Infiltrationen und Radiofrequenztherapie der lumbalen und zervikalen Facettengelenke und der Iliosakralgelenke: Überblick, Evidenz und Ergebnisse

Zusammenfassung

Einleitung Infiltrationen der Facettengelenke der HWS und LWS als auch der Iliosakralgelenke sind weltweit verbreitet und lang etabliert. Techniken, basierend auf röntgengestützter als auch sonografischer Bildgebung, stellen den Standard dar. Bez. der Indikationsstellung und der Ergebnisse sind die diagnostischen Infiltrationen von den therapeutischen Indikationen klar zu unterscheiden.

Diagnostische Infiltrationen Die diagnostischen Infiltrationen kommen im Rahmen einer funktionellen Diagnostik zum Einsatz, um eine arthrogene Schmerzursache zu sichern. Hier sind Ramus medialis Infiltrationen und intraartikuläre Infiltrationen in Ihrer Aussagekraft identisch anzusehen. Um die Rate falsch positiver Befunde zu reduzieren, sind serielle Infiltrationsprotokolle mit unterschiedlich lang wirksamen Lokalanästhetika bzw. Placebo zu bevorzugen. Die Evidenz der Studienlage ist überschaubar, da das Ausmaß der Schmerzreduktion das entscheidende Outcome-Kriterium darstellt und Schmerz per se multifaktoriell ist. Lumbale und zervikale Facettengelenksinfiltrationen zeigen unterschiedliche Raten falsch-positiver Befunde.

Therapeutische Infiltration Bei gesichert arthrogenem Schmerz können leitliniengerecht Facettengelenks- und Iliosakralgelenksinfiltrationen durchgeführt werden. Die Evidenz ist hierbei bei methodisch schwacher Studienlage allgemein mittel bis schlecht, insbesondere in Bezug auf langfristige Ergebnisse.

Radiofrequenztherapie Die Radiofrequenztherapie stellt ein etabliertes Verfahren bei vertebragenen Gelenkschmerzen dar. Hier ist vorab eine gesicherte Diagnose für die Indikationsstellung unabdingbar. Es gibt unterschiedliche Behandlungstechniken. Aufgrund methodischer Probleme und einer Vielzahl von Durchführungstechniken und Begleitpathologien ist die Studienlage auch hier schwach.

Abstract

Interventional therapies for facet joint pain of the lumbar and cervical spine as well as the iliosacral joints have been globally established for many years. Image guided techniques using xray or ultrasound modality are standardized. Indications for the interventions can be categorized in diagnostic testing and therapeutic injections.

Diagnostic injections Diagnostic injections are employed in the context of defining arthrogenic spinal pain sources. Medial branch blocks and intraarticular injections are found to be equally as effective. Serial injection protocols with different local anaesthetic agents should be employed to reduce the rate of false positive findings. Lumbar and cervical facet joint injections do have different rates of false positive findings. Scientific evidence, however, is moderate in many cases due to methodological reasons and the key aspects that the key outcome measure of the studies is the amount of pain reduction. This concept lacks a gold standard because of the multifactorial aspects of pain in general.

Therapeutic injections In cases of proven arthrogenic spinal pain, guidelines explicitly mention facet joint and iliosacral joint injections as a possible treatment modality. Long term evidence for subacute and chronic pain is poor.

Radiofrequency denervations Radiofrequency constitutes an established method of treating arthrogenic pain. There are a number of published standardized techniques. Evidence is moderate at best for mid and longterm outcome due to comparable methodological issues, limiting comparability in metanalytic studies.

Schlüsselwörter

Facettengelenke - Diagnostische Infiltration - Therapeutische Infiltration - Radiofrequenztherapie

Keywords

Facet joints - diagnostic injections - therapeutic injections - radiofrequency

Publikationsverlauf

Artikel online veröffentlicht:
13. August 2020

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