Lumbar Facet Arthropathy
No Results
No Results
processing….
Low back pain (LBP) remains a common musculoskeletal complaint, with a reported lifetime incidence of 60-90%. Various structures have been incriminated as possible sources of chronic LBP, including the posterior longitudinal ligament, dorsal root ganglia, dura, annular fibers, muscles of the lumbar spine, and facet joints. [1]
In 1911, Goldwaith first implicated the facet joints as a source of LBP. In 1933, Ghormley described the facet syndrome, and in 1941, Badgley endorsed the idea of the facets as the cause of LBP, based on pathomorphologic studies of the joint. [2, 3] Rees in 1972 and Shealy in 1974 accepted the notion and developed techniques in which the joint allegedly could be denervated to stop pain stemming from the facet joints. [4, 5]
In 1963, Hirsch and colleagues injected normal saline into facet joints, demonstrating that facet joints can produce LBP. [6] Systematic studies began in 1976, when Mooney and Robertson used fluoroscopy to confirm this location of intra-articular lumbar facet joint injections of normal saline in asymptomatic volunteers. [7] (Three years later, McCall and colleagues did the same. [8] ) These injections of normal saline caused back and lower extremity pain. In addition, Mooney and Roberts documented relief of low back and lower extremity pain in these patients after injection of local anesthetic into the provoked facet joints. A 1989 study by Marks demonstrated similar findings in patients with chronic LBP. [9]
In 1991, Kuslich and colleagues probed facet joint capsules in patients undergoing lumbar decompression surgeries and found that pain could be induced. [10] Many investigators developed techniques to diagnose facet joint pain using intra-articular joint blocks and medial branch nerve blocks, as well as ways to treat such pain with intra-articular steroids, surgical ablation, or radiofrequency (RF) denervation. Controversy continues regarding the true prevalence, most accurate diagnostic methods, and most efficacious treatment of symptomatic lumbar facet joints. [11]
The use of diagnostic blocks is fundamental to a diagnosis of lumbar facet joint pain. Regardless of the symptoms, one characteristic that all patients with such pain share is the relief of pain once a local anesthetic has been injected. Fluoroscopically guided blocks of the joints constitute the only available standard to correlate with any clinical or radiographic test for facet joint pain. [12]
Facet diagnostic blocks can be performed intra-articularly and at the dorsal medial branches that supply the joint. The latter site is used if the joint is not accessible or as a means of avoiding the theoretical risk of needle damage to the joint.
Abnormalities on plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans [13] are not specific for patients with back pain; degenerative changes are often found in asymptomatic persons.
Treatments for facet joint pain include (1) intra-articular steroid/local anesthetic injection under fluoroscopic guidance and (2) radiofrequency (RF) ablation to block the joint from all sensory input. Some authorities have also advocated the use of pulsed radiofrequency [14] at a lower temperature. Prior to radiofrequency ablation, medial branch blocks or intra-articular facet injections are typically done. Medial branch blocks appear to have better prognostic outcomes than intra-articular facet injections. [15]
In 2013, the American Society of Interventional Pain Physicians (ASIPP) released an update of their guidelines for interventional techniques in patients with chronic spinal pain. The guidelines state that evidence for the therapeutic efficacy of lumbar facet joint nerve blocks is fair to good but that there is only limited evidence for the efficacy of intra-articular lumbar injections. [16, 17]
Once the diagnosis of facet joint pain has been confirmed and pain has been brought under control with appropriate treatment, experienced clinicians generally recommend physical therapy for reconditioning, as well as lumbar stabilization exercises.
Bones of the spine articulate anteriorly by intervertebral disks and posteriorly by paired joints. The latter, formally known as zygapophyseal joints (but commonly termed facet joints), are true synovial joints, with a joint space, hyaline cartilage surfaces, a synovial membrane, and a fibrous capsule. Two medial branches of the dorsal rami innervate the facet joints. Medial branches of the lumbar dorsal rami issue from their respective intervertebral foramina, cross the superior border of the transverse process, and then run medially around the base of the facet joint before innervating the joints. [18]
In studies, autonomic nerves and nociceptive, substance P–immunoreactive nerve fibers have been identified in the lumbar facet joint capsule and synovial folds. Douglas and colleagues identified substance P–immunoreactive nerve fibers in erosion channels that extended through the subchondral bone and calcified cartilage into the articular cartilage. Giles and Harvey identified them in the inferior recess capsule and synovial folds, whereas Ashton and coauthors found them running freely in the facet capsule stroma. [19, 20] Grönblad and colleagues demonstrated sparsely distributed substance P–immunoreactive nerve fibers in facet joint plical tissue. [21]
The presence of nociceptive nerve fibers in the various tissue structures of facet joints, as well as the existence of autonomic nerves there, suggests that these structures may cause pain under increased or abnormal loads. Substance P is a well-known inflammatory mediator that may sensitize nociceptors to them and other mediators, resulting in chronic pain.
Like other joints, the facet joints consist of bone, cartilage, synovial tissue, and menisci that are rudimentary invaginations of the joint capsule. In the synovial fluid of patients with rheumatoid arthritis, osteoarthritis, or traumatic joint disease, increased levels of prostaglandins have been measured and are implicated as an important cause of pain. Prostaglandin, a known inflammatory mediator, also is released from facet joints.
A study by Netzer et al indicated that in patients with facet joint osteoarthritis associated with lumbar spinal stenosis, the subchondral bone in the osteoarthritic facet joints is characterized by the infiltration of macrophage-rich tissues into the marrow and by enhanced de novo bone formation. [22]
Biomechanically, facet joints assume a prominent role in resisting stress, and their importance is well established. A cadaveric study by Adams and Hutton demonstrated that the facet joints resist most of the intervertebral shear force and share in resisting the intervertebral compressive force, albeit only in lordotic postures. [23] In the rotation of the spine, the facet capsular ligaments are the spinal ligaments that undergo by far the most strain. They protect the intervertebral disks by preventing excessive movement. [24]
United States
The prevalence of facet joint pain in the general population or in persons with acute back pain has not been investigated. The reported rate of facet joint pain for patients with chronic low back pain (LBP) ranges from 4-75%. The reported prevalence seems to be a function of the size of the sample studied and the conviction of the authors.
Three studies report the prevalence of lumbar facet joint pain among chronic LBP patients based on 100% relief of pain using less than 2 mL of intra-articular diagnostic injection. In 1988, Jackson and colleagues reported that 7.7% of 454 patients with chronic LBP had 100% relief with diagnostic injection. [25] In 1991, Carette and coauthors reported that 11 (5.8%) of 190 patients experienced complete relief of symptoms with a single lidocaine injection. [26] In 1994, Schwarzer and colleagues reported that 7 (4%) of 176 patients reported 100% relief. [27, 28] This last study was the most stringent of the 3 because the authors performed a second confirmatory block with bupivacaine, documenting longer relief of pain commensurate with the longer half-life of the local anesthetic.
When less stringent criteria are used, higher prevalences of lumbar facet joint pain are reported. In 1988, Moran and colleagues reported relief in 9 (16.7%) of 45 patients using 1.5 mL of bupivacaine. [29] Pain provocation followed by pain relief with local anesthetic was used as the diagnostic criterion. In 1992, Schwarzer and co-investigators reported relief in 9 (9.8%) of 92 patients, using a 50% reduction of pain as the criterion and employing double-block screening with lidocaine and confirmatory bupivacaine block. [30] In a separate investigation, Schwarzer and colleagues reported a prevalence of 26 (15%) of 176 patients, using the same diagnostic criterion. [27, 28]
In another study, Schwarzer and coauthors reported that 23 (40.3%) of 57 patients obtained pain relief of 50% or more pain with bupivacaine but experienced no relief with saline control injection. [31] A 2004 study by Manchikanti and colleagues reported a 27% prevalence rate of lumbar facet pain, using controlled, comparative local anesthetic blocks of the dorsal medial nerves. [32]
Higher prevalence rates are reported when control blocks are not used. In 1984, Raymond and Dumas—using a strict intracapsular technique but no control block—reported a 16% prevalence rate. [33] In 1992, Revel and coauthors reported that 22 (55%) of 40 subjects had pain relief of 75% or more and that 17 (42.5%) of 40 patients had greater than 90% relief of their pain with a single intra-articular lidocaine injection. [34]
As seen from these data, reports of prevalence are a function of the investigators’ choice of selection criteria. Studies requiring the most stringent criteria (100% relief of symptoms after a diagnostic block) report a 4-7.7% prevalence rate of facet joint pain among chronic LBP patients. Investigations using double blocks and requiring 50% relief report prevalence rates of about 10-15%. Numerous other studies using a single diagnostic block report prevalence rates of 16-75%.
International
In a sample of 472 South Korean adults, aged 20-84 years, Ko et al found the prevalence of lumbar facet osteoarthritis, as derived through multidetector computed tomography (MDCT) scanning, to be 17.58%. The prevalence increased with age. [35]
See also Frequency/United States.
No studies specifically address the mortality and morbidity of chronic back pain from facet joint – mediated pain. The mortality and morbidity of chronic low back pain, however, have been extensively addressed.
No studies have specifically addressed the correlation between the prevalence of facet-mediated chronic low back pain and race.
No studies have specifically addressed the male-to-female prevalence ratio of chronic, facet-mediated low back pain.
A higher prevalence among the older population would be expected if the etiology of facet joint–mediated back pain arose from degenerative changes of the joint, similar to the way it does in other osteoarthritic joint damage. One small study by Revel and colleagues and a larger investigation by Jackson and coauthors noted that older patients responded more commonly to diagnostic injections. [25, 34] The 1995 study by Schwarzer and colleagues involving 57 patients reported higher positive response rates in older patients (40%), even with the use of saline control injections. [31] They noted that the average age of patients was 59 years, which was higher than the average age in studies reporting much lower prevalence rates.
A 2008 report by Manchikanti et al looked at the rate of facet joint–related chronic low back pain in 424 patients, separated into 6 age groups. [36] According to their retrospective analysis, the prevalence ranged from 18% (in individuals aged 31-40 years) to 44% (in persons aged 51-60 years).
Manchikanti L, Kaye AD, Boswell MV, et al. A Systematic Review and Best Evidence Synthesis of the Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. Pain Physician. 2015 Jul-Aug. 18 (4):E535-82. [Medline]. [Full Text].
Badgley CE. The articular facet in relation to low back pain and sciatic radiation. J Bone Joint Surg. 1941. 23:481.
Ghormley RK. Low-back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933. 101:1773-7.
Rees WS. Multiple bilateral subcutaneous rhizolysis of segmental nerves in the treatment of intervertebral disc syndrome. Ann Gen Prac. 1972. 26:126.
Shealy CN. Facets in back and sciatic pain. A new approach to a major pain syndrome. Minn Med. 1974 Mar. 57(3):199-203. [Medline].
Hirsch C, Ingelmark BE, Miller M. The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand. 1963. 33:1-17. [Medline].
Mooney V, Robertson J. The facet syndrome. Clin Orthop Relat Res. 1976 Mar-Apr. (115):149-56. [Medline].
McCall IW, Park WM, O”Brien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine. 1979 Sep-Oct. 4(5):441-6. [Medline].
Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain. 1989 Oct. 39(1):37-40. [Medline].
Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am. 1991 Apr. 22(2):181-7. [Medline].
Bokov A, Isrelov A, Skorodumov A, Aleynik A, Simonov A, Mlyavykh S. An analysis of reasons for failed back surgery syndrome and partial results after different types of surgical lumbar nerve root decompression. Pain Physician. 2011 Nov-Dec. 14(6):545-57. [Medline].
Cohen SP, Hurley RW. The ability of diagnostic spinal injections to predict surgical outcomes. Anesth Analg. 2007 Dec. 105(6):1756-75, table of contents. [Medline].
Carrino JA, Lurie JD, Tosteson AN, et al. Lumbar spine: reliability of MR imaging findings. Radiology. 2009 Jan. 250(1):161-70. [Medline].
Kroll HR, Kim D, Danic MJ, et al. A randomized, double-blind, prospective study comparing the efficacy of continuous versus pulsed radiofrequency in the treatment of lumbar facet syndrome. J Clin Anesth. 2008 Nov. 20(7):534-7. [Medline].
Cohen SP, Moon JY, Brummett CM, White RL, Larkin TM. Medial Branch Blocks or Intra-Articular Injections as a Prognostic Tool Before Lumbar Facet Radiofrequency Denervation: A Multicenter, Case-Control Study. Reg Anesth Pain Med. 2015 Jul-Aug. 40 (4):376-83. [Medline].
Manchikanti L, Falco FJ, Singh V, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part I: introduction and general considerations. Pain Physician. 2013 Apr. 16(2 Suppl):S1-48. [Medline].
Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr. 16(2 Suppl):S49-283. [Medline].
Waxenbaum JA, Futterman B. Anatomy, Back, Vertebrae, Lumbar. 2018 Jan. [Medline]. [Full Text].
Ashton IK, Ashton BA, Gibson SJ, et al. Morphological basis for back pain: the demonstration of nerve fibers and neuropeptides in the lumbar facet joint capsule but not in ligamentum flavum. J Orthop Res. 1992 Jan. 10(1):72-8. [Medline].
Giles LG, Harvey AR. Immunohistochemical demonstration of nociceptors in the capsule and synovial folds of human zygapophyseal joints. Br J Rheumatol. 1987 Oct. 26(5):362-4. [Medline].
Grönblad M, Korkala O, Konttinen YT, et al. Silver impregnation and immunohistochemical study of nerves in lumbar facet joint plical tissue. Spine. 1991 Jan. 16(1):34-8. [Medline].
Netzer C, Urech K, Hugle T, Benz RM, Geurts J, Scharen S. Characterization of subchondral bone histopathology of facet joint osteoarthritis in lumbar spinal stenosis. J Orthop Res. 2016 Aug. 34 (8):1475-80. [Medline].
Adams MA, Hutton WC. The effect of posture on the role of the apophysial joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980 Aug. 62(3):358-62. [Medline]. [Full Text].
Schmidt H, Heuer F, Wilke HJ. Interaction between finite helical axes and facet joint forces under combined loading. Spine. 2008 Dec 1. 33(25):2741-8. [Medline].
Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine. 1988 Sep. 13(9):966-71. [Medline].
Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med. 1991 Oct 3. 325(14):1002-7. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994 Aug. 58(2):195-200. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?. Spine. 1994 May 15. 19(10):1132-7. [Medline].
Moran R, O”Connell D, Walsh MG. The diagnostic value of facet joint injections. Spine. 1988 Dec. 13(12):1407-10. [Medline].
Schwarzer AC, Wang S, Laurent R, et al. The role of the zygapophysial joint in chronic low back pain [abstract]. Aust NZ J Med. 1992. 22:185.
Schwarzer AC, Wang SC, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis. 1995 Feb. 54(2):100-6. [Medline]. [Full Text].
Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004 May 28. 5:15. [Medline]. [Full Text].
Raymond J, Dumas JM. Intraarticular facet block: diagnostic test or therapeutic procedure?. Radiology. 1984 May. 151(2):333-6. [Medline]. [Full Text].
Revel ME, Listrat VM, Chevalier XJ, et al. Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil. 1992 Sep. 73(9):824-8. [Medline].
Ko S, Vaccaro AR, Lee S, Lee J, Chang H. The prevalence of lumbar spine facet joint osteoarthritis and its association with low back pain in selected Korean populations. Clin Orthop Surg. 2014 Dec. 6 (4):385-91. [Medline]. [Full Text].
Manchikanti L, Manchikanti KN, Cash KA, et al. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain Physician. 2008 Jan. 11(1):67-75. [Medline]. [Full Text].
Varlotta GP, Lefkowitz TR, Schweitzer M, Errico TJ, Spivak J, Bendo JA, et al. The lumbar facet joint: a review of current knowledge: Part II: diagnosis and management. Skeletal Radiol. 2011 Feb. 40(2):149-57. [Medline].
Odonkor CA, Chen Y, Adekoya P, et al. Inciting Events Associated With Lumbar Facet Joint Pain. Anesth Analg. 2018 Jan. 126 (1):280-8. [Medline].
Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine. 2008 Nov 1. 33(23):2560-5. [Medline].
Linov L, Klindukhov A, Li L, et al. Lumbar facet joint orientation and osteoarthritis: a cross-sectional study. J Back Musculoskelet Rehabil. 2013. 26(4):421-6. [Medline].
Yoshiiwa T, Miyazaki M, Notani N, Ishihara T, Kawano M, Tsumura H. Analysis of the Relationship between Ligamentum Flavum Thickening and Lumbar Segmental Instability, Disc Degeneration, and Facet Joint Osteoarthritis in Lumbar Spinal Stenosis. Asian Spine J. 2016 Dec. 10 (6):1132-1140. [Medline]. [Full Text].
Dory MA. Arthrography of the lumbar facet joints. Radiology. 1981 Jul. 140(1):23-7. [Medline]. [Full Text].
Lippitt AB. The facet joint and its role in spine pain. Management with facet joint injections. Spine. 1984 Oct. 9(7):746-50. [Medline].
Yamada K, Suzuki A, Takahashi S, et al. MRI evaluation of lumbar endplate and facet erosion in rheumatoid arthritis. J Spinal Disord Tech. 2014 Jun. 27(4):E128-35. [Medline].
Hawellek T, Hubert J, Hischke S, Rolvien T, Krause M, Püschel K, et al. Microcalcification of lumbar spine intervertebral discs and facet joints is associated with cartilage degeneration, but differs in prevalence and its relation to age. J Orthop Res. 2017 Dec. 35 (12):2692-9. [Medline].
Maus T. Imaging the back pain patient. Phys Med Rehabil Clin N Am. 2010 Nov. 21(4):725-66. [Medline].
Schwarzer AC, Wang SC, O’Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. 1995 Apr 15. 20(8):907-12. [Medline].
Lord SM, Barnsley L, Wallis BJ, et al. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996 Aug 1. 21(15):1737-44; discussion 1744-5. [Medline].
Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993 Nov-Dec. 18(6):343-50. [Medline].
Dreyfuss P, Schwarzer AC, Lau P, et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. A computed tomography study. Spine. 1997 Apr 15. 22(8):895-902. [Medline].
Han SH, Park KD, Cho KR, Park Y. Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain: A retrospective comparative study. Medicine (Baltimore). 2017 Apr. 96 (16):e6655. [Medline]. [Full Text].
Nedelka T, Nedelka J, Schlenker J, et al. Mechano-transduction effect of shockwaves in the treatment of lumbar facet joint pain: comparative effectiveness evaluation of shockwave therapy, steroid injections and radiofrequency medial branch neurotomy. Neuro Endocrinol Lett. 2014. 35(5):393-7. [Medline].
Lynch MC, Taylor JF. Facet joint injection for low back pain. A clinical study. J Bone Joint Surg Br. 1986 Jan. 68(1):138-41. [Medline]. [Full Text].
Huang AJ. Fluoroscopically guided lumbar facet joint injection using an interlaminar approach and loss of resistance technique. Skeletal Radiol. 2016 May. 45 (5):671-6. [Medline].
Gallagher J, Petriccioone di Vadi PL, Wedley JR. Radiofrequency facet joint denervation in the treatment of low back pain: a prospective controlled double-blind study to assess its efficacy. Pain Clin. 1994. 7(3):193-8.
van Kleef M, Barendse GA, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine. 1999 Sep 15. 24(18):1937-42. [Medline].
Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000 May 15. 25(10):1270-7. [Medline].
Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine. 2001 Jul 1. 26(13):1411-6; discussion 1417. [Medline].
van Wijk RM, Geurts JW, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain. 2005 Jul-Aug. 21(4):335-44. [Medline].
Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine. 2004 Nov 1. 29(21):2471-3. [Medline].
Kornick C, Kramarich SS, Lamer TJ, et al. Complications of lumbar facet radiofrequency denervation. Spine. 2004 Jun 15. 29(12):1352-4. [Medline].
Do KH, Ahn SH, Cho YW, Chang MC. Comparison of intra-articular lumbar facet joint pulsed radiofrequency and intra-articular lumbar facet joint corticosteroid injection for management of lumbar facet joint pain: A randomized controlled trial. Medicine (Baltimore). 2017 Mar. 96 (13):e6524. [Medline]. [Full Text].
Carl H Shin, MD Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Pennsylvania
Carl H Shin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society
Disclosure: Nothing to disclose.
Curtis W Slipman, MD Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center
Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, North American Spine Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital
Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.
Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans
Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.
J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR Senior Associate Dean, Interim Dean of Clinical Medicine, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Osteopathic Examiners, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Gold Humanism Honor Society, International Society for Communication Science and Medicine, Michigan Osteopathic Association, Oklahoma Osteopathic Association, Tennessee Osteopathic Medical Association
Disclosure: Nothing to disclose.
The editors wish to gratefully acknowledge Mark I Ellen, MD, Assistant Professor, Department of Orthopedics and Rehabilitation Medicine, The Emory Sports Medicine Center, for his previous participation in this article.
Lumbar Facet Arthropathy
Research & References of Lumbar Facet Arthropathy|A&C Accounting And Tax Services
Source
0 Comments