Lumbar Medial Branch Neurotomy Research Articles

A History of the Development of Radiofrequency Neurotomy.

The technique of lumbar medial branch radiofrequency neurotomy for facet joint pain has an intriguing history involving a diverse timeline of medical specialists. This paper aims to chart the pathway that led to its invention and the series of modifications and refinements that have led to modern practice. The story begins with the treatment of World War I soldiers by Nesfield, who used scalpels to cut “trapped” nerves. Inspired by Nesfield’s treatment, Rees developed the “percutaneous rhizolysis” technique in 1960. Shealy was the first to use radiofrequency electrodes for denervation of the facet joints, introducing his technique in 1971. Several radiofrequency electrode developments came about from collaborations with Cosman medical device entrepreneurs during the 1970s, including the Shealy Rhizolysis Kit, the Ray Rhizotomy Electrode, and the Sluijter-Mehta Kit. Subsequent dissections of Rees’ technique and modification of Shealy’s procedure by Bogduk saw the development of “percutaneous lumbar medial branch neurotomy” in 1980 by Bogduk and Long. Bogduk continued to contribute significantly to validation, refinement and acceptance of the technique. In 1998, the technique of pulsed radiofrequency was invented by Sluijter, Cosman, Rittman and van Kleef. Subsequent innovations have consisted of cooled radiofrequency neurotomy, multi-tined cannulae, endoscopic systems, and alternative denervation targets, such as the facet joint capsule. As we pass the first 100 years of the story, we believe there are more chapters to be written on this fascinating subject.

Comparison of the Effectiveness of Radiofrequency Neurotomy and Endoscopic Neurotomy of Lumbar Medial Branch for Facetogenic Chronic Low Back Pain: A Randomized Controlled Trial

To compare the effectiveness of radiofrequency neurotomy (RN) and endoscopic neurotomy (EN) of lumbar medial branch (MB) for facetogenic chronic low back pain (FCLBP). Forty patients with FCLBP were included and randomly assigned to the control group and the experimental group. The control group (20 cases) underwent X-ray-assisted RN and the experimental group (20 cases) underwent EN of the lumbar MB. The patients' Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI) score were evaluated and compared preoperatively, and at 3 weeks, 6 months, 1 year, and 2 years postoperatively. First, the RN group demonstrated successful treatment results (P < 0.05) at 3 weeks, 6 months, and 1 year after surgery. At 2 years, patients reported no significant effectiveness (P > 0.05). Second, the EN group demonstrated more prolonged successful treatment outcomes compared with the RN group. At 2 years, although the efficacy declined further, the VAS and ODI scores showed significant improvements compared with the preoperative data (P < 0.05). Third, there was no difference in VAS and ODI scores between the 2 groups at 3 weeks after surgery (P > 0.05). At 6 months and later, the EN group demonstrated better outcomes (P < 0.05). For FCLBP, EN and X-ray-assisted RN of lumbar MB are both effective treatments. However, endoscopic lumbar MB neurotomy has the better and longer effectiveness.

Technical aspects of conventional and water-cooled monopolar lumbar radiofrequency rhizotomy

Radiofrequency ablation (RFA) is a safe and effective pain therapy with efficacy principally reliant upon induced thermal damage of neural sensory afferents. Most peripheral RFA involves induced axonal damage but cell bodies may be involved indirectly. Radiofrequency electrodes (RFE) are not simple high-temperature probes and better insight regarding RFE function from an electrical engineering viewpoint may improve clinical outcomes by reducing the risk of poor or inadequate heating of the target nerves. RFE heating is highly influenced by the configuration and properties of the perielectrode tissues with the shape and size of RFE-produced protein coagulum seen in vitro with homogeneous media such as egg white, liver, or chicken skeletal muscle undoubtedly significantly different than the biological lesions occurring during in vivo clinical use. Understanding RFA requires consideration of the nature of the specific perielectrode tissues. A theoretical basis for optimized RFE function for lumbar medial branch (MB) neurotomy is presented with introduction of the concepts of clinically useful heating and useless heating. Conventional RFE is limited in the amount of current/heating produced for a given active electrode surface area before producing a radiofrequency generator fault and an inverse relationship exists between clinically useful heating and useless heating. Technical details of RFE function are discussed that may differ from presently accepted technique. Tined RFE, similar in function to conventional RFE, may offer a small advantage if properly used, and possibly a disadvantage if used incorrectly. Directly conducted heat is often neglected in considering RFA, but should be considered, especially with water-cooled RFE (WCRFE). Theory and empirical results suggest that WCRFE might become a preferred tool for much, but not all, RFA, but adoption has been limited by electrode cost and reimbursement policies. Conventional and tined RFE may produce poor outcomes if placed improperly, but complications due to overheating are quite rare. Conversely, WCRFE introduces far more heat into perielectrode tissues and reduces the likelihood of a poor clinical outcome, but avoidance of complications due to overheating of adjacent tissues requires a thoughtful understanding of the spatial and thermal characteristics of the WCRFE.

Correlation of Lumbar Medial Branch Neurotomy Results with Diagnostic Medial Branch Block Cut off Values: A Letter to the Editor

We read the article by Derby et al. with interest (Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cut off values to optimize therapeutic outcome: Pain Medicine 2012;13:1533–1546) ⇓. It is a well-conducted study that aims to establish a diagnostic test protocol to obtain a satisfactory result following medial branch neurotomy (MBN). A direct relationship between the diagnostic test protocol and the outcome of MBN can only be established once all the confounding factors affecting the outcome have been ruled out. However, in the present study, we could find few such factors described later. Whether the …

Response to Letter “Correlation of Lumbar Medial Branch Neurotomy Results with Diagnostic Medial Branch Block Cutoff Values to Optimize Therapeutic Outcome.” by Dr. Roy C. and Chatterjee N.: Table 1

Dear Editor, Thank you for taking the time for critically reviewing our article and allowing us an opportunity to further explain our results and to correct our omissions. Although we prospectively collected data, I again emphasize that the study is an audit of our usual and customary practices and techniques. The comparison in outcome between a single MBB protocol and a double MBB protocol is not a randomized comparison, but an opportunistic comparison based on insurance and patient preferences. In as much as our patient population is similar to other practices and in as much as the MBB and MBN techniques are similar or comparable, our audit could be used by others to provide their patients with an evidenced-based informed consent regarding the likelihood that they will be satisfied with the procedure and achieve a minimum of 50% subjective pain improvement for 6 months or longer based on a one- vs a two-MBB protocol. The likelihood degree is correlated to their perceived degree of improvement following a one- or two-session MBB protocol. Although we stated the senior author performed all the MBB thus implying he also performed the MBN, we should have specifically stated the following: The senior author with 30-year experience using MBB and MBN performed all the MBB and MBN procedures. The second author confirmed the prospectively collected audit by phone interview with the patients. The technique of performing MBB is a debatable topic that is beyond the scope of the article. The short …

Correlation of Lumbar Medial Branch Neurotomy Results with Diagnostic Medial Branch Block Cutoff Values to Optimize Therapeutic Outcome

We sought an optimal medial branch block (MBB) cutoff value for both single and double MBB protocols that would best correlate with a positive outcome of medial branch neurotomy (MBN). We analyzed the percentage of subjective pain relief following MBB, confirmed by numerical rating scale (NRS) in aggravating positions before and 45 minutes after MBB. The percentage of overall pain relief following MBB was plotted against the following outcome variables: degree of subjective pain relief, duration of relief, patient satisfaction and activity level, no other doctor's visits, and reduction in medications use. Using the percent of pain relief post-MBB plotted in 10% increments in the double-MBB group, patients reporting 70% or greater pain relief following MBB showed statistically favorable outcome for the following four criteria: percentage of pain relief, duration of relief, patient satisfaction, and pain medications reduction. In the single MBB group, patients reporting 80% or greater pain relief following MBB had favorable outcomes for improvement in activity level and patient satisfaction. The double MBB protocol better correlated with favorable MBN outcomes compared with a single MBB protocol. Using a double MBB protocol, a 70% cutoff value for reported subjective pain relief post-MBB best predicted overall outcome following MBN. Without a confirmatory MBB, an 80% cutoff value was the optimal value.

Repeat Percutaneous Radiofrequency Facet Joint Denervation for Chronic Back Pain: A Prospective Study

ABSTRACTObjective: To investigate whether repeat lumbar percutaneous radiofrequency facet joint denervation [RFJD] is an efficacious ongoing treatment for chronic low back pain [LBP] using the Low Back Outcome Score [LBOS] and subjective measures of patient satisfaction.Methods: A prospective open-label, single intervention study was carried out on a consecutive series of patients undergoing repeat lumbar RFJD performed by a single operator in 2007. Patients with an initially successful RFJD procedure were selected for the study excluding patients with greater than four procedures in total. Lumbar medial branch neurotomy was conducted using a 20-gauge silicone-coated probe inserted under fluoroscopic control and neuroleptic intravenous sedation with radiofrequency thermal energy applied for 90 seconds per joint at a maximum probe tip temperature of 90°C. The patients completed a LBOS questionnaire before and 12 months following the repeat RFJD procedure. They were also asked about their satisfaction with ...

Abstract No. 179: Percutaneous radiofrequency neurotomy is effective in the treatment of lumbar facet joint syndrome

Lumbar medial branch neurotomy has been applied in the treatment of facet joint (zygapophysial) syndrome by means of percutaneous radiofrequency denervation (RFD). The data so far available on its efficacy is still controversial because of differences in patients selection and surgical technique. The aim of this study was to provide new evidence on the clinical outcome of this procedure.

A Narrative Review of Lumbar Medial Branch Neurotomy for the Treatment of Back Pain

Confusion persists concerning the nature and efficacy of procedures variously known as facet denervation, lumbar medial branch radiofrequency neurotomy, and radiofrequency neurotomy or denervation for the treatment of back pain. Systematic reviews have not recognized the importance of patient selection and correct surgical technique when appraising the literature. As a result, negative conclusions about procedures have been drawn because lack of efficacy of one procedure has been misattributed to other, cognate, but different procedures. To demonstrate how the rationale and efficacy of lumbar medial branch neurotomy depends critically on correct selection of patients and use of surgically correct technique. A narrative review and description of the available evidence, drawn from the personal libraries of the authors and from the bibliographies of systematic reviews. Three studies, commonly accepted as evidence of lack of effectiveness, were not valid tests of lumbar medial branch neurotomy because of errors in selection of patients or errors in surgical technique, or both. Two descriptive studies and three controlled studies that used valid or acceptable techniques consistently showed that lumbar medial branch neurotomy had positive effects on pain and disability. All valid, randomized controlled trials showed medial branch neurotomy to be more effective than sham treatment. Negative results have been reported only in studies that selected inappropriate patients or used surgically inaccurate techniques. All valid studies showed positive outcomes that cannot be attributed to placebo. Inappropriate conclusions have been drawn by systematic reviews that misrepresent invalid studies as providing evidence against the efficacy of lumbar medial branch neurotomy.

Radiofrequency Lumbar Zygapophysial (Facet) Joint Denervation: A Preliminary Report of a New Concept

This is a preliminary report of a new concept of lumbar medial branch neurotomy by measurement of minimal sensory threshold. This technique is not recommended for routine clinical use until further controlled data are available. The lumbar zygapophysial joints (Z-joint) or facet joints, are a potential source of low back pain. In general, the principle innervation of the Z-joint is the medial branch of the posterior primary ramus of the same level as the target Z-joint as well as the level above. Denervation of the multifidus as evaluated by electromyography has become a measurement of successful Z-joint denervation. Two drawbacks to this method are that it takes one to several weeks for denervation potentials to develop and thus does not give the physician any sense of successful denervation intra-operatively. The other is that the Z-joint is innervated by the sensory fibers of the medial branches. As a result, the multifidus may be successfully denervated as demonstrated by electromyography but the Z-joints may be inadequately denervated. As a result, this technique describes measurement of minimal sensory threshold prior to lesioning and seeking to double that threshold as an additional, intra-operative measure of successful sensory denervation of the Z-joint.

The surgical anatomy of thoracic facet denervation.

Thoracic percutaneous facet denervation has been employed for the treatment of thoracic zygapophysial joint pain. But the surgical anatomy of this procedure has been assumed to be the same as for lumbar medial branch neurotomy. To establish the anatomical basis for thoracic medial branch neurotomy, an anatomical study was undertaken. Using an X40 dissecting microscope, a total of 84 medial branches from 7 sides of 4 embalmed human adult cadavers were studied. The medial branches of the thoracic dorsal rami were found to assume a reasonably constant course. Upon leaving the intertransverse space, they typically crossed the superolateral corners of the transverse processes and then passed medially and inferiorly across the posterior surfaces of the transverse processes before ramifying into the multifidus muscles. Exceptions to this pattern occurred at mid-thoracic levels (T5-T8). Although the curved course remained essentially the same, the inflection occurred at a point superior to the superolateral corner of the transverse process. At no time during the dissection were nerves encountered crossing the junctions between the superior articular processes and transverse processes which have been the target points advocated for thoracic facet denervation. Rather, the results of this study indicate that the superolateral corners of the transverse processes are more accurate target points.

腰椎椎間関節症に対する腰神経後内側枝の経皮的電気焼灼術について

Fifteen patients who underwent Electrosurgical Lumbar Medial Branch Neurotomy had been followed 4 to 36 months, and the degrees of pain releif were evaluated by JOA score. Neurotomy was performed using a electrosurgical unit and evoked EMG at lumbar PVM was monitored at the same time to make sure of the denervation. Following the neurotomy, 9 patients showed increase and 4 patients decrease in their scores. And one patient showed no score changing. It was considered that among 5 patients who showed no improvement, there were 2 patients who had psychological, pain, 2 patients had multiple focuses and 1 patient had another origin of pain.

Percutaneous lumbar medial branch neurotomy: a modification of facet denervation.

Percutaneous lumbar medial branch neurotomy is a technique for facet denervation in which the target is specifically the medial branch of the dorsal ramus. The radiology of the technique is illustrated, and the technical aspects of the procedure are described. The accuracy of previous techniques for facet denervation as compared with medial branch neurotomy is reviewed in a comparative analysis of radiographs illustrating the various techniques. It is suggested that the greater accuracy of medial branch neurotomy will permit a more adequate trial of the rationale and efficacy of facet denervation.