Percutaneous Radiofrequency Neurotomy Research Articles

Delphi-Based Expert Consensus Statements for the Management of Percutaneous Radiofrequency Neurotomy in the Treatment of Lumbar Facet Joint Syndrome.

A modified Delphi strategy was implemented for obtaining recommendations that could be useful in the management of percutaneous radiofrequency treatment of lumbar facet joint syndrome, as the literature on the argument was poor in quality. An Italian research team conducted a comprehensive literature search, defined the investigation topics (diagnosis, treatment, and outcome evaluation), and developed an explorative semi-structured questionnaire. They also selected the members of the panel. After an online meeting with the participants, the board developed a structured questionnaire of 15 closed statements (round 1). A five-point Likert scale was used and the cut-off for consensus was established at a minimum of 70% of the number of respondents (level of agreement ≥ 4, agree or strongly agree). The statements without consensus were rephrased (round 2). Forty-one clinicians were included in the panel and responded in both rounds. After the first round, consensus (≥ 70%) was obtained in 9 out of 15 statements. In the second round, only one out of six statements reached the threshold. The lack of consensus was observed for statements concerning the use of imaging for a diagnosis [54%, median 4, interquartile range (IQR) 3-5], number of diagnostic blocks (37%, median 4, IQR 2-4), bilateral denervation (59%, median 4, IQR 2-4), technique and number of lesions (66%, median 4, IQR 3-5), and strategy after denervation failure (68%, median 4, IQR 3-4). Results of the Delphi investigations suggest that there is a need to define standardized protocols to address this clinical problem. This step is essential for designing high-quality studies and filling current gaps in scientific evidence.

Incidence of Cervicogenic Headache Following Lower Cervical Radiofrequency Neurotomy

Background: The facet joints contribute to chronic cervical spine pain in an estimated 55% of chronic neck pain cases and can be treated with percutaneous radiofrequency neurotomy (PRN). Damage to surrounding structures during treatment or successful treatment of the primary pain source leading to unmasking could lead to new onset of pain, including cervicogenic headache (CGH). In this study, we aimed to define the incidence of headache in patients who have been previously treated with PRN for lower cervical facet pain. Setting: All patients treated at a single academic institution’s pain management clinic from 2014 to 2016 with cervical PRN were reviewed. Methods: All patients treated at a single institution’s pain management clinic from 2014 to 2016 were reviewed. Those treated with lower cervical PRN were identified, and incidence of CGH was described as a percentage of the study population. Patient age and pain scores between those with and without headaches following treatment were compared by unpaired T-tests. Gender, presence of comorbid disease and levels involved, quality of pain, exacerbating and alleviating factors, location of referred pain, and previous treatments between those with and without headaches following treatment were compared using chi-square tests. Results: Among the 88 patients in the study group, 12 were found to have only moderate relief of their pretreatment pain as well as a new onset headache meeting the diagnostic criteria for cervicogenic headache. Compared to those without a headache after treatment, those diagnosed with cervicogenic headache were more likely to be female (P = 0.041), report a higher maximum pain level on presentation (P = 0.015), have a diagnosis of diabetes prior to presentation (P = 0.011), and have had the procedure performed at levels which included C3 (P = 0.013) (Table 1). Limitations: The limitations of this study include its single-center design, as this cohort may not be truly representative of the population of patients receiving cervical PRN as a whole, and as a result, these results may not be generalizable. Due to the small size of the cohort, more subtle differences in presenting signs and symptoms between those with and without headaches may not be detectable. Finally, as previously mentioned, the lack of data on some of the patients who presented with headache may have led to underdiagnosis of the true incidence of cervicogenic headache. Future work should look to re-examine the incidence of CGH in a larger cohort to validate the findings here and further define risk factors for post-procedural CGH. Conclusions: This retrospective review of all patients seen over 2 years in an academic pain clinic found a 13.6% incidence of cervicogenic headache following cervical radiofrequency neurotomy at levels C3-C7. This supports the possibility of the unmasking phenomenon following the procedure, though contributing mechanisms underlying this phenomenon may be multifactorial and require further study. IRB: This study was approved by the institution’s Institutional Review Board (IRB2010601795). Key words: Cervical spine, facetogenic pain, percutaneous radiofrequency neurotomy, cervicogenic headache, chronic pain, zygapophysial joints, innervation convergence, retrospective chart review

Percutaneous Radiofrequency Facet Joint Denervation With Monitoring of Compound Muscle Action Potential of the Multifidus Muscle Group for Treating Chronic Low Back Pain

A retrospective review. The aim of this study was to study the effectiveness of percutaneous radiofrequency neurotomy of facet joints by monitoring compound muscle action potentials (CMAPs) of the multifidus muscle group as an objective index of treatment efficacy. Percutaneous radiofrequency neurotomy of the medial branches of the dorsal rami of the lumbar nerves is a widely accepted treatment for chronic lumbar intervertebral joint pain. However, its success rate has varied in different studies because an objective method for evaluating the facet joint denervation is lacking. Fifty-five patients (age range, 19-76 y; mean age, 55 y) with low back pain persisting for ≥3 months, in whom facet block and/or block of the medial branch of the dorsal ramus were only temporarily effective, were included. The Japanese Orthopaedic Association (JOA) scoring system for back pain was used for clinical assessment. JOA scores were measured before treatment and 1 week, 3 months, 6 months, and 12 months afterward. The improvement rate was calculated with ≥40% improvement rate defined as successful, and the success rate was subsequently evaluated. The patient success rate was 75% (41/55) at 1 week, 71% (39/55) at 3 months, 60% (33/55) at 6 months, and 51% (28/55) at 12 months after treatment. Two cases had minor postoperative complications, which were localized burning pain lasting <1 week at the site of electrode insertion. Our results suggest that percutaneous radiofrequency facet joint denervation with CMAPs monitoring is a safe, long-lasting, and effective treatment for chronic facet joint pain. CMAP monitoring may be useful as an objective index for facet denervation.

Update on the Role of Z-Joint Injection and Radiofrequency Neurotomy for Cervicogenic Headache

Cervicogenic headache is a common secondary headache that typically is referred from the upper cervical spine, that is, segments C3-C4 and rostral. Diagnostic injections to one or more of these segmental joints (including the atlanto-occipital joint, atlanto-axial joint, and C2-C3 and C3-C4 zygapophysial joints [z-joints]) frequently are used to establish the pain generator in the cervical spine that is responsible for the radiation of pain into the head. Therapeutic interventions used to alleviate pain include corticosteroid injections into the z-joint (ie, C2-C3 and C3-C4) or bony articulations (ie, C0-C1 and C2-C2), and percutaneous radiofrequency (RF) neurotomy at the C2-C3 and C3-C4 z-joints. RF neurotomy may provide the most sustained relief of headache symptoms although the relief typically is not permanent. Pulsed RF, a nondestructive modality, may also have benefit for cervicogenic headaches.

Outcomes of Percutaneous Zygapophysial and Sacroiliac Joint Neurotomy in a Community Setting

To evaluate the analgesic, physical, and psychological outcomes of percutaneous radiofrequency neurotomy for persistent zygapophysial and sacroiliac joint pain in a community setting. A prospective evaluation of 379 consecutive neurotomies in a single specialist practice over an extended period 2001-2010. A provincial community environment in Australia. All patients who had positive responses to diagnostic blocks, performed according to the guidelines of the International Spine Intervention Society by three trained specialists, underwent percutaneous radiofrequency thermal neurotomies performed by the author. Radiofrequency neurotomies to denervate the zygapophysial or sacroiliac joints according to the standards of the International Spine Intervention Society. Numerical Rating Scale for Pain, Functional Rating Index, 4-Activities of Daily Living Scale, General Health Questionnaire, Depression Anxiety Stress Scale, duration of pain relief, "whether they would do it again," and overall amount of pain relief. Of 379 procedures, 272 (72%) were regarded as successful by the patients. Irrespective of region treated. The results were highly significant by t-test, and the effect size was large as determined by the Cohen's d. Adverse events were infrequent and relatively minor. Repetitions of the procedure were highly successful. Neurotomy of the cervical, thoracic, lumbar, and sacroiliac joints were uniformly successful with 72% recipients obtaining an average of 86% reduction in pain for a period of 12 months.

Low-Level Laser Therapy in the Management of Neck Pain

Chronic neck pain is a highly prevalent condition with high economic costs affecting 10% to 24% of the population [1]. Sometimes, the pain can be brief and inconsequential, but for many people the pain can be severe and disabling. Many therapies are used in this condition including NSAIDs, cervical epidurals, therapeutic massages, acupuncture, percutaneous radiofrequency neurotomy, neck muscle training, stretching exercise, botulinum neurotoxin A, and low-level laser therapy (LLLT) among others. LLLT uses laser to aid tissue repair, relieve pain, and stimulate acupuncture points. Laser light is generated by high-intensity electrical stimulation of a medium, which can be a gas, liquid, crystal, dye, or semiconductor [2]. LLLT is noninvasive, painless, and can be easily administered in primary-care settings. Incidence of adverse effects is low and similar to that of placebo, with no reports of serious events. Research into the use of LLLT for pain reduction and tissue repair spans more than 30 years. However, reports do not identify this therapy as a potential treatment option, possibly because of skepticism about its mechanism of action and effectiveness [3].

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.

Percutaneous Lumbar Zygapophysial (Facet) Joint Neurotomy Using Radiofrequency Current, in the Management of Chronic Low Back Pain

A randomized controlled study of percutaneous radiofrequency neurotomy was conducted in 40 patients with chronic low back pain (20 active and 20 controls). The aim of the study was to evaluate the possible beneficial effect of percutaneous radiofrequency zygapophysial joint neurotomy in reducing pain and physical impairment in patients with pain from the lumbar zygapophysial joints, selected after repeated diagnostic blocks. Facet or zygapophysial joint pain may be one of the causes of chronic low back pain and may be treated by a percutaneous radiofrequency denervation. Patients may possibly be identified by a positive diagnostic block. These blocks need to be repeated as false positive responses to single blocks occur.In all previous studies patients treated with radiofrequency denervation have been selected after single diagnostic blocks resulting in a varying degree of relief. All patients were examined by an orthopedic surgeon before and 6 months after the treatment (sham or active). Inclusion criteria were 3 separate positive facet blocks. Denervation was achieved by multiple lesions at each level in an effort to provide effective denervation. The active treatment group showed statistically significant improvement not only in back and leg pain but also back and hip movement as well as the sacro-iliac joint test. Pre operative sensory deficit and weak or absent ankle reflex normalized (P < 0.01) and (P < 0.05), respectively. There was significant improvement in quality of life variables, global perception of improvement, and generalized pain.The improvement seen in the active group was significantly greater then that seen in the placebo group with regard to all the above-mentioned variables. None of our patients had any complication other than transient postoperative pain that was easily managed. Our study indicates that radiofrequency facet denervation is not a placebo and could be used in the treatment of carefully selected patients with chronic low back pain.

Radiofrequency Neurotomy of the Medial Branch for the Management of Lumbar Zygapophysial Joint Pain

Purpose: We wanted to investigate efficacy of percutaneous radiofrequency (RF) neurotomy of medial branch for management of chronic low back pain due to lumbar zygapophysial joint dysfunction. Materials and Methods: Thirteen patients who had unremitting chronic low back pain for more than 6 months and whose VAS scores were over 7 were selected on basis of double comparative nerve blocks. The patients consist of three males and 10 females, and their nean age was 67 years. Sensory stimulation was performed to detect the pathologic branchesthat were responsible for pain generation. RF neurotomy was performed using a lesion generator at 80 C for 90 seconds. The postoperative outcome was classified, depending on degree of pain reduction, as excellent (≥ 75%), good (50-75%), and poor (

Percutaneous Radiofrequency Neurotomy for Chronic Neck Pain: Outcomes in a Series of Consecutive Patients

Randomized controlled trials in research settings have demonstrated the efficacy of percutaneous radiofrequency neurotomy of the medial branches of the cervical dorsal rami in the palliation of chronic zygapophysial joint pain, a common cause of chronic neck pain, but one that is under-recognized in some quarters. This study aimed to determine the outcomes of radiofrequency neurotomy in usual clinical practice for patients with established cervical zygapophysial joint pain. The study was conducted in a public hospital, incorporating the private practice and public clinic elements of a single physician. All patients who underwent radiofrequency neurotomy had a diagnosis of cervical zygapophysial joint pain established by controlled cervical medial branch blocks. The primary outcome of duration of pain relief was determined for all consecutive procedures performed during a two-year period. Data were collected by chart review and telephone contact by an independent assessor. Forty-seven procedures were performed on 35 patients. Two patients were lost to follow-up. Twelve patients had two procedures. Thirty-six of 45 assessable procedures (80%) achieved significant pain relief. These 36 procedures achieved a mean duration of pain relief of 36 weeks, with a median of 35 weeks. Repeat procedures usually achieved reproducible pain relief. Most patients had significant postprocedural pain for about one week. Only one serious adverse event (local superficial infection) was reported. Radiofrequency neurotomy is an effective palliative treatment for chronic cervical zygapophysial joint pain when performed in routine clinical practice.

Raiofrequency Neurotomy for Lumbar Facet Joint Pain in the Patients with Failed Back Surgery Syndrome

Background: A significant number of patients complain of persistent pain or neurologic symptoms after lower back surgery. It is reported that facet joint pain plays a role in failed back surgery syndrome. To the best of our knowledge, there are few studies that have investigated the outcome of radiofrequency neurotomy in the patients with failed back surgery syndrome. Methods: The study group was composed of thirteen patients who were operated on due to their low back pain, and they displayed no postoperative improvement. All the patients underwent double diagnostic block of the lumbar medial branch of the dorsal rami with using 0.5% bupivacaine. The patients who revealed a positive response to the double diagnostic block were then treated with percutaneous radiofrequency neurotomy. The effect on their pain was evaluated with using a 4 point Likert scale. Results: Eleven patients revealed a positive response to the double diagnostic block. Ten patients were given percutaneous radiofrequency neurotomy. Nine patients showed sustained pain relief for 3 months after the percutaneous radiofrequency neurotomy. Conclusions: We found lumbar facet joint syndrome in the patients with failed back surgery syndrome by performing double diagnostic block and achieving pain relief during the short term follow-up after percutaneous radiofrequency neurotomy of the lumbar zygapophysial joints. This suggested that facet joint pain should be included in failed back surgery syndrome. (Korean J Pain 2005; 18: 151-155)

Whiplash: pathophysiology, diagnosis, treatment, and prognosis.

We have reviewed the literature relevant to pathophysiology, diagnosis, treatment, and prognosis of whiplash-associated disorder (WAD) since 1995 and provided a brief summary of literature pertaining to forces action on the head and neck during a motor vehicle accident. The scope of the current review is confined to the Quebec guidelines for WAD grades 1-3 but excludes grade 4 (neck complaints and fracture or dislocation). After excluding papers without scientific data and single case reports or case series with fewer than 20 patients, articles were reviewed for methodological quality. The diagnosis remains clinical. No imaging, physiological, or psychological study provides specific diagnostic criteria. In the acute period up to 2 weeks, soft collars or rest and work-leave do not shorten the duration of neck pain. Sick leave is reduced by high-dose methylprednisolone given within 8 h of injury, but confirmatory studies examining the cost-benefit relationship are needed. In the first 6 months, active as opposed to passive treatment results in improved outcomes. Specific exercise strategies have not been studied. For those with symptoms lasting more than 6 months, percutaneous radio-frequency neurotomy can provide pain relief for many months in those responding to blind local anesthetic facet blocks. Intra-articular corticosteroids are ineffective. Uncontrolled trials suggest that multimodal rehabilitation programs result in improved overall function. The overall prognosis for recovery has varied considerably across studies. Such variability is likely due to differences in case identification methods and whether outcome is assessed in terms of symptoms or the receipt of financial compensation for injury. The impact on prognosis of both collision- and patient-related factors is also reviewed.

Radiofrequency neurotomy for the treatment of third occipital headache

Objective: To evaluate the efficacy of a revised technique of percutaneous radiofrequency neurotomy for third occipital headache. Methods: The revisions included using a large gauge electrode, ensuring minimum separation between...

796 A Role of Percutaneous Radiofrequency Neurotomy of Posterior Primary Rami

Park, Jung Y. MD, PhD; Cho, Tai Hyung MD; Chung, Yong Ku MD; Suh, Jung Keun MD; Lee, Hoon Kap MD; Lee, Ki Chan MD

Percutaneous Radiofrequency Neurotomy of the Cervical Medial Branches

SummaryPercutaneous radiofrequency neurotomy is a minimally invasive, neuroablative procedure used to interrupt nociceptive pathways in patients with intractable pain. In the context of chronic cervical zygapophysial joint pain, the target nerves are the medial branches of the cervical dorsal rami t

Resolution of psychological distress of whiplash patients following treatment by radiofrequency neurotomy: a randomised, double-blind, placebo-controlled trial

It is well recognised that patients with chronic pain, in particular, chronic whiplash-associated neck pain, exhibit psychological distress. However, debate continues as to whether the psychological distress precedes and causes the chronic pain or, conversely, the psychological distress is a consequence of chronic pain. Using cervical zygapophysial joint pain as a model for chronic pain, the effect of a definitive neurosurgical treatment on the associated psychological distress was studied. Seventeen patients with a single painful cervical zygapophysial joint participated in a randomised, double-blind, placebo-controlled trial of percutaneous radiofrequency neurotomy. Their pain and psychological status were evaluated pre-operatively and 3 months post-operatively by medical interview and examination, a visual analogue pain scale, the McGill Pain Questionnaire, and the SCL-90-R psychological questionnaire. All patients who obtained complete pain relief exhibited resolution of their pre-operative psychological distress. In contrast, all but one of the patients whose pain remained unrelieved continued to suffer psychological distress. Because psychological distress resolved following a neurosurgical treatment which completely relieved pain, without psychological co-therapy, it is concluded that the psychological distress exhibited by these patients was a consequence of the chronic somatic pain.

Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution.

Percutaneous radiofrequency neurotomy has been used in the treatment of pain from the cervical zygapophysial joints, but the results have been modest and not compelling. Several factors might account for its apparent poor success rate, including inadequate patient selection, inaccurate surgical anatomy, and technical errors. In an effort to overcome these confounders, we used comparative local anesthetic blocks to preoperatively, definitively diagnose cervical zygapophysial joint pain and developed an amended operative technique based on formal anatomical studies. An audit was conducted of our experience with 19 patients to determine whether there was sufficient merit in the amended procedure to justify a randomized, double-blind, controlled trial. The duration of complete pain relief was the principal outcome measure. Side effects and complications were also monitored. Of the 10 patients who underwent third occipital neurotomy for the treatment of C2-C3 zygapophysial joint pain, only 4 obtained long-lasting relief. The other six patients reported an early return of their pain and constituted technical failures; the third occipital nerve was inadequately coagulated and recovered in the immediate postoperative period. Of the 10 patients who underwent lower cervical medial branch neurotomy, 7 obtained complete pain relief for clinically useful periods and were able to resume their activities of daily living and employment. After procedures at all levels, a brief period of postoperative pain was experienced by the patients and ataxia was a side effect of third occipital neurotomy. There were no cases of postoperative infection or anesthesia dolorosa. Given the high technical failure rate of third occipital neurotomy, we recommend that this procedure be abandoned until the technical problems can be overcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous Radiofrequency Neurotomy in the Treatment of Cervical Zygapophysial Joint Pain

Percutaneous Radiofrequency Neurotomy in the Treatment of Cervical Zygapophysial Joint Pain

Technical Limitations to the Efficacy of Radiofrequency Neurotomy for Spinal Pain

Prompted by clinical failures of percutaneous radiofrequency neurotomy in the treatment of back pain and neck pain, we performed a study to determine the shape and size of lesions made by radiofrequency electrodes. Experimental lesions were made in egg white and fresh meat at temperatures recommended in clinical practice. The cardinal finding was that lesions do not extend distal to the tip of the electrode. They only extend radially around the electrode tip in the shape of an oblate spheroid, with a maximal effective radius of only 2 mm. Consequently, if electrodes are directed perpendicularly onto a nerve, the nerve may not be encompassed by the lesion generated. Some of the clinical failures of percutaneous medial branch neurotomy (facet rhizotomy) may be due to this phenomenon. We suggest modified techniques for medial branch neurotomy in which the electrodes are introduced parallel to the target nerve whereupon it is more readily encompassed by the radial spread of the lesion.

Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain.

Prompted by clinical failures of percutaneous radiofrequency neurotomy in the treatment of back pain and neck pain, we performed a study to determine the shape and size of lesions made by radiofrequency electrodes. Experimental lesions were made in egg white and fresh meat at temperatures recommended in clinical practice. The cardinal finding was that lesions do not extend distal to the tip of the electrode. They only extend radially around the electrode tip in the shape of an oblate spheroid, with a maximal effective radius of only 2 mm. Consequently, if electrodes are directed perpendicularly onto a nerve, the nerve may not be encompassed by the lesion generated. Some of the clinical failures of percutaneous medial branch neurotomy ("facet rhizotomy") may be due to this phenomenon. We suggest modified techniques for medial branch neurotomy in which the electrodes are introduced parallel to the target nerve whereupon it is more readily encompassed by the radial spread of the lesion.