Minireviews Open Access
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Anesthesiol. Jul 27, 2016; 5(2): 38-43
Published online Jul 27, 2016. doi: 10.5313/wja.v5.i2.38
Interventional pain therapy in cervical post-surgery syndrome
Stephan Klessinger, Department of Neurosurgery, Nova Clinic, 88400 Biberach, Germany
Stephan Klessinger, Department of Neurosurgery, University of Ulm, 89081 Ulm, Germany
Author contributions: Klessinger S solely contributed to this paper; He wrote the complete manuscript.
Conflict-of-interest statement: None, no funding.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Stephan Klessinger, PD, MD, Department of Neurosurgery, Nova Clinic, Eichendorffweg 5, 88400 Biberach, Germany. klessinger@nova-clinic.de
Telephone: +49-7351-44030 Fax: +49-7351-440311
Received: April 4, 2016
Peer-review started: April 8, 2016
First decision: May 17, 2016
Revised: May 31, 2016
Accepted: July 11, 2016
Article in press: July 13, 2016
Published online: July 27, 2016
Processing time: 111 Days and 9.8 Hours

Abstract

Fifteen percent to forty percent of patients present with persistent disabling neck pain or radicular pain after cervical spine surgery. Persistent pain after cervical surgery is called cervical post-surgery syndrome (CPSS). This review investigates the literature about interventional pain therapy for these patients. Because different interventions with different anatomical targets exist, it is important to find the possible pain source. There has to be a distinction between radicular symptoms (radicular pain or radiculopathy) or axial pain (neck pain) and between persistent pain and a new onset of pain after surgery. In the case of radicular symptoms, inadequate decompression or nerve root adherence because of perineural scarring are possible pain causes. Multiple structures in the cervical spine are able to cause neck pain. Hereby, the type of surgery and also the number of segments treated is relevant. After fusion surgery, the so-called adjacent level syndrome is a possible pain source. After arthroplasty, the load of the facet joints in the index segment increases and can cause pain. Further, degenerative alterations progress. In general, two fundamentally different therapeutic approaches for interventional pain therapy for the cervical spine exist: Treatment of facet joint pain with radiofrequency denervation or facet nerve blocks, and epidural injections either via a transforaminal or via an interlaminar approach. The literature about interventions in CPSS is limited to single studies with a small number of patients. However, some evidence exists for these procedures. Interventional pain therapies are eligible as a target-specific therapy option. However, the risk of theses procedures (especially transforaminal epidural injections) must be weighed against the benefit.

Key Words: Post-surgery syndrome; Neck pain; Cervical epidural injections; Cervical interlaminar injections; Cervical transforaminal injections; Cervical facet joint pain; Cervical radiofrequency neurotomy; Facet joint nerve block; Epidural steroids; Local anesthetics

Core tip: This review investigates the evidence for interventional pain therapy treatments for patients with cervical post-surgery syndrome. Persistent pain after cervical surgery is a common problem. Interventional therapies are specific therapy options which are well investigated for patients with neck pain and radicular symptoms. Unfortunately, only single studies for patients with post-surgery syndrome exist. These studies, the different approaches (radiofrequency, facet joint nerve blocks, transforaminal and interlaminar epidural injections), and pain sources for patients after cervical surgery are discussed.



INTRODUCTION

The indications for cervical spine surgery for degenerative findings are relatively well described as radiculopathy or myelopathy with compression of the nerve roots or spinal cord, or instability[1,2]. The most common surgical interventions are intersomatic decompressions and fusion with a cage with or without additional anterior instrumentation[2-7]. However, some patients who undergo spinal surgery continue to suffer pain. Persistent pain after cervical surgery is called cervical post-surgery syndrome (CPSS), and can incur increased costs to the healthcare system[8]. CPSS occurs irrespective of the type of surgery and despite the best endeavors of the surgeon[9]. CPSS is a cluster of clinical findings. The result fails to achieve the expected outcome of the surgery by both the patient and the surgeon[8].

To develop therapeutic strategies for the patient with CPSS and for a specific treatment, it is important to define the source of postsurgical pain[8,10,11]. Whether conservative management, interventional pain therapy or revision surgery are adequate depends on the cause of the pain. The rate of reoperations after the treatment of degenerative cervical spine disorders is 13.4%[2]. Indications for revision surgery are pseudarthrosis, adjacent segment degeneration, inadequate decompression, instability, and deformity[1,3]. If there is no indication for revision surgery or if there is a need to avoid surgery, interventional therapies are an option. Interventional pain therapy is a specific treatment for an expected pain source. Two different therapeutic approaches exist: (1) facet joint pain (the facet joints are the pain source) can be treated with medial branch blocks (MBBs) and radiofrequency (RF) neurotomy[12-15]; (2) epidural injections are used to treat radicular pain and chronic neck pain of discogenic origin (a disc is the pain source). They are performed either by interlaminar or transforaminal approaches[16].

While several studies about the prevalence and therapy modalities for the failed back surgery syndrome of the lumbar spine exist[17,18], the literature about CPSS is sparse. This review provides an overview of the available literature about interventional pain therapy for CPSS.

Prevalence

Fifteen percent to forty percent of patients after cervical spine surgery present with persistent disabling neck pain. Only two studies have revealed the prevalence of persistent neck pain in CPSS. In a study with 251 patients with persistent neck pain (45 post-surgery vs 206 nonsurgical), the prevalence of cervical facet joint pain was calculated after controlled, comparative blocks with local anesthetics with 80% pain relief as the threshold for a positive response. The positive response rate was 36%[8]. This retrospective evaluation demonstrated a similar prevalence of facet joint pain in postsurgical and non-surgical patients. Another study of 242 patients with persistent neck pain after cervical spine surgery demonstrated a 13% prevalence of facet joint pain[10], using a criterion of 80% pain relief after controlled MBBs was the criterion. The extent of surgery and a higher number of levels treated are risk factors for facet joint pain after surgery[2,10].

The main indications for primary cervical spine surgery are nerve root or spinal cord compression or instability[1]. Excellent results can be achieved for this indications[1]. However, if the indication for surgery is expanded to axial neck pain, the number of good to excellent results for fusion decrease to only 70%[1,3]. Thus, cervical spine surgery for axial neck pain will fail more often. Most patients with CPSS will suffer from neck pain.

Pain sources

In cases of intra-operative complications, the problem, and therefore, the pain source is often known. Possible causes are dislocation of the cage or failure of the implant, inadequate decompression or iatrogenic instability or deformities (incorrect alignment, kyphosis)[1]. These etiologies are the most frequent reasons for revision surgery[1]. It is necessary to distinguish between complications and patients with complaints despite optimal surgery. Often, it is challenging to discover the pain sources in patients after unremarkable surgery.

To detect the etiology of the persistent or new pain after surgery, it is important to determine whether the pain differs from the preoperative pain or if the complaints are exactly the same as before surgery. It is also necessary to elucidate whether the patient experienced a pain-free interval after surgery or if the pain was persistent. The difference between radicular symptoms and axial pain, which are distinct entities[19], is very important.

If there is persistent radicular pain after surgery, an inadequate decompression of the nerve root or nerve root adherence because of perineural scarring are possible causes[1,3,8]. A recurrent disc herniation after complete removal of the disc and interbody fusion is not typical; however, retention of disc material or ligament and, of course, disc herniation in an adjacent level are conceivable. In particular, in cases with radiculopathy (sensory loss or motor weakness) further diagnostics including magnetic resonance imaging are necessary. This also applies to the new onset of radicular symptoms or the new onset of a radiculopathy.

A common situation is excellent relief of the radicular symptoms but new or persistent axial pain. Multiple structures are able to cause neck pain, including the intervertebral disc, facet joints, ligaments, fascia, and muscles, which are capable of transmitting pain[8,16]. The type of surgery and the number of segments treated are relevant. In a review of 900 patients, anterior decompression with fusion and anterior instrumentation in one or two levels showed the lowest revision rate (11%) compared with a 32% revision rate after multi-level corpectomy with posterior instrumentation[2]. The influence of the fusion length on the revision rate was high[2]. Similarly, the prevalence of facet joint pain in patients with CPSS was significantly higher after double level fusions compared to single level surgery[10].

The anterior approach is most common[1-7]. An alternative to an interbody fusion with or without anterior instrumentation is the implantation of a disc prosthesis. After interbody fusion, the so-called “adjacent level syndrome” (the pain source is located not in the level of surgery, but in the adjacent level above or below) is a possible pain source[1,8,10]. There is no range of motion in the index level after fusion, which has to be compensated by an increase in motion at the adjacent segments[20]. Therefore, the incidence of disc degeneration in adjacent levels is increased[21-23], and changes in the load on the facet joints occur[21]. Especially during extension the force in the adjacent joints increases significantly, for which reason the joint capsules are stretched whereby pain can be provoked[24,25]. In contrast, after arthroplasty with implantation of a disc prosthesis, the range of motion in the index segment increases (most prosthesis use a ball-socket joint). The continuing movement in the index segment protects the adjacent segments from overload; however, the forces on the facet joints increase in the index level, especially if the center of rotation of the prosthesis is not in the ideal position[10,26]. Many of these etiologies are interrelated and arise from biomechanical derangement at the facet joints[8], potentiated by inflammation[3].

Furthermore, degenerative alterations of the spine can often not be changed by surgery. Particularly, the degeneration of adjacent levels can remain a painful condition as the underlying degenerative disease progresses[10]. Another reason for CFSS is poor decision making or an inadequate indication for surgery[1].

INTERVENTIONAL THERAPY

Generally, two fundamentally different therapeutic approaches in interventional pain therapy for the cervical spine exist: Treatment of facet joint pain (MBBs and RF neurotomy) and epidural injections (transforaminal and interlaminar).

The rationale of cervical medial branch thermal RF neurotomy is to achieve pain relief by coagulating the medial branch, which conducts the pain, and, thereby, interrupting the nociceptive pathways[10,27]. The only prerequisite is that the pain is mediated by a cervical medial branch. Therefore, the indication for RF neurotomy is analgesic response to comparative (or controlled) diagnostic MBBs[12,27]. MBBs are a diagnostic procedure to test whether the pain is mediated by one or more of the medial branches[28]. The nerve is anesthetized with a small volume of local anesthetic under fluoroscopic control. Sometimes, MBBs are used in a therapeutic intention; steroids are added to the local anesthetic to treat inflammatory processes[10-12,29-31]. Cervical epidural injections are used to treat radicular pain from a herniated disc or a spinal canal stenosis, but also to treat chronic neck pain of discogenic origin[3,10,32]. Either transforaminal or interlaminar approaches are used.

The recent literature about cervical interventions in patients with CPSS provides some evidence, but is limited to single studies with a small number of patients (Table 1).

Table 1 Studies of patients with cervical post-surgery syndrome treated with interventional therapies.
Ref.InterventionsOutcome measuresNumber of patientsFollow-up periodPositive results
Klessinger[10]Thermal radiofrequency neurotomyPain relief ≥ 50%3215 mo59% of patients ≥ 50% pain relief
Klessinger[11]Facet joint nerve blockPain relief ≥ 80% or satisfied patient1046 mo53% satisfying result
Manchikanti et al[3]Interlaminar, epiduralPain relief ≥ 50%561 yr71% of patients local anesthetic
Improvement in functional status64% of patients local anesthetic with steroid
Thermal RF neurotomy and MBBs

Different forms of RF for spinal pain exist and can be confused with medial branch thermal RF neurotomy. Some techniques are not anatomically valid and do not produce effective thermal lesions, others use different techniques like pulsed-RF[15]. A recent review about cervical thermal RF lesions[15] has taken these differences into account; comprising only the indication and technique as described in the guidelines of the International Spine Intervention Society[27,28]. Earlier studies validated the technique and became the basis for the guidelines[33-35]. Thermal medial branch neurotomy is only done if the facet joint pain is diagnosed definitively by comparative MBBs. The face validity, construct validity and predictive validity has been demonstrated[36-38] for comparative MBBs. Engel et al[15] included six observational studies[14,33-35,39,40] and two explanatory studies[41,42]. Evidence shows that 63% of patients are pain-free 6 mo after RF and 38% are pain-free at one year. This effectiveness is dependent on the type of RF procedure and cannot be generalized for different techniques[15].

Only one study (Table 1) exists evaluating the effectiveness of thermal RF neurotomy in patients with CPSS[10]; overall, 32 patients were treated. Facet joint pain was diagnosed with single MBBs and 80% pain relief as a positive response. Here, 59% of the treated patients achieved at least 50% pain relief and 25% of the patients complete pain relief with a mean follow-up time of 15 mo. It has to be taken into account that patients might have different pain sources at the same time after surgery. Therefore, 59% satisfying pain relief is important for patients with a diagnosis for which there are few specific therapy options[10].

Although MBBs are actually a diagnostic tool, facet joint nerve blocks are sometimes used in a therapeutic intention[10-12,29-31], because some studies show encouraging results[29,30]. A recent study[31] reveals Level II evidence for the long-term effectiveness of facet joint nerve blocks in managing cervical facet joint pain. In a single study (Table 1) of 104 patients with CPSS, 53% of the patients treated with facet joint nerve blocks, using local anesthetic and a steroid, reported a satisfying result after single injection[11].

Epidural injections

The evidence for cervical epidural injections is a subject of debate and depends on, whether an interlaminar or a transforaminal approach was chosen. For the interlaminar approach, a recent review[43] including eight randomized controlled studies[3,44-50] was performed. The evidence for the management of a cervical disc herniation, discogenic pain, or spinal canal stenosis is Level II (evidence from at least one relevant high quality randomized controlled trial or multiple relevant moderate or low quality randomized trials)[43]. For the transforaminal approach, the review of Engel et al[51] found six primary papers[52-57] presenting the effectiveness of transforaminal injections. The evidence was found to be of low quality[51]. The outcome in the different studies shows moderate effectiveness. However, the number of reports of severe complications (spinal cord infarction, cerebral ischemia, quadriplegia, seizures) increases[51]. Therefore, cervical transforaminal injections are not strongly recommended. When comparing the interlaminar and the transforminal approach, better evidence and less reports of severe complications make the interlaminar approach superior[43,51]. The main advantage of the transforminal approach is the selection of a single nerve root which. Therefore, the result after transforaminal injection can be helpful for the decision, which level is eligible for surgery.

Patients with CPSS are sporadically included in studies about the effectiveness of epidural injections[35,47,48,58]. Only one trial (Table 1) evaluated the effect of interlaminar epidural injections explicitly in patients after surgery[3]. The randomized, double-blind study with a one-year follow-up of 56 patients with CPSS demonstrated a minimum pain relief of 50% and improvement in functional status in 71% of patients receiving local anesthetic only and in 64% of patients receiving steroids and local anesthetic. The average duration of pain relief was 12 to 15 wk after two initial injections. The evidence for CPSS is assessed as Level III (evidence from one nonrandomized trial with multiple observational studies)[43].

CONCLUSION

Persistent pain after cervical spine surgery is a frequent problem. Interventional pain therapies are eligible as a target-specific therapy option. Both, facet joint interventions and epidural injections are used. Some evidence exists for these procedures. However, the risk of theses procedures (especially transforaminal epidural injections) must be weighed against the benefit. Patients with CPSS are sporadically included in evaluations about the effectiveness of cervical injections. In addition, regarding thermal RF neurotomy, therapeutic MBBs, and interlaminar epidural injections only single studies exist that specifically follow-up CPPS patients. Further studies focusing on CPPS patients are necessary.

Footnotes

Manuscript Source: Invited manuscript

Specialty Type: Anesthesiology

Country of Origin: Germany

Peer-Review Report Classification

Grade A (Excellent): A

Grade B (Very good): B, B

Grade C (Good): C

Grade D (Fair): 0

Grade E (Poor): E

P- Reviewer: De Cosmo G, Edeer AO, Ewers A, Higa K, Xie YF S- Editor: Song XX L- Editor: A E- Editor: Li D

References
1.  Helgeson MD, Albert TJ. Surgery for failed cervical spine reconstruction. Spine (Phila Pa 1976). 2012;37:E323-E327.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 6]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
2.  Greiner-Perth R, Allam Y, El-Saghir H, Röhl F, Franke J, Böhm H. Analysis of reoperations after surgical treatment of degenerative cervical spine disorders: a report on 900 cases. Cent Eur Neurosurg. 2009;70:3-8.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 12]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
3.  Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic cervical interlaminar epidural injections in managing chronic pain of cervical postsurgery syndrome: preliminary results of a randomized, double-blind, active control trial. Pain Physician. 2012;15:13-25.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Wang MC, Chan L, Maiman DJ, Kreuter W, Deyo RA. Complications and mortality associated with cervical spine surgery for degenerative disease in the United States. Spine (Phila Pa 1976). 2007;32:342-347.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Patil PG, Turner DA, Pietrobon R. National trends in surgical procedures for degenerative cervical spine disease: 1990-2000. Neurosurgery. 2005;57:753-758; discussion 753-758.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 140]  [Cited by in F6Publishing: 147]  [Article Influence: 8.2]  [Reference Citation Analysis (0)]
6.  Irwin ZN, Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, Glaser J, Hart RA. Variation in surgical decision making for degenerative spinal disorders. Part II: cervical spine. Spine (Phila Pa 1976). 2005;30:2214-2219.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 56]  [Cited by in F6Publishing: 53]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
7.  Shamji MF, Cook C, Pietrobon R, Tackett S, Brown C, Isaacs RE. Impact of surgical approach on complications and resource utilization of cervical spine fusion: a nationwide perspective to the surgical treatment of diffuse cervical spondylosis. Spine J. 2009;9:31-38.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 101]  [Cited by in F6Publishing: 107]  [Article Influence: 7.1]  [Reference Citation Analysis (0)]
8.  Manchikanti L, Manchikanti KN, Pampati V, Brandon DE, Giordano J. The prevalence of facet-joint-related chronic neck pain in postsurgical and nonpostsurgical patients: a comparative evaluation. Pain Pract. 2008;8:5-10.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 35]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
9.  Klessinger S. Zygapophysial joint pain in post lumbar surgery syndrome. The efficacy of medial branch blocks and radiofrequency neurotomy. Pain Med. 2013;14:374-377.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 15]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
10.  Klessinger S. Radiofrequency neurotomy for the treatment of therapy-resistant neck pain after ventral cervical operations. Pain Med. 2010;11:1504-1510.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
11.  Klessinger S. The benefit of therapeutic medial branch blocks after cervical operations. Pain Physician. 2010;13:527-534.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Falco FJ, Erhart S, Wargo BW, Bryce DA, Atluri S, Datta S, Hayek SM. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician. 2008;12:323-344.  [PubMed]  [DOI]  [Cited in This Article: ]
13.  Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review. Arch Phys Med Rehabil. 2008;89:770-774.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 50]  [Cited by in F6Publishing: 53]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
14.  MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med. 2012;13:647-654.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 73]  [Cited by in F6Publishing: 77]  [Article Influence: 6.4]  [Reference Citation Analysis (0)]
15.  Engel A, Rappard G, King W, Kennedy DJ; Standards Division of the International Spine Intervention Society. The Effectiveness and Risks of Fluoroscopically-Guided Cervical Medial Branch Thermal Radiofrequency Neurotomy: A Systematic Review with Comprehensive Analysis of the Published Data. Pain Med. 2015;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 10]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
16.  Diwan S, Manchikanti L, Benyamin RM, Bryce DA, Geffert S, Hameed H, Sharma ML, Abdi S, Falco FJ. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician. 2012;15:E405-E434.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Bordoni B, Marelli F. Failed back surgery syndrome: review and new hypotheses. J Pain Res. 2016;9:17-22.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 27]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
18.  Chan CW, Peng P. Failed back surgery syndrome. Pain Med. 2011;12:577-606.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med Rehabil Clin N Am. 2011;22:367-382, vii.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 58]  [Cited by in F6Publishing: 65]  [Article Influence: 5.4]  [Reference Citation Analysis (0)]
20.  Chang UK, Kim DH, Lee MC, Willenberg R, Kim SH, Lim J. Range of motion change after cervical arthroplasty with ProDisc-C and prestige artificial discs compared with anterior cervical discectomy and fusion. J Neurosurg Spine. 2007;7:40-46.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 78]  [Cited by in F6Publishing: 72]  [Article Influence: 4.2]  [Reference Citation Analysis (0)]
21.  Chang UK, Kim DH, Lee MC, Willenberg R, Kim SH, Lim J. Changes in adjacent-level disc pressure and facet joint force after cervical arthroplasty compared with cervical discectomy and fusion. J Neurosurg Spine. 2007;7:33-39.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 161]  [Cited by in F6Publishing: 151]  [Article Influence: 8.9]  [Reference Citation Analysis (0)]
22.  Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am. 1993;75:1298-1307.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999;81:519-528.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Yang KH, King AI. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine (Phila Pa 1976). 1984;9:557-565.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 365]  [Cited by in F6Publishing: 297]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
25.  Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI. Lumbar facet pain: biomechanics, neuroanatomy and neurophysiology. J Biomech. 1996;29:1117-1129.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 171]  [Cited by in F6Publishing: 132]  [Article Influence: 4.7]  [Reference Citation Analysis (0)]
26.  Pickett GE, Rouleau JP, Duggal N. Kinematic analysis of the cervical spine following implantation of an artificial cervical disc. Spine (Phila Pa 1976). 2005;30:1949-1954.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 143]  [Cited by in F6Publishing: 129]  [Article Influence: 6.8]  [Reference Citation Analysis (0)]
27.  International Spine Intervention Society  Cervical Medial Branch Thermal Radiofrequency Neurotomy. In: Bogduk N (ed). Practice Guidelines for Spinal Discgnostic and Treatment Procedures, 2nd edn. International Spine Intervention Society, San Francisco, 2013, 165-209.  [PubMed]  [DOI]  [Cited in This Article: ]
28.  International Spine Intervention Society  Cervical Medial Branch Blocks. In: Bogduk N (ed). Practice Guidelines for Spinal Discgnostic and Treatment Procedures, 2nd edn. International Spine Intervention Society, San Francisco, 2013, 101-140.  [PubMed]  [DOI]  [Cited in This Article: ]
29.  Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10:229-253.  [PubMed]  [DOI]  [Cited in This Article: ]
30.  Manchikanti L, Damron K, Cash K, Manchukonda R, Pampati V. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician. 2006;9:333-346.  [PubMed]  [DOI]  [Cited in This Article: ]
31.  Manchikanti L, Hirsch JA, Kaye AD, Boswell MV. Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies. Postgrad Med. 2016;128:54-68.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 25]  [Cited by in F6Publishing: 18]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
32.  Manchikanti L, Falco FJ, Diwan S, Hirsch JA, Smith HS. Cervical radicular pain: the role of interlaminar and transforaminal epidural injections. Curr Pain Headache Rep. 2014;18:389.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 17]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
33.  Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry. 2003;74:88-93.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 156]  [Cited by in F6Publishing: 111]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
34.  Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: A validated treatment for cervical zygapophysial joint pain. Neurosurg Q. 1988;8:288-308.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 72]  [Cited by in F6Publishing: 75]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
35.  McDonald GJ, Lord SM, Bogduk N. Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery. 1999;45:61-67; discussion 67-68.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 109]  [Cited by in F6Publishing: 130]  [Article Influence: 5.2]  [Reference Citation Analysis (0)]
36.  Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993;18:343-350.  [PubMed]  [DOI]  [Cited in This Article: ]
37.  Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain. 1993;9:124-130.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 162]  [Cited by in F6Publishing: 167]  [Article Influence: 5.4]  [Reference Citation Analysis (0)]
38.  Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain. 1993;55:99-106.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 250]  [Cited by in F6Publishing: 252]  [Article Influence: 8.1]  [Reference Citation Analysis (0)]
39.  Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery. 1995;36:732-739.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 149]  [Cited by in F6Publishing: 110]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
40.  Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain: outcomes in a series of consecutive patients. Pain Med. 2005;6:282-286.  [PubMed]  [DOI]  [Cited in This Article: ]
41.  Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996;335:1721-1726.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 607]  [Cited by in F6Publishing: 449]  [Article Influence: 16.0]  [Reference Citation Analysis (0)]
42.  Wallis BJ, Lord SM, Bogduk N. Resolution of psychological distress of whiplash patients following treatment by radiofrequency neurotomy: a randomised, double-blind, placebo-controlled trial. Pain. 1997;73:15-22.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
43.  Kaye AD, Manchikanti L, Abdi S, Atluri S, Bakshi S, Benyamin R, Boswell MV, Buenaventura R, Candido KD, Cordner HJ. Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis. Pain Physician. 2015;18:E939-1004.  [PubMed]  [DOI]  [Cited in This Article: ]
44.  Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic epidural injections in cervical spinal stenosis: preliminary results of a randomized, double-blind, active control trial. Pain Physician. 2012;15:E59-E70.  [PubMed]  [DOI]  [Cited in This Article: ]
45.  Manchikanti L, Cash KA, Pampati V, Malla Y. Two-year follow-up results of fluoroscopic cervical epidural injections in chronic axial or discogenic neck pain: a randomized, double-blind, controlled trial. Int J Med Sci. 2014;11:309-320.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 28]  [Cited by in F6Publishing: 30]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
46.  Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. A randomized, double-blind, active control trial of fluoroscopic cervical interlaminar epidural injections in chronic pain of cervical disc herniation: results of a 2-year follow-up. Pain Physician. 2013;16:465-478.  [PubMed]  [DOI]  [Cited in This Article: ]
47.  Castagnera L, Maurette P, Pointillart V, Vital JM, Erny P, Sénégas J. Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain. Pain. 1994;58:239-243.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 80]  [Cited by in F6Publishing: 89]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
48.  Stav A, Ovadia L, Sternberg A, Kaadan M, Weksler N. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand. 1993;37:562-566.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
49.  Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F, Paladini A, Mojoli F. Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion. Clin J Pain. 2007;23:551-557.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 43]  [Cited by in F6Publishing: 56]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
50.  Cohen SP, Hayek S, Semenov Y, Pasquina PF, White RL, Veizi E, Huang JH, Kurihara C, Zhao Z, Guthmiller KB. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121:1045-1055.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 61]  [Cited by in F6Publishing: 60]  [Article Influence: 6.0]  [Reference Citation Analysis (0)]
51.  Engel A, King W, MacVicar J. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014;15:386-402.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 76]  [Cited by in F6Publishing: 64]  [Article Influence: 5.8]  [Reference Citation Analysis (0)]
52.  Vallée JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, Vallée CA. Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection. Radiology. 2001;218:886-892.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 120]  [Cited by in F6Publishing: 119]  [Article Influence: 5.2]  [Reference Citation Analysis (0)]
53.  Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir (Wien). 2005;147:1065-1070; discussion 1070.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 70]  [Cited by in F6Publishing: 53]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
54.  Dreyfuss P, Baker R, Bogduk N. Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med. 2006;7:237-242.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
55.  Razzaq AA, O’Brien D, Mathew B, Bartlett R, Taylor D. Efficacy and durability of fluoroscopically guided cervical nerve root block. Br J Neurosurg. 2007;21:365-369.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 23]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
56.  Lee JH, Lee SH. Comparison of clinical effectiveness of cervical transforaminal steroid injection according to different radiological guidances (C-arm fluoroscopy vs. computed tomography fluoroscopy). Spine J. 2011;11:416-423.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 21]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
57.  Persson L, Anderberg L. Repetitive transforaminal steroid injections in cervical radiculopathy: a prospective outcome study including 140 patients. Evid Based Spine Care J. 2012;3:13-20.  [PubMed]  [DOI]  [Cited in This Article: ]
58.  Benyamin RM, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009;12:137-157.  [PubMed]  [DOI]  [Cited in This Article: ]