Low back pain (LBP) is a highly prevalent and painful condition affecting a substantial part of the population, with very high associated treatment costs and high rates of disability.1,2 Dorsal ramus syndrome refers to a variety of symptoms caused by irritation to the dorsal ramus, a nerve in the spine which contributes motor and sensory innervation to the posterior spine. Any abnormality of the zygapophysial joint including degenerative changes, osteophytes, hypertrophy of ligaments or joint capsules, or fractures can cause symptoms including chronic pain.3-7
RADIOFREQUENCY ABLATION
The prevalence of lumbar zygapophyseal joint pain has been estimated to be somewhere between 20-44% and may be exacerbated by pathology of the dorsal ramus nerve.8 Pain management physicians routinely perform medial branch blocks of the dorsal rami with local anesthetic prior to performing radiofrequency ablation (RFA) in patients with chronic pain. RFA is the intentional denervation of the medial branch of the dorsal ramus to treat localized pain.
Direct treatment of the dorsal ramus is effective in reducing pain over the short term;9 however, the inherent problem with using RFA relates to the sensitization of adjacent spinal levels and nerve fibers combined with the eventual “reinnervation” of the structure with collateral branches and arborization.10,11 Additionally, RFA can lead to atrophy and fatty infiltration of the multifidus muscle which has been associated with increased rates of LBP recurrence.12
EFFICACY OF RADIOFREQUENCY ABLATION
The efficacy of RFA wanes over time, with some studies showing increases in pain at the 6-month mark.13,14 In studies designed to mimic real world application of RFA, results showed only 32% of patients reported successful outcomes at 6 months. At the one-year mark, only 22% reported success, with 10% gaining complete relief and 9% yielding lasting functional results.13,14 Many studies found a limited short-term benefit that lasts approximately 10 months, with repeated RFA being necessary for continued success.7
In fact, placebo and RFA may have similar success rates at one year, with 29.3% of placebo control patients (i.e., the 5 mm electrode and cannula were inserted but not turned) experiencing a successful outcome versus 27.5% of those undergoing RFA.15
RADIOFREQUENCY ABLATION VS. ELECTRICAL DRY NEEDLING
Using acupuncture needles to target the dorsal rami over the posterolateral articular pillar may give providers the ability to target pathologic tissues without the negative side effects of RFA. Notably, a recent case study suggests periosteal dry needling over the cervical articular pillar may be useful in patients with chronic neck pain and headache.16
TARGETING THE DORSAL RAMI WITH DRY NEEDLING
Electrical dry needling (EDN) has been shown to potentiate opiate pathways and increase the efficacy of the opiate drugs, which could lead to smaller dosages for the patient.17 With intramuscular dry needling the practitioner can target the dorsal rami branches that innervate joint capsules, intervertebral discs, and intrinsic segmental musculature.18 According to most RFA studies and those targeting the region perineural to the dorsal ramus, the optimal technique to target the dorsal ramus is to aim between the superior articular process and the transverse process.7,9-11,14,16,19,20
For symptoms that are medial to the facet, clinicians can use a posterior to anterior needle insertion with a backdrop over the base of the spinous process, posterior surface of the vertebral lamina, or posterolateral aspect of the ZJ capsule to desensitize and stimulate the medial dorsal branch. Notably, using a bony back drop also gives the clinician the opportunity to stimulate the periosteum, which has been shown to have both sympathetic and sensory nerve endings.21,22
For pain lateral to the facet, the transverse process can be targeted to stimulate the lateral branch of the dorsal ramus using an oblique needle insertion.19 Furthermore, dry needling in addition to standard care may improve pain and function in patients with lumbar disc herniation.23 Several other trials have reported positive outcomes for musculoskeletal spinal conditions by targeting the dorsal rami.20,24
MULTIFIDI FATTY INFILTRATION
Multifidi fatty infiltration (MFI) is measured by Pfirrman grades. MFI in healthy individuals is seen as grade 0, having less than 10% MFI. MFI can progress from grade 0 to grade 4, where fat has replaced greater than 50% of the contractile tissue. Interestingly, MFI is often overlooked because the cross-sectional area (CSA) of the multifidi is preserved by fatty infiltrates. However, modern techniques using MRI and ultrasound allow providers to fully understand the composition of the CSA of the multifidus. Higher levels of fatty infiltration have been correlated with higher levels of disability in individuals with LBP. Fatty replacement changes muscle pennation angle, introduces inflammatory cytokines, disrupts longitudinal fibers, and decreases proximal joint stability.25 Moreover, abnormal levels of MFI are strongly associated with “ever having had back pain” and with “having back pain in the past year”.26
Degenerative disc disease secondary to herniation often reduces the size of the central spinal canal and/or lateral intervertebral foramen. Disc herniation can lead to nerve damage and inflammatory conditions that sensitize the spinal nerve in both the affected level and adjacent levels. The vast majority of lumbar disc herniations occur between the L4-L5 and L5-S1 segments. The L5-S1 segment has the highest prevalence of fatty infiltration, with women more severely affected than men.27,28 When the dorsal rami are damaged, the multifidi experience atrophy and increased fatty infiltration, which predisposes the region to further injury.28
Multifidi fatty infiltration (MFI) can occur after nerve injury due to muscular inactivity and deconditioning. MFI occurs throughout the spine with higher prevalence at junctional zones. Fat infiltration in the upper cervical spine is associated with increased disability levels and loss of lordosis.29 Notably, the multifidi are innervated by multiple levels; thus, an injury to the L5 nerve root can lead to MFI at the L4, L5 and S1 levels. Dorsal rami travel through a fibro-osseous tube that ossifies over time turning into a “bone tunnel.”3,30 It may be that the increased MFI seen in aging populations is associated with neural impingement and secondary to trophic changes, degenerative disc disease, and inflammatory conditions. Aging accounts for approximately 30% of the variance in fatty composition of the multifidus and erector spinae muscles in individuals with chronic lumbar spine pathology.25,31
Patients with low back pain have nearly double the fatty infiltration as healthy individuals; that is, the average MFI in healthy subjects is close to 14.5% compared to 23.6% in patients with chronic LBP.12
ATROPHY, WASTING & FIBER TYPE CHANGES IN CHRONIC LBP
Pain causes inhibition of alpha motor neuron activity in the anterior horn of the spinal cord and inhibits activity of the multifidus. Notably, neurogenic inhibition continues even after remission of low back pain.12 The cross-sectional area of the multifidus is reduced in chronic low back pain.32 Denervation and subsequent atrophy of the multifidi leads to a gradual conversion of type 1 aerobic slow twitch oxidative muscle fibers to type IIa/x glycolytic fast twitch muscle fibers. There is also a reduction in capillary density that occurs with an increase in inflammatory cell density that may play an important role in muscle wasting.
CONCLUSIONS
Treating dorsal ramus syndromes can be difficult. There are countless pain clinics performing RFA daily. RFA results in complete denervation of the multifidus muscle causing decreased segmental motor control along with increased fatty infiltration.33 RFA is an alternative to prolonged opioid use, however the effects are short term in most cases. Dry needling with electrical stimulation has been shown to be useful option in the treatment of cluneal neuralgia, suboccipital headaches, and lumbar dorsal ramus syndrome.20,24,34
For symptoms that are medial to the facet, clinicians can use a posterior to anterior needle insertion with a backdrop over the base of the spinous process, posterior surface of the vertebral lamina, or posterolateral aspect of the ZJ capsule to desensitize and stimulate the medial dorsal branch. Distinguishing degeneration from multifidi atrophy is critical, as current methods for reversing muscle atrophy do not seem to induce the expected hypertrophic adaptations seen in normal skeletal muscle.31,35
EDN may reduce the concentration of inflammatory cytokines, improve the local pH, and in turn desensitize the dorsal ramus.36 Using ultrasound or MRI with 1-year outcomes, and following a treatment regimen of EDN or RFA, future studies should consider comparing changes to the level of MFI (and associated pain and disability scores) in a subgroups of patients with chronic dorsal spinal pain.
AUTHORS
Anthony Rich, DPT, FAAOMPT, Dip. Osteopractic
Owner and CEO, Access Therapy
Access Therapy, Sierra Vista, AZ
James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in OMPT
President, American Academy of Manipulative Therapy
Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL
Paul Bliton, DPT, NCS, OCS, SCS, FAAOMPT, Dip. Osteopractic
Associate Director, AAMT Fellowship in OMPT
William S. Middleton Veterans Hospital, Madison, WI
Sam Fischer, DPT, OCS, FAAOMPT, Dip. Osteopractic, RMSK
Assistant Director, AAMT Fellowship in OMPT
ActivePT, Rochester, MN
Joshua Prall, DPT, EdD, FAAOMPT, Dip. Osteopractic
Associate Director of Clinical Research, AAMT Fellowship in OMPT
Assistant Professor, Lebanon Valley College, PA
James Escaloni, DPT, OCS, FAAOMPT, Dip. Osteopractic, RMSK
Senior Faculty, AAMT Fellowship in Musculoskeletal Sonography
Assistant Director of Clinical Research, AAMT Fellowship in OMPT
Wellward Regenerative Medicine, Lexington, KY
Ian Young, DSc, OCS, SCS, Dip Osteopractic, RMSK
Senior Faculty, AAMT Fellowship in Musculoskeletal Sonography
Director of Clinical Research, AAMT Fellowship in OMPT
Tybee Wellness & Osteopractic, Tybee Island, GA
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