans using a 4-grade scale. The association between FJ OA and LBP was examined used multiple logistic regression models, while adjusting for gender, age, and BMI.

RESULTS:
CT imaging revealed a high prevalence of FJ OA (59.6% of males and 66.7% of females). Prevalence of FJ OA increases with age. By decade, FJ OA was present in 24.0% of <40-years-olds, 44.7% of 40- to 49-years-olds, 74.2% of 50- to 59-years-olds, 89.2% of 60- to 69-year-olds, and 69.2% of >70-years-olds. By spinal level the prevalence of FJ OA was: 15.1% at L2-L3, 30.6% at L3-L4, 45.1% at L4-L5, and 38.2% at L5-S1. In this community-based population, individuals with FJ OA at any spinal level showed no association with LBP.

CONCLUSION:
There is a high prevalence of FJ OA in the community. Prevalence of FJ OA increases with age with the highest prevalence at the L4-L5 spinal level. At low spinal levels women have a higher prevalence of lumbar FJ OA than men. In the present study, we failed to find an association between FJ OA, identified by multidetector CT, at any spinal level and LBP in a community-based study population
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Timeoutofmind said:
I know we are saying that normal mri does not R/o facetogenic pain...but wouldn't u agree that facet disease on MRI helps rule it in?

Doesn't it help u pick which levels to treat?...I mean I just feel like it has to be more sensitive/specific than gestalt from H and P
Click to expand...

Yes to both.

If it looks bad on MRI, that simplifies the diagnosis and targeting.

However when the patient just has mild facet DDD at many levels or you are dealing with an MVA or other trauma then physical exam and palpation is important.

With generic mild facet DDD, sure most of the time lower neck pain is C5-C7 and lumbar L3-L5, but palpating takes 60 seconds and I know we didn't miss anything.

palpation is particularly important after MVA or trauma, as more commonly you get involvement of other levels. Particularly useful for cervical facet pathology and I recommend learning to palpating both lateral and posteriorly on the neck, as posterior is often just a big broad myofascial pain, but you can identify discrete levels more easily with lateral palpation. I still do both as sometimes I learn something from posterior, but lateral is most helpful.
 
101N said:
My, a fortuitous dilemma. Boduk thinks he's created a Gordian knot with "Only the needle knows". We'll see when there is a RCT of MBB vs saline.
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No no, 101N. If that were done, you would claim the saline washed out the inflammogen, and demand an MBB vs sham study to confirm that the saline placebo was a true placebo.
 
bedrock said:
Yes to both.

If it looks bad on MRI, that simplifies the diagnosis and targeting.

However when the patient just has mild facet DDD at many levels or you are dealing with an MVA or other trauma then physical exam and palpation is important.

With generic mild facet DDD, sure most of the time lower neck pain is C5-C7 and lumbar L3-L5, but palpating takes 60 seconds and I know we didn't miss anything.

palpation is particularly important after MVA or trauma, as more commonly you get involvement of other levels. Particularly useful for cervical facet pathology and I recommend learning to palpating both lateral and posteriorly on the neck, as posterior is often just a big broad myofascial pain, but you can identify discrete levels more easily with lateral palpation. I still do both as sometimes I learn something from posterior, but lateral is most helpful.
Click to expand...
No to both. No study has ever correlated MRI and/or SPECT findings with response to MBBs. In fact, there has been a negative correlation
 
ampaphb said:
No to both. No study has ever correlated MRI and/or SPECT findings with response to MBBs. In fact, there has been a negative correlation
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I'm not saying MRI is always right, but i've never seen someone with horrible L4-L5, L5-S1 facet joints and pain with extension who didn't have some facet joint pain. Maybe multiple pain generators, but facets are one of them.

I agree that the only proven way to know if someone has facet pain is MBB. I have a very low threshold for MBB.
 
Timeoutofmind said:
I know we are saying that normal mri does not R/o facetogenic pain...but wouldn't u agree that facet disease on MRI helps rule it in?

Doesn't it help u pick which levels to treat?...I mean I just feel like it has to be more sensitive/specific than gestalt from H and P
Click to expand...
I don't think so.

My reading of the literature, and my experience - is that a bad looking joint does not mean a painful joint.

I tell patients, and I truly believe (although no one else I work with does....) - you get an MRI for two reasons (in a patient with low back pain)....to rule out infection and tumor. Other than that, it doesn't help you.

If you have neurological symptoms, I think that changes things.

I will never get an MRI on my back. I think the results mess with your (the patient's) head.
 
epidural man said:
I don't think so.

My reading of the literature, and my experience - is that a bad looking joint does not mean a painful joint.

I tell patients, and I truly believe (although no one else I work with does....) - you get an MRI for two reasons (in a patient with low back pain)....to rule out infection and tumor. Other than that, it doesn't help you.

If you have neurological symptoms, I think that changes things.

I will never get an MRI on my back. I think the results mess with your (the patient's) head.
Click to expand...

Agreed. For Axial lbp X-ray tells me plenty. Spondy, stable/unstable, severe disc height narrowing. I need nothing else for axial.

MRI cya only in a chronic case. I also won't put a needle in a back anywhere even facet without MRI or at least ct. Granted most of my facets on are elderly where badness more common.

I also never want to see an MRI of my back. I've got chronic intermittent discogenic appearing axial pain and don't want to see how bad it may look. No good will come if it.; Don't tell 101 about my axial lbp.... I'm fine to stick my w NSAIDs and core work. Don't need cbt yet.




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Taus said:
Agreed. For Axial lbp X-ray tells me plenty. Spondy, stable/unstable, severe disc height narrowing. I need nothing else for axial.

MRI cya only in a chronic case. I also won't put a needle in a back anywhere even facet without MRI or at least ct. Granted most of my facets on are elderly where badness more common.

I also never want to see an MRI of my back. I've got chronic intermittent discogenic appearing axial pain and don't want to see how bad it may look. No good will come if it.; Don't tell 101 about my axial lbp.... I'm fine to stick my w NSAIDs and core work. Don't need cbt yet.




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Click to expand...

Good thing it is not daily. I would stop your nsaid due to risk. then off to drusso for mscs.
 
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101N said:
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Interesting video.

1. I would pay good money to have this translated into the Hadza language and played to Hadza tribes in Tanzania. I'd kill to listen to their reactions to this woman.
2. She seems to have too much good insight to have made the choices she has in the past.
3. First world problems.
 
Jesus, 2 minutes of that Sh't makes me want to abuse Norco
 
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