Research Article: The Role of Thoracic Medial Branch Blocks in Managing Chronic Mid and Upper Back Pain: A Randomized, Double-Blind, Active-Control Trial with a 2-Year Followup

Date Published: July 19, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Laxmaiah Manchikanti, Vijay Singh, Frank J. E. Falco, Kimberly A. Cash, Vidyasagar Pampati, Bert Fellows.


Study Design. A randomized, double-blind, active-control trial. Objective. To determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain. Summary of Background Data. The prevalence of thoracic facet joint pain has been established as 34% to 42%. Multiple therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include medial branch blocks, radiofrequency neurotomy, and intraarticular injections.
Methods. This randomized double-blind active controlled trial was performed in 100 patients with 50 patients in each group who received medial branch blocks with local anesthetic alone or local anesthetic and steroids.
Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months.
Results. Significant improvement with significant pain relief and functional status improvement of 50% or more were observed in 80% of the patients in Group I and 84% of the patients in Group II at 2-year followup.
Conclusions. Therapeutic medial branch blocks of thoracic facets with or without steroids may provide a management option for chronic function-limiting thoracic pain of facet joint origin.

Partial Text

Leboeuf-Yde et al. [1] showed the prevalence of thoracic pain to be 13% of the general population, in contrast to 43% with low back pain and 32% with neck pain during the past year. The data in reference to mid back or upper back pain illustrates that it is less common than chronic persistent lumbar or cervical spinal pain [1–4]. However, the degree of disability resulting from thoracic pain disorders may be similar to that of the cervical and lumbar regions [2, 4]. In interventional pain management settings, reports of thoracic pain have ranged from 3% to 23% of patients [5–9]. Even then, multiple interventional techniques performed in the thoracic spine are rising [10–20].

The study was performed based on Consolidated Standards of Reporting Trials (CONSORT) guidelines [49], with an approved study protocol by the Institutional Review Board (IRB), and appropriate registration with a clinical registry of NCT00355706. The study was conducted in a private practice, specialty referral center, and interventional pain management practice in the United States, utilizing the internal resources of the practice and without any external funding either from industry or from elsewhere.

The first randomized, double-blind, active-controlled trial of 100 patients with chronic function-limiting thoracic pain of facet joint origin, using therapeutic thoracic medial branch blocks, showed significant improvement with pain relief and functional status improvement in 80% of the patients in Group I and 84% in Group II at 2-year followup. This study also showed an average number of procedures of 6 over a period of 2 years. Patients experienced 84.7 ± 26.1 weeks of relief in Group I and 88.7 ± 22.1 weeks of relief in Group II. The study illustrated the average relief per procedure as 20.4 ± 20.8 weeks in Group I and 17.4 ± 14.4 in Group II with steroids with relief per procedure from 2 weeks to 2 years. While there was no significant difference in opioid intake or employment characteristics, employment characteristics showed that all the eligible participants were employed at the end of one year and 2 years with one fewer participant in Group I because of retirement. Thus, pain relief and improvement in functional status were significant. Strict criteria were utilized for diagnosing facet joint pain with controlled comparative local anesthetic blocks to avoid the criticism of including patients without facet joint pain in the study.

This randomized, double-blind, active-controlled trial report demonstrates that thoracic facet joint pain diagnosed by controlled comparative local anesthetic blocks may be treated with thoracic medial branch blocks of local anesthetics with or without steroids with similar results.