Synvisc Injections for Lumbar Facet Joint Pain

Patients will enter the study once the putatively painful joint or joints have been
confirmed by single blind, double local-comparative anesthetic blockade. The joint(s)
suspected by historical features and physical examination will be injected under
fluoroscopic guidance with contrast-enhancement confirming intra-articular placement. The
initial injectate will be 1cc of 2% xylocaine. Single diagnostic lumbar facet joint
injections carry a false positive rate of 38%. In order to maximize the specificity of the
diagnostic injections a second 1cc injection of a longer-acting local anesthetic, 0.5%
marcaine, will be performed on all patients reporting clinically significant pain reduction
(> 75% VAS reduction from pre-injection baseline) within 10-15 minutes after the xylocaine
injection. This second diagnostic injection will be completed upon return of the patient’s
pain back to baseline (no sooner than 3 days after the initial diagnostic injection). A true
positive response will be defined as > 50% VAS reduction after the second injection.
Patients will then undergo 2 IA Synvisc injections into the painful facet joint(s). An
initial IA injection of 1.0cc (or a volume, not to exceed 1.0cc, accepted by the joint upon
reaching a capsular endpoint) of Synvisc (1cc, 10mg/ml) will be injected into the painful
joint(s) 7 days after the second diagnostic injection after the baseline pain has returned.
A 2nd injection will then be performed 10 days after the initial injection. A 3rd injection
may be offered to patients not satisfied with the results obtained with the first 2 Synvisc
injections. A 2.0cc vial of Synvisc per patient will be shipped including other trial
materials to the investigator for implementation. A fluid dispenser connector will allow
direct dispensation of 1.0cc of Synvisc from the pre-packaged 2.0cc unmarked vial. Outcome
measurement tools will include Visual Analogue Scale, Oswestry Disability Questionnaire,
SF-36, lumbar spine range of motion (ROM), sitting and walking tolerance, analgesic usage,
and patient satisfaction. Data will be collected at baseline, at 7-10 days after the second
Synvisc injection, and at 1, 3, 6, and 12 month follow up (after the final Synvisc
injection) visits. For example, patient X will undergo an initial 2 Synvisc injections and
then be evaluated in the office 7 days later. If the patient experiences significant
benefit, no other injections will be pursued. However, if a therapeutic benefit is achieved
but is not satisfactory to the patient, a 3rd Synvisc injection will be performed within 3
days. A side effect and complications questionnaire will be completed by each patient within
30 minutes, 24 hours, and 72 hours after each injection (including diagnostic injections).

Inclusion Criteria:

1. Ongoing axial lumbar pain, greater than any lower limb pain if present, for > 3
months duration.

2. No improvement despite 6-8 weeks of physical therapy (PT), oral nonsteroidal
anti-inflammatory drugs (NSAIDs), relative rest, and activity modification.

3. Radiographic evidence of facet joint arthrosis on advanced imaging studies defined as
joint capsule hypertrophy, osteophyte formation, joint space narrowing, irregularity
of joint contours, subchondral sclerosis, and synovial cyst formation.

4. Age 30 years or older.

5. Positive double, local comparative anesthetic diagnostic block injections at one
unilateral or bilateral joint(s).

Exclusion Criteria:

1. Pregnancy.

2. Active or remote history of spinal malignancy.

3. Active infection.

4. Blood dyscrasias/coagulopathy.

5. Unwillingness to follow through with follow up evaluations.

6. Negative response to all diagnostic facet joint injections.

7. Application for/currently receiving worker’s compensation.

8. Allergy to avian products.

9. Allergy to prior viscosupplementation products.

10. Prior viscosupplementation of lumbar facet joints.

11. Improper intra-articular needle placement at time of Synvisc injection.

12. Painful bilateral or multi-level facet joint arthropathy.