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Ozonucleolysis
Ozonucleolysis for slipped/prolapsed Disc

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist
09871985514

Ozone may be a wonder molecule to the clinicians though its potentials yet to be fully explored. It has role in controlling bacterial, fungal & viral infections including AIDS, treating non-healing ulcers, Rheumatoid and other kinds of arthritis, different kind of skin diseases and many others.

What is ozone?

Ozone is a tri-atomic Oxygen molecule, O3, with a different molecular structure than Oxygen. Its name is derived from the Greek word ozein meaning “to smell”. At room temperature, Ozone is a colorless gas with a characteristic odor (similar smell after thunderstorms, at high altitudes or near the sea etc). At ground level its concentration 0.03 - 0.04 ppm. Ozone in the atmosphere is produced by action of UV rays and thunderstorm on the atmospheric Oxygen; but Medical Ozone is produced from pure medical grade oxygen with the help of high voltage electrical discharge. Medical ozone is a mixture of oxygen and ozone of different concentration. Medical ozone is always freshly prepared on site (in a special generator) for immediate administration. A trained physician according to the medical indication and the patient’s condition determines the exact dose of ozone.

Safety and efficacy of Ozone therapy

Treating patients with ozone is not a new procedure. The first ozone generators were developed by Werner von Siemens in Germany in 1857, and 1870 saw the first report on ozone being used therapeutically to purify blood, by C. Lender in Germany.
During World War 1, ozone was used to treat wounds, trench foot, gangrene and the effects of poison gas. Dr. Albert Wolff of Berlin also used ozone for colon cancer, cervical cancer and decubitus ulcers in 1915. Today, after 125 years of usage, ozone therapy is a recognized modality in many nations: Germany, France, Italy, Russia, Romania, Czech Republic, Poland, Hungary, Bulgaria, Israel, Cuba, Japan, Mexico, and in five US states. It was also used extensively to treat war wounds during World War-II.
It was not popularized before, as ozone resistant materials were not used to produce ozone generators. Also the exact concentration of ozone was unknown. Former Ozone generators are either UV light Ozone generators or plasma type Ozone generators. Here, it was very difficult to know the precise concentration of ozone. Now with the present Corona-discharge Ozone generators, it is possible to know the exact concentration of Ozone. Also, by changing the current or the oxygen flow, Ozone concentration can be precisely modified.
Ozone has been found to be an extremely safe medical therapy, free from side effects. In a 1980 study done by the German Medical Society for Ozone Therapy, 644 therapists were polled regarding their 384,775 patients, comprising a total of 5,579,238 ozone treatments administered. There were only 40 cases of side effects noted out of this number that represents the incredibly low rate of .000007%. Ozone Therapy has been described as the safest known medical therapy.

Indications of Ozone therapy

Among the various diseases presented with pain the following has been treated with very good results; e.g. rheumatoid arthritis, systemic lupus erythemoatosis, scleroderma, polymyositis/fibromyositis, ankylosing spondylitis, osteo-arthritis, Reiter syndrome, psoriasis, synovitis, gout, chrondrocalcinosis, pyrophosphate arthropathy, calcific peri-arthritis, calcific tendinitis, calcinosis and inter-vertebral disc prolapse. In my Pain Clinic I have been treating osteo-arthritis of knee, trigger point injections for fibromyalgia/ Myofascial pain, and inter-vertebral disc prolapse or slipped disc successfully.

How Ozone should be administered?

There are different methods like injections of ozone/oxygen mixture; insufflations through rectum; treating with ozonated water (drinking, dressing wound/ulcers etc.); auto-transfusion of ozonated blood, application of ozonated oil and so on depending on type and site of disease. But for treatment of different pain we use injection of different concentrations of ozone gas only. Ozone molecule is not stable. It has a half-life of 20 minutes only. So, within 20 minutes only half of the original ozone remains, the rest becomes oxygen. Increase in temperature decreases its half-life. For injection it is always freshly prepared on site for immediate administration. Only Ozone resistant syringes can be used for injecting it. The contraindications for treatment with ozone are only a few. They are active bleeding from any site, pregnancy, and active hyperthyroidism.

Mechanism of action

The mechanisms of action of ozone are many. Most of its actions are due to the active oxygen atom liberated from breaking down of ozone molecule. Besides its action as bactericidal, fungicidal, viricidal agent, it activates cellular metabolism, modulates the immune system & increases and activates body's own antioxidants and radical scavengers. In the treatment of pain different other mechanism acts. There is enhancement of circulation. Ozone reduces or eliminates clumping and red cell. Its flexibility is restored, along with oxygen carrying ability (due to the stimulation of 2,3-diphosphoglycerate). Oxygenation of the tissues increases as the arterial partial pressure increases and viscosity decreases. Ozone also oxidizes the plaque in arteries, allowing the removal of the breakdown products, unclogging the blood vessels. All these leads to an increase in the amount of oxygen released to the diseased tissues. There is also reduced formation of inflammatory mediators like different prostaglandins and so there is an anti-inflammatory action.

Ozone in PIVD/Slipped disc

In case of prolapsed inter-vertebral disc (or, slipped disc) different other mechanism acts. Inter-vertebral disc is filled with nucleus pulposus which is a jelly like material which holds water (90% of disc material is water). When ozone is injected into the disc the proteo-glycan bridges in the jelly-like material are broken down and they no longer capable of holding water. As a result disc shrinks and mummified which is equivalent to surgical discectomy and so the procedure is called ozone discectomy or ozonucleolysis. It has been published in ANESTHESIA AND PAIN journals that up to 85% of disc operation can be avoided with these non-surgical interventions. Success rate is about 88% which is comparable to surgical discectomy (50% to 90%). Complications are remarkably low and much less than surgery.

Future

Ozone is gradually gaining popularity in various medical fields especially in pain management. Newer modification in techniques and administration of ozone, more and more publication of scientific materials in the medical journals and animal studies have made it more acceptable to the medical community and gradually it is becoming more popular.

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osteoporosis and interventions for vertebral fracture
World osteoporosis month
Osteoporosis:
Interventions to manage vertebral fractures

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist

Some important facts about osteoporosis
• Osteoporosis is a systemic skeletal disorder characterized by low bone mass, disruption of the microarchitecture of bone tissue, and compromised bone strength which leads to an increased risk for fracture.
• Bone strength is a product of both bone density and bone quality. Bone density is expressed as grams of mineral per area or volume; bone quality refers to factors such as architecture, turnover, damage accumulation (e.g., microfractures), and mineralization
• Osteoporosis is common among menopausal women but is often clinically silent until a fragility fracture occurs. Osteoporosis is also being recognized with increasing frequency in older men.
• After peak bone mass is reached, the bone remodeling process is in a state of equilibrium until menopause. Cessation of estrogen production leads to rapid bone loss of approximately 2% to 3% per year in the spine for up to 6 to 8 years, which accounts for 50% of the total spinal bone loss among normal women .This is then followed by a slower rate of bone loss (0.5%/year), which is attributed to aging.
• Even among men, it is now known that estrogen deficiency plays a big role in bone loss, perhaps an even bigger role than played by testosterone . Studies among osteoporotic males have shown a closer correlation between estradiol levels and bone mineral density (BMD) than testosterone and BMD. A finding that men with osteoporosis may have low estradiol yet normal testosterone levels further supported this correlation.
• Clinically, osteoporosis is diagnosed when bone mineral density (BMD) is reduced or when fragility fractures (ie, fractures after little or no trauma) occur. Dual-energy x-ray absorptiometry (DXA) is by far the best standardized technique and is preferred for diagnosing osteoporosis and monitoring responses to therapy. BMD assessment by DXA has been used by the World Health Organization to define osteopenia and osteoporosis
Normal BMD T-score –1

Low bone mass (osteopenia) BMD T-score < –1 and > –2.5
Osteoporosis BMD T-score –2.5

Severe osteoporosis BMD T-score –2.5 with one or more fragility fractures


• The most common misuse of the WHO criteria is applying it to nonwhite postmenopausal populations. The fracture risk/T-score relationship used for these criteria was derived solely from a database of white, postmenopausal women. Thus, the criteria cannot be taken to mean or suggest the same fracture risk when the individual being measured is male, premenopausal, or nonwhite.
• The T-scores obtained from peripheral sites do not have the same fracture implication as those obtained with central machines.
• Degenerative changes in the spine are exceedingly common among the elderly. These are seen as sclerotic changes in the facets and discs as well as osteophyte formation. They elevate BMD and may lead to falsely normal BMD and T-scores in the spine.
• Vertebrae with compression fractures are denser than normal vertebrae and would have higher T-scores. It would be a big mistake to withhold therapy for a patient who appears to have normal T-scores due to compression fractures.
The most common osteoporosis-related fractures involve the thoracic and lumbar spine, the hip, and the distal radius.

Biochemical evaluation
Successful management of osteoporosis requires a careful choice of biochemical tests to determine the presence of secondary causes of osteoporosis. At a minimum, laboratory evaluation should include a complete blood cell count, serum chemistry panel, liver function tests, and serum thyroid-stimulating hormone and calcium determinations.

Complete Blood Count

Complete blood count (CBC) tests can detect anemia, which can be seen in many secondary causes of osteoporosis; these include celiac sprue and other malabsorptive states, chronic liver disease, chronic kidney failure, metastatic bone disease, and multiple myeloma.
KFT
Renal insufficiency often leads to a deficiency in 1–25 OH vitamin D deficiency and secondary hyperparathyroidism, which must be addressed prior to initiation of osteoporosis therapy. Bisphosphonates are contraindicated when GFR falls below 30 mg/24 hours
Liver Function Tests

An alanine aminotransferase (ALT) test is the most cost-effective way to screen for liver disease among osteoporotic patients. Elevated ALT levels suggest liver dysfunction, which, regardless of the cause, increases the risk of vitamin D deficiency.

Serum calcium

Postmenopausal women as a group are commonly affected by primary hyperparathyroidism .A serum calcium determination adequately screens for this disorder


Treatment of osteoporosis

The essentials of management for most forms of osteoporosis include the following:
• Lifestyle modifications.
• Nutritional interventions.
• Pharmacologic therapies.
• Interventional procedures for vertebral fractures
Lifestyle Modifications
Safety of the patient's immediate environment to prevent falls and fractures, eliminating habits that are deleterious to skeletal integrity and that can contribute to falls

Discontinue smoking and alcohol consumption.

Weight-bearing exercise program

In patients with inflammatory diseases who are receiving long-term glucocorticoid therapy and are at risk for osteoporosis, an exercise and physical therapy program is imperative

Nutritional Interventions

Nutritional interventions for osteoporosis should assure that the diet plus supplements provide at least 1200 mg of elemental calcium per day and up to 1500 mg in high-risk patients over the age of 70 with established disease or with steroid-induced osteoporosis.

Pharmacologic Therapy
Drugs for osteoporosis can be divided into two major classes: antiresorptive and anabolic agents. Antiresorptive agents inhibit bone resorption, mainly through their action on osteoclasts, whereas anabolic agents stimulate osteoblastic differentiation and activity.



Antiresorptive Therapy

Bisphosphonates

These pyrophosphate analogues bind to hydroxyapatite crystals in the bone, are taken up by osteoclasts in the bone, and exert their action by inhibiting the mevalonate pathway, subsequently leading to inhibition of osteoclast function and increase in rates of apoptosis. Oral bioavailability is generally low, only 1% to 3%, and is greatly inhibited by food, calcium, iron supplements, and drinks. Patients must be advised to take this medication in the morning, to withhold food and drinks to ensure good absorption, and to remain upright for at least 30 minutes.
• • Bisphosphonates
Alendronate 5 mg/d or 35 mg/wk for prevention of osteoporosis; 10 mg/d or 70 mg/wk for treatment of postmenopausal, male, and glucocorticoid-induced osteoporosis

Risedronate 5 mg/d or 35 mg/wk for prevention and treatment of postmenopausal and glucocorticoid-induced osteoporosis
Ibandronate:2.5 mg /d or 150 mg/month .or 3mg iv 03 monthly

Raloxifene
Raloxifene is a selective estrogen receptor modulator, with agonistic effects on bone. The major efficacy trial for raloxifene was the Multiple Outcomes of Raloxifene Evaluation (MORE) Trial. The LS BMD increase over the 3-year study period was 2% to 3%, and vertebral fracture reduction rates in women with and without preexisting fractures were 50% and 30%, respectively.
Calcitonin
Because of its modest effect on BMD, and small fracture risk reduction, calcitonin is rarely used as first-line therapy; rather, owing to its mild analgesic effects, this drug is more commonly used now as an adjunctive therapy after an acute vertebral fracture, usually combined with a stronger antiresorptive.


Hormone Replacement Therapy
Hormone replacement therapy (HRT) was the original antiresorptive therapy used for osteoporosis. However, current controversies centered on increased breast cancer, and cardiovascular risks have resulted in a marked decline in use for osteoporosis indications.

Anabolic Therapy
Teriparatide
Synthetic human parathyroid hormone [PTH (1–34)], or teriparatide, is an anabolic agent that has been approved for postmenopausal and male osteoporosis treatment


Combination Therapy
Trials that have studied combination therapy for osteoporosis had BMD and not fracture risk reduction as the primary endpoint. Thus, although the effects appear to be additive, it is unknown whether there is indeed a greater reduction in fracture risk when two agents are combined.

Interventional procedures for vertebral fractures


Kyphophasty and Vertebroplasty


These two surgical modalities have been reported to successfully relieve pain from acute compression fractures and decrease kyphosis slightly .The procedures entail injection of polymethylmethacralate or bone cement directly into the fractured vertebra in vertebroplasty, and into a balloon within the vertebra, in kyphoplasty.


Vertebroplasty is a percutaneous procedure with a low complication rate that provides immediate and long-¬term pain relief to patients suffering from chronic ver¬tebral compression fracture pain. Vertebro¬plasty is a minimally invasive procedure that not only provides immediate relief but continued and prolonged relief that may increase the patient's daily activity level, which in turn helps provide a better quality of life. In several studies it has been shown that in more than 90% cases it provide immediate pain relief.
Some of the potential complications include leakage of the cement into the spine, surrounding structures, and vessels.

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Facet joint arthropathy-interventional pain management
THE FACET SYNDROME

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist
Introduction


The facet joints are a pair of joints in the posterior aspect of the spine. Although these joints are most commonly called the facet joints, they are more properly termed the zygapophyseal joints (abbreviated as Z-joints), a term derived from the Greek roots zygos, meaning yoke or bridge, and physis, meaning outgrowth. The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint or the posterior intervertebral joint.
As is true of any synovial joint, the facet-joint is a potential source of pain. In fact, the facet-joint is one of the most common sources of low back pain (LBP). The first discussion of the facet-joint as a source of LBP was by Goldwaith in 1911. (1) In 1927, Putti (2) illustrated osteoarthritic changes of facet-joints in 75 cadavers of persons older than 40 years. In 1933, Ghormley(3) coined the term facet syndrome, suggesting that hypertrophic changes secondary to osteoarthritis of the zygapophyseal processes led to lumbar nerve root entrapment, which caused LBP. In the 1950s, Harris and Mcnaz (4) and McRae (5) determined that the etiology of facet-joint degeneration was secondary to intervertebral disc degeneration. Hirsch et al were later able to reproduce LBP with injections of hypertonic saline solution into the facet-joints, thus affirming the role of the facet-joints as a source of LBP (6)
Functional Anatomy
The spine is composed of a series of functional units. Each unit consists of an anterior segment, which is made up of 2 adjacent vertebral bodies and the intervertebral disc between them, and the posterior segment, which consists of the laminae and their processes. One joint is formed between the 2 vertebral bodies, whereas the other 2 joints, known as the facet-joints, are formed by the articulation of the superior articular processes of one vertebra with the inferior articular processes of the vertebra above. Thus, the facet-joints are part of an interdependent functional spinal unit consisting of the disc-vertebral body joint and the 2 facet-joints, with the facet-joints paired along the entire posterolateral vertebral column.(7)
Facet joints are well innervated by the medial branches of the dorsal rami. In the thoracic and lumbar spine, the facet joints are in¬nervated by medial branches of the dorsal rami of the spinal nerves except at L5 lev¬el (8). After the medial branch splits off from the dorsal ramus, it courses caudally around the base of the superior articular process of the level below toward that level's Z-joint (e.g., the L2 medial branch wraps around the L3 superior articular process to approach the L2-L3 facet-joint). The medial branch then continues in a groove between the superior articular process and transverse process (or, in the case of the L5 medial branch, between the superior articular process of S1 and the sacral ala of S1, which is the homologous structure to the transverse processes of the lumbar vertebrae). As it makes this course, the medial branch is held in place by a ligament joining the superior articular process and the transverse process, termed the mamillo-accessory ligament (MAL).
The MAL is so named because it adjoins the mamillary process of the superior articular process to the accessory process of the transverse process. The MAL is clinically important because it allows precise location of the medial branch of the dorsal ramus using only bony landmarks, which is essential for fluoroscopically guided procedures.
After passing underneath the MAL, the medial branch of the dorsal ramus gives off 2 branches to the nearby facet-joints. One branch innervates the facet-joint of that level, and the second branch descends caudally to the level below. Therefore, each medial branch of the dorsal ramus innervates 2 joints—that level and the level below (e.g., the L3 medial branch innervates the L3-L4 and L4-L5 facet-joints). Similarly, each facet-joint is innervated by the 2 most cephalad medial branches (e.g., the L3-L4 facet-joint is innervated by the L2 and L3 medial branches). Medial branch also innervates the multifidus, interspinales, and intertransversarii mediales muscles, the interspinous ligament, and, possibly, the ligamentum flavum. (9)
This has several important clinical implications. First, pain relief from anesthetizing the medial branch does not necessarily implicate the facet-joints as the primary pain generator, because one of the other structures innervated by the medial branch may have been the pain generator. Second, denervation of the medial branch by RFA may affect the nerve supply to the multifidus muscle. This is important because lumbosacral radiculopathy is often another consideration in the differential diagnosis of LBP.
The L5 dorsal ramus divides into me¬dial and lateral branches, with the medi¬al branch continuing medially, innervat¬ing the lumbosacral joint.

Pathogenesis
As with any synovial joint, degener¬ation, inflammation and injury of facet joints can lead to pain upon joint motion. Pain leads to restriction of motion, which eventually leads to overall physical decon¬ditioning. Irritation of the facet joint in¬nervation in itself also leads to secondary muscle spasm. It has been assumed that degeneration of the disc would lead to as¬sociated facet joint degeneration and sub¬sequent spinal pain. These assumptions were based on the pathogenesis of degen¬erative cascade in the context of a three joint complex that involves the articula¬tion between two vertebrae consisting of the intervertebral disc and adjacent fac¬et joints, as changes within each mem¬ber of this joint complex will result in changes in others (10, 11). It was also the view of Vernon-Roberts and Pi¬rie (12) that disc degeneration causes os¬teophyte formation and facet joint chang¬es, because facet joints at relatively normal disc levels are either normal or only slight¬ly degenerate.

The Facet joint is a common pain generator in the lower back. The 2 common mechanisms for this generation of pain are either (1) direct, from an arthritic process within the joint itself, or (2) indirect, in which overgrowth of the joint (e.g., facet joint hypertrophy or a synovial cyst) impinges on nearby structures. (13)
The Facet-joints are diarthrodial joints with a synovial lining, the surfaces of which are covered with hyaline cartilage, which is susceptible to arthritic changes and arthropathies. Repetitive stress and osteoarthritic changes to the facet joint can lead to zygapophyseal hypertrophy. Like any synovial joint, degeneration, inflammation, and injury can lead to pain with joint motion, causing restriction of motion secondary to pain and, thus, deconditioning. In addition, facet-joint arthrosis, particularly trophic changes of the superior articular process, can progress to narrowing of the neural foramen. In addition, as is the case for any synovial joint, the synovial membrane can form an outpouching and, thus, a cyst. Facet-joint cysts are most commonly seen at the L4-L5 level (65%), but they are also seen at the L5-S1 (31%) and L3-L4 (4%) levels. These synovial cysts can be clinically significant, particularly if they impinge on nearby structures (e.g., the exiting nerve root).
Facet-joint hypertrophy or a synovial cyst can also contribute to lateral and central lumbar stenosis, which can lead to impingement on the exiting nerve root. Thus, facet-joint pain can occasionally produce a pain referral pattern that is indistinguishable from disc herniation.
Numerous other causes, including rheumatoid arthritis, ankylosing spondy¬litis and capsular tears, etc., also have been described as sources of facet joint pain (14).

Facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain (15), 54% to 67% of patients with neck pain and 48% of patients with thoracic pain in controlled stud¬ies. These figures were based on respons¬es to controlled diagnostic blocks of these joints, in accordance with the criteria es¬tablished by the International Associa¬tion for the Study of Pain


Diagnosis

Clinical
Establishing a diagnosis of lumbosacral facet syndrome is difficult because the findings are nonspecific and correlation between the history and physical examination findings is poor. However, obtaining a detailed history and performing a physical examination help rule out other entities and assist with guiding the examiner in establishing the diagnosis of facet-joint–mediated LBP.
Although no single sign or symptom is diagnostic, Jackson et al demonstrated that the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular facet-joint injection (16):
1. Older age
2. Previous history of LBP
3. Normal gait
4. Maximal pain with extension from a fully flexed position
5. The absence of leg pain
6. The absence of muscle spasm
7. The absence of exacerbation with a Valsalva maneuver
Facet-joint pathology should be considered if the patient describes nonspecific LBP with a deep and achy quality that is usually localized to a unilateral or bilateral Paravertebral area.

The common referral areas for facet-joint–mediated pain are flank pain, buttock pain (often extending into the posterior thigh, but rarely below the knee), pain overlying the iliac crests, and pain radiating into the groin.

The pain is often exacerbated by twisting the back, by stretching, by lateral bending, and in the presence of a torsional load. Some patients describe their pain as worse in the morning, aggravated by rest and hyperextension, and relieved by repeated motion. Often, this lumbosacral facet syndrome may occur after an acute injury (e.g., extension and rotation of the spine), or it
may be chronic in nature.

Unlike other lumbar spine pathologies such as disc herniation, facet-joint–mediated pain likely will not worsen with an increase in intra-abdominal and thoracic pressure. Therefore, worsening of pain with coughing, laughing, or a Valsalva maneuver is suggestive that the facet-joint is not the primary pain generator.

Examination
• Sensory examination: Sensory examination (i.e., light touch and pinprick in a dermatomal distribution) findings are usually normal in persons with facet-joint pathology.
• Muscle stretch reflexes: Patients with facet-joint–mediated LBP usually have normal muscle stretch reflexes. Radicular findings are usually absent unless the patient has nerve root impingement from bony overgrowth or a synovial cyst.
• Straight leg–raise test: This maneuver is usually normal for facet-joint–mediated pain. However, if facet-joint hypertrophy or a synovial cyst encroaches on the intervertebral foramen, causing nerve root impingement, this maneuver may elicit a positive response.

Diagnostic blocks

It has been postulated that for any structure to be deemed a cause of back pain, the structure should have been shown to be a source of pain in patients, using diagnostic techniques of known reliability and validity (25). The diagnostic blockade of a structure with a nerve supply with the ability to generate pain can be performed to test the hypothesis that the target structure is a source of a patient’s pain

The choice between intraarticular blocks and medial branch blocks is to some extent preference and training of the physician. However, various considerations apply in choosing either intraarticular injection or medial branch. Intraarticular injections are more difficult and time consuming than nerve blocks because they require accurate placement of the needle within the joint cavity with care not to over distend the joint. In contrast, medial branch blocks are expeditious and carry no risk of over distention. Furthermore, at times joint entry may be impossible because of the severe age related changes or post traumatic arthropathy; no such processes affect access to the nerves .Significant leakage of intraarticular injected fluid into epidural space and spillage over to the nerve roots has been described. With appropriate care this is minimal with medial branch blocks. Finally, intraarticular blocks are appropriate if intraarticular therapy is proposed but if radiofrequency therapy is proposed, medial branch blocks become the diagnostic procedure of choice. In addition, in the past only intraarticular injections were considered as therapeutic. However, recent evidence has shown that medial branch blocks have better evidence for the therapeutic effectiveness than intraarticular blocks (17).

o Valid information is only obtained by performing controlled blocks, either in the form of placebo injections of normal saline or comparative local anesthetic blocks, in which on two separate occasions, the same joint is anesthetized using local anesthetics with different durations of action. . In a double-block protocol, the patient is given an injection with a short-acting anesthetic (e.g., lidocaine) and records the duration of pain relief in a diary. On a follow-up visit (typically 1-2 wk later), a second injection is performed, using an anesthetic with a different duration of action (e.g., bupivacaine, which has a longer half-life than lidocaine), and the patient again should chart pain relief in a diary. A patient is diagnosed as having a positive block if they receive pain relief (typically >80%) for both injections for a length of time corresponding to the duration of action of the medication. (18, 19,20) Given the dual innervation of each Z-joint, one must anesthetize or block the cephalad and subadjacent medial branches (eg, anesthetize the L3 and L4 medial branches for the L4-L5 Z-joint). Injections are diagnostic if patients report significant relief of symptoms, usually at least a 50% reduction in pain.
Lab Studies
• Laboratory studies are not generally necessary for the diagnosis of lumbosacral facet joint syndrome.
Imaging Studies
• Plain radiography

o Plain radiographs are traditionally ordered as the initial step in the workup of lumbar spine pain. The main purpose of plain films is to determine underlying structural pathologic conditions. These studies are not generally recommended in the first month of symptoms in the absence of red flags. An exception to this would be if the low back symptoms are related to a sports injury and a fracture is suggested.
o Three views are commonly obtained, including an anteroposterior (AP), lateral, and oblique; however, the utility of oblique views has been questioned.
o Plain radiographs may reveal degenerative changes, but these findings have not been found to correlate with facet-joint–mediated pain.
• Bone scanning

o Bone scanning can be helpful when a tumor, infection, or fracture (occult or traumatic) is suggested.
o Bone scanning is not usually indicated in the initial workup, and the results are normal in persons with lumbosacral facet joint syndrome.
o Bone scan findings have not been found to correlate with facet-joint–mediated pain.
• Computed tomography (CT) scanning

o Generally, CT scanning is not necessary unless other bony pathology (eg, fracture) must be excluded.
o A CT scan of the lumbosacral spine provides excellent anatomic imaging of the osseous structures of the spine, especially to rule out fractures or arthritic changes. Single-photon emission CT (SPECT) images may offer better resolution if spondylolysis is suggested.
o With facet-joint pathology, one may find arthritic changes in the facet-joints and degenerative disc disease; however, facet-joint pathology is also frequently seen in asymptomatic patients, and, therefore, abnormal findings on a CT scan are not diagnostic.
o Despite the excellent imaging of the bony anatomy of the facet-joint, CT scans are not useful for the diagnosis of the facet-joint as a pain generator. For example, Schwarzer et al found no correlation between facet-joint pathology on a CT scan and those patients who responded to diagnostic facet-joint blocks. (21) .Therefore, the correlation of an abnormal facet-joint anatomy as observed on CT scans with true facet -joint–mediated pain is poor.
• Magnetic resonance imaging (MRI)
o In general, MRI is not indicated for the evaluation of nonradicular LBP.
o The main utility of MRI is for excluding pathologies other than facet-joint arthropathy, because many degenerative changes in the facet-joint are asymptomatic. Similarly, true facet-joint–mediated pain may be present despite a normal MRI examination.
o MRI provides detailed anatomic images of the soft structures of the spine, such as the intervertebral discs, which often show degenerative changes before facet-joint pathology. (22)
o MRI also may illustrate nerve root entrapment secondary to facet-joint hypertrophy or a synovial cyst and may help visualize the intervertebral foramen; however, facet-joint pathology may be present despite normal imaging study findings.
o MRI is particularly useful for the evaluation of a synovial cyst emanating from a facet-joint and for distinguishing a synovial cyst from other abnormalities. Gadolinium enhancement is useful in the evaluation of a potential synovial cyst. Also helpful is to make the radiologist aware that a synovial cyst is part of the differential diagnosis because this entity is often overlooked.
Other Tests
• Electrodiagnosis
o Electro diagnostic studies, such as nerve conduction studies and needle EMG, are not usually indicated for possible lumbosacral facet syndrome. However, these studies should be considered if the history and physical examination findings suggest nerve root impingement or if the diagnosis remains unclear.
o Persons with facet-joint pathology typically present with normal sensory and motor examination findings; however, some patients describe the pain as radiating in nature and others report a positive straight leg–raise test result. Thus, electro diagnostic testing may be helpful for excluding other causes of pain, such as radiculopathy.
o RFA of the medial branch of the dorsal ramus affects the innervation of not only the facet-joint, but also the multifidus muscle. Normally, denervation potentials in the multifidus muscles in the setting of LBP are most commonly associated with lumbosacral radiculopathy. In the setting of a patient who has had previous RFA, however, the denervation potential is likely secondary to denervation from the procedure and not a radiculopathy.
TREATMENT
Therapeutic Interventional Techniques
The requirements for safe use of therapeutic interventions include a sterile operating room or a procedure room, appropriate monitoring equipment, radiological equipment; special instruments based on technique, sterile preparation with all the resuscitative equipment, needles, gowns, injectable drugs, intravenous fluids, anxiolytic medications, and trained personnel for preparation and monitoring of the patients. Minimum requirements include history and physical examination, informed consent, and appropriate documentation of the procedure.

Facet joint pain may be managed by intraarticular injections, medial branch blocks, or neurolysis of medial Branches (Facet denervation). (24)

Based on the available literature and scientific application, the most commonly used formulations of long-acting steroids, which include methylprednisolone (Depo-Medrol), triamcinolone diacetate (Aristocort), triamcinolone acetonide (Kenalog), and betamethasone acetate and phosphate mixture (Celestone Soluspan), appear to be safe and effective (23)

Based on the present literature, it appears that if repeated within 2 weeks, betamethasone may be the best choice in avoiding side effects; whereas, if treatment is carried out at 6-week intervals or longer, any one of the 4 formulations will be safe and effective.

Facet Joint Injections and Medial Branch Blocks

♦ In the diagnostic phase, a patient may receive 2 procedures at intervals of no sooner than 1 week or preferably 2 weeks.
♦ In the therapeutic phase (after the diagnostic is completed), the suggested frequency would be 2–3 months or longer between injections, provided that >50% relief is obtained for 6 weeks.
♦ If the interventional procedures are applied for different regions, they may be performed at intervals of no sooner than 1 week or preferably 2 weeks for most types of procedures. It is suggested that therapeutic frequency remain at 2 months for each region. It is further suggested that all regions be treated at the same time, provided all procedures can be performed safely.
♦ In the treatment or therapeutic phase, the interventional procedures should be repeated only as necessary according to the medical necessity criteria, and it is suggested that these be limited to a maximum of 4 to 6 times for local anesthetic and steroid blocks over a period of 1 year, per region.
♦ Under unusual circumstances with a recurrent injury or cervicogenic headache, procedures may be repeated at intervals of 6 weeks after stabilization in the treatment phase.



Medial Branch Neurotomy (Facet denervation)
♦ The suggested frequency would be 3 months or longer (maximum of 3 times per year) between each procedure, provided that > 50% relief is obtained for 10 to 12 weeks.
♦ The therapeutic frequency for medial branch neurotomy should remain at intervals of at least 3 months for each region. It is further suggested that all regions be treated at the same time, provided all procedures are performed safely.


Contraindications
Contraindications include ongoing bacterial infection, possible pregnancy, bleeding diathesis, and anticoagulant therapy. Precautions are warranted in patients with anticoagulant or antiplatelet therapy, diabetes mellitus and artificial heart valves.

Special Concerns:
Always obtain informed consent for any interventional procedure. In addition, patients must be informed of the risks, benefits, and potential outcomes associated with the procedure.
Patients with LBP who demonstrate red flags, such as unexplained weight loss, fever, and chills, should be further evaluated to rule out malignancy or occult infectious processes.
Interventional procedures with anesthetics and corticosteroids, can lead to transient lower-extremity weakness, insomnia, headache, fluid and electrolyte disorders (especially in patients with congestive heart failure), GI upset, bone demineralization, and impaired glucose tolerance (patients with diabetes). Less common effects are mood swings, increased appetite, and, the most serious, adrenocortical insufficiency. Dural puncture can lead to infection and an increased incidence of headaches.

References:

1. Goldwaith JE. The lumbosacral articulation: an explanation of many cases of "lumbago," "sciatica" and "paraplegia". Boston Med Surg J. 1911;164:365-72
2. Putti V. New conceptions in the pathogenesis of sciatic pain. Lancet. 1927; 2:53-60.
3. Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933; 101:1773-7.
4. Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br. May 1954; 36-B (2):304-22.
5. McRae DL. Asymptomatic intervertebral disc protrusions. Acta radiol. Jul-Aug 1956;46(1-2):9-27
6. Hirsch C, Ingelmark B E, 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
7. Bogduk N. The zygapophysial joints. In Clinical Anatomy of the Lumbar Spine and Sacrum, Third edition. Churchill Living¬stone, New York, 1997, pp 33-41.
8. Dreyfuss P, Schwarzer AC, Lau P et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. Spine 1997; 22:895-902.
9. Dreyfuss P, Schwarzer AC, Lau P et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. Spine 1997; 22:895-902.
10. Fujiwara A, Tamai K, Yamato M et al. The relationship between facet joint osteoar¬thritis and disc degeneration of the lum¬bar spine: An MRI study. Eur J Spine 1999; 8:396-401
11. Fujiwara A, Lim T, an H et al. The effect of disc degeneration and facet joint os¬teoarthritis on the segmental flexibility of the lumbar spine. Spine 2000; 25:3036-3044
12. Vernon-Roberts B, Pirie CJ. Degenerative changes in the intervertebral discs of the lumbar spine and their sequelae. Rheum Rehabil 1977; 16:13-21.
13. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. Mar 2007; 106(3):591-614.
14. Bogduk N. Low back pain. In Clinical Anatomy of the Lumbar Spine and Sa¬crum, ed. 3. Churchill Livingstone, New York, 1997; pp 187-214.
15. Manchikanti L, Singh V, Pampati V et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001; 4:308-316
16. Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine. Sep 1988; 13(9):966-71.
17. Boswell MV, Colson JD, Sehgal N, Dunbar E, Epter R. Systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10:229-253.
18. Bogduk N, McGuirk B. Management of Acute and Chronic Neck Pain. Evidence- Based Approach. Elsevier, 2006.
19. Bogduk N. International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophyseal joint blocks. Clin J Pain 1997; 13:285-302.
20. Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: A systematic review of evidence. Pain Physician 2005; 8:211-224.
21. 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. Apr 15 1995;20(8):907-12
22. D'Aprile P, Tarantino A, Jinkins JR, Brindicci D. The value of fat saturation sequences and contrast medium administration in MRI of degenerative disease of the posterior/perispinal elements of the lumbosacral spine. Eur Radiol. Feb 2007;17(2):523-31
23. Rozenberg S. Glucocorticoid therapy in common lumbar spinal disorders. Rev Rhum Engl Ed 1998; 65:649-655
24. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician 2007; 10:7-111 • ISSN 1533-3159
25. Pang WW, Mok MS, Lin ML, Chang DP, Hwang MH. Application of spinal pain mapping in the diagnosis of low back pain—analysis of 104 cases. Acta Anaesthesiol Sin 1998; 36:71-74.

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BACK AND SPINE PAIN-MINIMALY INVASIVE NON SURGICAL MANAGEMENT
Low Back Pain

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist


Back pain is a problem which is very often faced by all the human beings at least once in their lifetime. This pain, if not taken seriously can turn in to a deadly disease which can put your life at stake.

Some Important Facts about back pain

• Low back pain is the most common musculoskeletal complaint, with potentially devastating consequences.

• 90% of patients with acute low back pain do not require surgery. Most specialists agree that non-surgical treatment should be tried first.

• Surgery as first line treatment is indicated only in few selected cases. These are medical emergencies such as a broken neck or if you have symptoms such as weakness in the legs that gets progressively worse and/or bladder and/or bowel incontinence caused by the back problem.

• The incidence of back pain is highest between the ages of 35 and 55.

• Disc is not always the culprit. Small joints of spine are the source of pain in majority of patients.

• The pain combined with depression and anxiety in long-term cases places sufferers at risk for suicide.

• People who work at sedentary occupations are at a higher risk of disk injury than those who do moderate amounts of physical work.

• Up to 85 per cent of persons with back pain can’t recall a specific incident that brought on their pain.

• Early interventional treatments in Back pain management have been found to return patients to work and regular activities more rapidly than past conservative therapies.

• Early intervention decreases unnecessary chronic pain, long-term treatments and disabilities.

• Heat and massage therapy cannot cure the disease. These do not provide long term solutions to the problems of back. These are mainly used for managing pain during the recovery period.




Important Causes of back pain

The most common causes of low back pain are:
• Injury or overuse of muscles, ligaments, facet joints, and the sacroiliac joints.
• Pressure on nerve roots in the spinal canal. Nerve root compression can be caused by:
o A herniated disc, often brought on by repeated vibration or motion (as during machine use or sport activity, or when lifting improperly), or by a sudden heavy strain or increased pressure to the lower back.
o Osteoarthritis (joint degeneration), which typically develops with age. When osteoarthritis affects the small facet joints in the spine, it can lead to back pain. Osteoarthritis in other joints, such as the hips, can cause you to limp or to change the way you walk. This can also lead to back pain.
o Spondylolysis and spondylolisthesis, vertebra defects that can allow a vertebra to slide over another when aggravated by certain activities.
o Spinal stenosis, or narrowing of the spinal canal, which typically develops with age.
o Fractures of the vertebrae caused by significant force, such as from an auto or bicycle accident, a direct blow to the spine, or compressing the spine by falling onto the buttocks or head.
o Spinal deformities, including curvature problems such as severe scoliosis or kyphosis.
• Compression fractures. Compression fractures are more common among postmenopausal women with osteoporosis, or in men or women after long-term corticosteroid use. In a person with osteoporosis, even a small amount of force put on the spine, as from a sneeze, may cause a compression fracture.
Less common spinal conditions that can cause low back pain include:
• Ankylosing spondylitis, which is a form of joint inflammation (arthritis) that most often affects the spine.
• Bacterial infection. Bacteria are usually carried to the spine through the bloodstream from an infection somewhere else in the body or from IV drug use. But bacteria can enter the spine directly during surgery or injection treatments, or as the result of injury. Back pain may be the result of an infection in the bone (osteomyelitis), in the spinal discs, or in the spinal cord.
• Spinal tumors, or growths that develop on the bones and ligaments of the spine, on the spinal cord, or on nerve roots.
• Paget's disease, which causes abnormal bone growth most often affecting the pelvis, spine, skull, chest, and legs.
• Scheuermann's disease, in which one or more of the bones of the spine (vertebrae) develop wedge-shaped deformities. This causes curvature of the spine (rounding of the back, or kyphosis), most commonly in the chest region
Newer Developments and Better Understanding in Management of Back pain
A wide range of treatment is available for low back pain, depending on what is causing the pain and how long it lasts. Most people find that their low back pain improves within a few weeks. Chances are good that your pain will go away soon with some basic self-care.
• If you have recently developed low back pain, stay active and consider taking over-the-counter pain medicines .
• Staying active is better for you than bed rest. In fact, staying in bed more than 1 or 2 days can actually make your pain worse and lead to other problems such as stiff joints and muscle weakness.
• If your low back pain has lasted longer than 3 months, you will probably benefit from more intensive treatment.
• Must visit Interventional pain and spine specialist :-
• if you have moderate to severe low back pain that lasts more than a couple of days;
• if you have back or leg symptoms that have gotten worse;
• if your symptoms have not gone away after 2 weeks of home treatment;
• or if improved symptoms flare up again.
• A physical examination by pain specialist and possibly an imaging(x-ray/MRI) test may produce new information about your condition and help direct your treatment decisions.
• Physical Therapy: TENS, Ultrasound, Heat and Cryotherapy:
o These Modalities should always be considered an adjunct to an active treatment program in the management of acute low back pain.
o They should never be used as the sole method of treatment.

Interventions: Minimally invasive non surgical procedures for management of Back Pain


For back pain sufferers, interventional pain management techniques can be particularly useful. In addition to a thorough medical history and physical examination, interventional pain management physicians have a wide array of treatments that can be used including the following:

Epidural injections (in all areas of the spine):

The use of anesthetic and anti-inflammatory medications injected into the epidural space to relieve pain or diagnose a specific condition.

Nerve, root, and median branch blocks:

Injections done to determine if a specific spinal nerve root is the source of pain. Blocks also can be used to reduce inflammation and pain.

Facet joint injections:

An injection used to determine if the facet joints are the source of pain. These injections can also provide pain relief.

Discography:

An "inside" look into the discs to determine if they are the source of a patient's pain. This procedure involves the use of a dye that is injected into a disc and then examined using x-ray or CT Scan.

Pulsed Radiofrequency Neurotomy (PRFN):

A minimally invasive procedure that disables spinal nerves and prevents them from transmitting pain signals to the brain.

Rhizotomy:

A procedure in which pain signals are "turned off" through the use of heated electrodes that are applied to specific nerves that carry pain signals to the brain.

Spinal cord stimulation:

The use of electrical impulses that are used to block pain from being perceived in the brain.

Intrathecal pumps:

A surgically implanted pump that delivers pain medications to the precise location in the spine where the pain is located.

Percutaneous Discectomy / Nucleoplasty:

A minimally invasive day care procedure in which tissue is removed from the disc with the help of decompressor through a very minute hole ,in order to decompress and relieve pressure on the spinal nerves.


Ozoneucleolysis or Ozone discectomy:

Has emerged as an affordable, least invasive approach and costs 2/3 of the price of conventional surgery. Ozone injected inside the affected intervertebral disc under c- arm guidance, causes shrinkage of disc and thus reducing the volume and lessening the pressure on nerves.

Intradiscal Electrothermoplasty (IDET)
This procedure involves the insertion of a needle into the affected disc with the guidance of an x-ray machine. A wire is then threaded down through the needle and into the disc until it lies along the inner wall of the annulus. The wire is then heated which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc.

These techniques are exciting. They offer the possibility of treating low back pain and sciatica with much less trauma and risk than surgery.


Quick tips to a healthier back


• Following any period of prolonged inactivity, begin a program of regular low-impact exercises.
• Speed walking, swimming, or stationary bike riding 30 minutes a day can increase muscle strength and flexibility.
• Yoga can also help stretch and strengthen muscles and improve posture
• Always stretch before exercise or other strenuous physical activity.
• Don’t slouch when standing or sitting. When standing, keep your weight balanced on your feet. Your back supports weight most easily when curvature is reduced.
• At home or work, make sure your work surface is at a comfortable height for you.
• Sit in a chair with good lumbar support and proper position and height for the task. Keep your shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of your back can provide some lumbar support. If you must sit for a long period of time, rest your feet on a low stool or a stack of books.
• Wear comfortable, low-heeled shoes.
• Sleep on your side to reduce any curve in your spine. Always sleep on a firm surface.
• Ask for help when transferring an ill or injured family member from a reclining to a sitting position or when moving the patient from a chair to a bed.
• Don’t try to lift objects too heavy for you. Lift with your knees, pull in your stomach muscles, and keep your head down and in line with your straight back. Keep the object close to your body. Do not twist when lifting.
• Maintain proper nutrition and diet to reduce and prevent excessive weight, especially weight around the waistline that taxes lower back muscles.
• If you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.

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Myths and Facts about cancer pain
Myths and Facts about cancer pain

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist

The key messages are:
• Your pain can be managed.
• Controlling pain is part of your cancer treatment.
• Talking openly with your pain physician will help them manage your pain.
• The best way to control pain is to stop it from starting or keep it from getting worse.
• There are many different medicines and interventions to control pain. Everyone's pain control plan is different.
• Keeping a record of your pain will help create the best pain control plan for you.
• People who take cancer pain medicines as prescribed rarely become addicted to them.
• Your body does not become immune to pain medicine. Stronger medicines should not be saved for "later."
When pain is not treated properly, you may be:
• Tired
• Depressed
• Angry
• Worried
• Lonely
• Stressed
When cancer pain is managed properly, you can:
• Enjoy being active
• Sleep well
• Enjoy family and friends
• Improve your appetite
• Enjoy sexual intimacy
• Prevent depression

Myths and facts about pain medications

• Not all the pain killers are same. Each drug has its own side effects profile.

• Adjuvants like antidepressants and anticonvulsants in lower doses have effect on modulation of pain mechanism and are not prescribed by pain specialist to treat depression or seizure.

• Opioids (narcotics) and steroids are not harmful if taken in appropriate doses under medical supervision

• For cancer-related pain that remains uncontrolled despite oral or transdermal options, the use of nerve blocks, spinal administration of anesthetics, and minimally invasive non surgical interventions may be beneficial.

• A risk: benefit ratio is always considered prior to implementing invasive analgesic methods.

• Usually the side effects last only a few days. But if they last longer, your doctors can change the medicine or dose you're taking. Or they may also add another medicine to your pain control plan to control the side effects.

• Don't let side effects stop you from getting your pain under control.

• Medicine tolerance is not the same as addiction.
As mentioned, medicine tolerance happens when your body gets used to the medicine you're taking. The result is that the dose no longer works as well. Each person's body is different. Many people don't develop a tolerance to opioids. But if tolerance happens to you, don't worry.Under your doctor's care, you can:
• Increase your dose in small amounts
• Add a new kind of medicine
• Change the kind of medicine that you're taking for pain
• The goal is to relieve your pain. Increasing the dose to overcome tolerance does not lead to addiction.


Take home message
• Cancer pain is very common and is often underestimated and undertreated. A successful management of pain is essential in the care of patients living with cancer or facing the end of life.

• Principles of pain management include a proper and regular assessment of pain, encouragement of patients and their families to use opioids for cancer pain, and aggressive management of side effects.

• Pharmacotherapy continues to be the cornerstone of cancer pain management. A three-step analgesic “ladder” described by the WHO provides a general guideline for pain management. - -Opioids are the drugs of choice for moderate to severe cancer pain of all causes.

• Usefulness and proper implementation of the interventional anesthetic techniques is essential in the cancer patients with uncontrollable or refractory pain.

• Nonpharmacological and complimentary therapies may also be considered when needed.

• Ultimate goal for the cancer pain management is to ensure a good quality of life and restoring physical and psychological health as far as possible.

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