Facet Radiofrequency Denervation Research Articles

Clinical Outcome after Endoscopic Facet Denervation in Patients with Chronic Low Back Pain.

Several studies have reported that low back pain has a high prevalence among the population, with up to 85%. Percutaneous radiofrequency facet denervation (PRFD) is the gold standard of today's rhizotomy for chronic low back pain (CLBP). However, previously published studies present controversial results for the efficacy of PRFD. Therefore, this study aimed to analyse the use of endoscopic facet joint denervation (EFJD) to treat chronic low back pain and to identify potential risk factors that could limit indications for surgery.We retrospectively included 31 eligible patients into the study with at least 24 months of CLBP. All patients underwent EFJD and had to complete ODI, COMI, EQ-5D and VRS scores postoperatively, with a minimum follow up of 12 months. Basic patient data was recorded to analyse correlations.We found a significant improvement in all clinical scores measured, such as ODI, COMI, EQ-5D and VRS scores. While the best result was found at the 3 months follow-up, a slight deterioration was found at 12 months follow-up. However, significant benefit was observed when compared to preoperative scores. 28/31 patients (93.3%) reported reduced pain at 12 months follow-up and were satisfied with the procedure. Older age and psychiatric precondition were identified as potential risk factors associated with poorer outcome. Postoperative complications such as haematoma, a sensibility disorder and temporary low extremity muscular weakness were rarely observed.EFJD showed significant improvement of the clinical outcome scores and VRS when compared to preoperative results of patients, with a minimum of 12 months of CLBP prior to surgery. Older patients and patients with a psychiatric precondition seem to benefit less from the procedure.

Anatomic-Topographic Investigation of the Branches of the Dorsal Ramus of Thoracic Spinal Nerves.

Percutaneous radiofrequency facet denervation (PRFD) by thermocoagulation is a useful treatment for nonspecific thoracic pain syndrome. To guarantee that maximal thermal lesion is applied to the nerve, it is essential to have precise knowledge of the topography of the thoracic dorsal branches of the spinal nerves. This special anatomy was investigated, and the results were compared with the existing technique for PRFD, where the active needle tip is placed in the junction of the superior articular process and the transverse process. Twenty thoracic spines of cadavers (10 females and 10 males) embalmed according to Thiel's method were bilaterally dissected. After careful removal of skin and subcutaneous fat tissue, the lateral and medial branches were traced centrally. In addition, the articular branch to the thoracic facet joint was traced peripherally. The distance of the medial branch to the inferior articular process at the level of the nerve passing the superior costotransverse ligament was measured. The dorsal branch bifurcates into lateral and medial branches medial to the superior costotransverse ligament. The medial branch runs laterally first to pass in between two parts of the intertransverse ligament running dorsally and to turn medially superficial to this ligament. The zygapophysial branch always originated from the medial branch passing the inferior articular process laterally by running caudally to turn medially and send branches to the capsule of the zygapophyseal joint. The distance of the medial branch lateral to the inferior articular process was constantly 3 mm. The current technique of PRFD at the thoracic spine targets the medial branch distal to the separation of the articular branch, rendering the lesion ineffective at denervating the zygapophyseal joint. For selective thermocoagulation of the articular branches of the thoracic zygapophyseal joint, a new technique should be developed. We propose an anatomically informed needle position that can now be confirmed clinically.

Open facet joint denervation as an adjunct in patients undergoing posterior lumbar decompression for spinal stenosis-a single blinded randomized controlled trial.

Facet radiofrequency denervation is a prevalent procedure used to try and relieve back pain. Despite the increasing use of this treatment, its effectiveness has been questioned. In consideration of the conflicting reports in the literature, we sought to conduct a trial to study the short-term effect of facet denervation in patients undergoing lumbar laminectomy(s) to determine the short-term effect of adding facet denervation to patients undergoing lumbar laminectomy(s) where the anatomy was exposed, allowing an open technique to be used for the denervation. Sixty patients with a diagnosis of degenerative lumbar spinal stenosis who complained of neurogenic claudication and back pain for at least 3 months were randomized to undergo a lumbar laminectomy(s) either with or without facet joint denervation. Pain and self-reported function using a 10 cm visual analogue scale (VAS) and the Roland-Morris Disability Questionnaire (RMDQ) were measured before surgery and at patients' 6-, 12- and 24-week follow-up clinic visit. Various parametric and non-parametric tests including the Chi-square, independent samples t-tests, the Mann Whitney U, Wilcoxon sign ranks, one-way ANOVA with a Bonferroni post hoc test were used to analyze the data. The RMDQ scores were analyzed between groups and within groups over time. No differences in pain or functional ability were seen between groups. Both groups significantly improved in both pain and function from baseline to follow up times. Our findings do not support the addition of facet denervation for short-term treatment of back pain in patients undergoing lumbar laminectomy(s) for spinal stenosis within our study design.

Comments on Efficacy of Radiofrequency Facet Denervation Procedures

To the Editor: Thank you for the opportunity to comment on our study published in the Clinical Journal of Pain in 2005 [1]. This study was a randomized, double-blind, sham lesion-controlled trial on radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain (CLBP). The study results have been widely referenced and often used to substantiate that lumbar radiofrequency facet (RF-facet) denervation procedures are ineffective. As stated in our article, we designed the study to evaluate if common practice in our community, at that time, had efficacy. In our study, less rigorous selection of patients was undertaken to more closely represent community practice. Previous low back surgery and/or other concomitant causes for CLBP were not excluded. Additionally, single instead of controlled diagnostic blocks were used with a less demanding percentage of relief (50%) to select patients for RF in view of the low risk to benefit ratio of RF-facet. In addition, the false negative rates of controlled diagnostic blocks may preclude a number of patients from undergoing a potentially beneficial procedure [2]. At the time of the trial, based on limited available evidence [3], the perception was that intra-articular blocks were as diagnostically specific as medial branch blocks. Thus, consistent with our clinical practice at that …

Does Sensory Stimulation Threshold Affect Lumbar Facet Radiofrequency Denervation Outcomes? A Prospective Clinical Correlational Study

Radiofrequency facet denervation is one of the most frequently performed procedures for chronic low back pain. Although sensory stimulation is generally used as a surrogate measure to denote sufficient proximity of the electrode to the nerve, no study has examined whether stimulation threshold influences outcome. We prospectively recorded data in 61 consecutive patients undergoing lumbar facet radiofrequency denervation who experienced significant pain relief after medial branch blocks. For each nerve lesioned, multiple attempts were made to maximize sensory stimulation threshold (SST). Mean SST was calculated on the basis of the lowest stimulation perceived at 0.1-V increments for each medial branch. A positive outcome was defined as a ≥50% reduction in back pain coupled with a positive satisfaction score lasting ≥3 months. The relationship between mean SST and denervation outcomes was evaluated via a receiver's operating characteristic (ROC) curve, and stratifying outcomes on the basis of various cutoff values. No correlation was noted between mean SST and pain relief at rest (Pearson's r=-0.01, 95% confidence interval [CI]: -0.24 to 0.23, P=0.97), with activity (r=-0.17, 95% CI: -0.40 to 0.07, P=0.20), or a successful outcome. No optimal SST could be identified. There is no significant relationship between mean SST during lumbar facet radiofrequency denervation and treatment outcome, which may be due to differences in general sensory perception. Because stimulation threshold was optimized for each patient, these data cannot be interpreted to suggest that sensory testing should not be performed, or that high sensory stimulation thresholds obtained on the first attempt should be deemed acceptable.

A Report of 3 Soldiers Returned to Full Duty after Lumbar Radiofrequency Facet Denervation in a Theater of War: Table 1

To provide the advanced interventional procedure of zygapophysial joint neurotomy to soldiers meeting the diagnostic criteria in a combat environment and thus reduce medical evacuations of soldiers from a theater of war. Retrospective chart review was performed on three consecutive soldiers who received neuroablation of the lumbar ZP joint. Patients received single MBB with 1 cc of 1% lidocaine at the b/l L3-L5 levels considered diagnostic if >50% analgesia was achieved concordant with duration of anesthetic. All procedures were co-performed by the two authors at the Ibn Sina hospital in Baghdad, Iraq over a 3-month period. Three consecutive patients with >50% pain relief from diagnostic medial branch blocks were treated with radiofrequency ablation of the bilateral L3-L4 medial branch nerves and L5 posterior primary ramus. Sensory test stimulation at 50 Hz and motor stimulation at 2 Hz were performed at each level. The nerves were then lesioned at 80° Centigrade for 90 seconds after injection of lidocaine and methylprednisolone. Procedure was considered successful if patients were able to wear body armour without significant discomfort (at least 1 hour/day). Medical evacuation from Iraq was prevented and all soldiers returned to rigorous combat duties including the wearing of body armour daily. We believe to be the first to report on the use of RF nerve ablation in a war time setting and with this functional outcome.

Diagnostic Medial Branch Blocks before Lumbar Radiofrequency Zygapophysial (Facet) Joint Denervation

Diagnostic Medial Branch Blocks before Lumbar Radiofrequency Zygapophysial (Facet) Joint Denervation

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 lumbar facet denervation: A comparative study of the reproducibility of lesion size after 2 current radiofrequency techniques

Radiofrequency facet denervation procedures are widely used for the treatment of chronic low-back pain. Currently, both temperature-controlled and voltage-controlled techniques are used. In this combined in vivo and in vitro study, the electrophysiologic consequences and the effects on lesion size of these techniques were determined. Thirty-three patients were randomly assigned to receive a lumbar radiofrequency facet denervation by using either temperature-controlled (80 degrees C, 60 seconds) or voltage-controlled (20 V, 60 s) mode. Electrophysiologic parameters in both groups during radiofrequency lesioning were registered. Observed differences between electrodes were quantified and interpreted, using lesion-size data from egg-white experiments. Seventeen patients in the temperature group were treated with a total of 55 radiofrequency lesions, all considered technically adequate. In the voltage-controlled group, 16 patients received 63 lesions. Of these, 44 (69.8%) procedures were found to be technically inadequate. Voltage-controlled radiofrequency lesioning resulted in uncontrollable fluctuations of temperature, with resultant uncontrollable variations in lesion size. Temperature-controlled mode created reproducible lesion sizes. There is no consistent relation between voltage and the temperature obtained during radiofrequency lumbar facet denervation. Temperature-controlled radiofrequency lesioning is preferred to create reproducible lesion sizes.

Radiofrequency Lumbar Medial Branch Denervation Using Bipolar Probe in Patient with Facet Joint Syndrome

Background: The facet joint is one structure that can cause lower back pain and radiofrequency (RF) denervation of the medial branch has been shown to be effective in treating this type of pain. However, the proper positioning of needle to the medial branch by sensory testing may be difficult when there are severe degenerative changes in the spine. In these cases, bipolar electrodes might be effective in making a wider strip lesion as in a sacroiliac joint. This study performed an RF facet denervation using a bipolar probe in a patient suffering from facet pain and investigated whether or not the bipolar method could be an alternative choice by observing the voltage of the sensory test that elicits concordant pain at the first challenge of the needle positioning. Methods: Thirteen patients with 50% relief of their back pain followed by a diagnostic medial branch block, received a bipolar RF lumbar facet denervation in the prone position under fluoroscopic guidance. The first needle was positioned at the junction of the superior articular process and pedicle, and it was advanced 1 - 2 mm. A second needle was positioned slightly inferolateral to the first needle at the junction of the transverse process and pedicle. RF procedures were undertaken at an unchanged needle position from acceptable sensory testing to the lesioning that was regarded as being a success. In addition, the voltage and success rate were measured. After 2 weeks, the outcome was assessed through the change in the VAS. Results: In 13 patients, a total of 62 (pulsed RF = 17) RF procedures were performed. In the first trial of sensory testing, the success rate was 72% (45/62) at 0.5 volt and 95% (59/62) at 1.0 volt (mean = 0.47 volt). At 2 weeks after RF, 6 patients 50% or more relief of their back pain, 10 patients were satisfied with the RF and no patients complained any complications. Conclusions: Bipolar RF can be an alternative to the treatment of facet pain, particularly when there are severe degenerative changes in the spine.

Application of spinal ablative techniques for the treatment of benign chronic painful conditions: history, methods, and outcomes.

The literature on current neuroablative techniques for treating benign chronic painful conditions is comprehensively reviewed. To provide the reader with an understanding of the indications, techniques, and outcomes for the various ablative procedures used to treat chronic pain syndromes. Neuromodulatory techniques are rapidly supplanting the traditional neuroablative procedures used to treat many types of pain. A MEDLINE search was conducted for each of the following procedures: radiofrequency facet denervation, cordotomy, myelotomy, sympathectomy, DREZotomy, rhizotomy, and ganglionectomy. In the review of each article, special attention given to the outcome, length of follow-up, complications, and number of patients. Summaries of this data were compiled to provided historical perspective, current techniques, indications, and outcomes for each of the aforementioned procedures. The outcomes cited for each procedure generally represent the data from the three or four largest series with adequate follow-up length. The aforementioned procedures have 30% to 90% success rates, with success defined as at least a 50% reduction in perceived pain. These results tend to diminish with time. However, most are associated with a significant degree of morbidity and relatively high complication rates. In addition, many of the techniques lead to deafferentation pain syndromes. Ablative spinal techniques offer pain relief for many patients, but the use of these methods should be considered carefully in the light of available nondestructive procedures that may achieve similar goals with potentially lower morbidities.

Relevance of nerve blocks in treating and diagnosing low back pain--is the quality decisive?

Relevance of nerve blocks in treating and diagnosing low back pain--is the quality decisive?

(624) Clinical Outcomes after Percutaneous Radiofrequency Facet Denervation

(624) Clinical Outcomes after Percutaneous Radiofrequency Facet Denervation

Percutaneous Radiofrequency Facet Rhizotomy – Experience with 118 Procedures and Reappraisal of its Value

There have been many reports of percutaneous radiofrequency facet rhizotomy, perhaps better referred to as facet denervation, usually performed under general anaesthesia, with inconsistent success rates. To report the authors' outcome data using both general and local anaesthesia and to reassess the value of this controversial procedure. Our experience with 118 consecutive percutaneous radiofrequency facet rhizotomies performed on 90 patients in the Toronto Western Hospital was analyzed. Sixty percent of the procedures were performed under general anaesthesia, 40% under local anaesthesia. All patients had been temporarily virtually relieved of pain after local anaesthetic blockade of the subject facets by an independent radiologist. The patients were monitored from 1-33 (mean 5.6) months after surgery, with complete elimination or a greater than 50% subjective reduction of pain considered the criteria for success. For the first or only procedure this was 41% overall, 37% in cases done under local anaesthesia, 46% in cases done under general anaesthesia (difference not statistically significant p=0.52). There was no statistically significant difference in success rates for procedures performed in the cervical, thoracic or lumbosacral facets, with unilateral versus bilateral denervations, when two to three as compared with more than three facets were denervated, nor for operations done in patients who had had previous spinal surgery compared with those who had not. Results were not better regardless of whether hyperextension of the spine aggravated the patient's preoperative pain or not, and when the procedures were repeated in the same patient outcomes tended to be consistent, arguing against repetition of failed facet denervations. The morbidity was low, the chief problem being sensory loss and transient neuropathic pain in the distribution of cutaneous branches of posterior rami in the cervical and thoracic areas; mortality was zero. Percutaneous radiofrequency facet denervation is simple and safe, still worth considering in patients with disabling spinal pain that fails to respond to conservative treatment. The use of general anaesthesia shortens the operating time and the patient's discomfort without impairing success rate.

Percutaneous radiofrequency facet denervation in low-back and extremity pain.

The present series includes 47 patients (35 females 12 males) with an average observation time of 8 months after percutaneous lumbar facet denervation by radiofrequency electrocoagulation. All patients had static and kinetic lumbar pain; 90% of them had pain radiating into the legs. None had clinical or radiologic (radiculography and/or CT scan) evidence of a lumbar disc herniation, and all had exhausted conservative therapy. All but one had provocation of their habitual pain on arthrography of the relevant intervertebral lumbar joints and/or on intraoperative stimulation prior to electrocoagulation. 22/47 of the patients had no immediate or late beneficial effect of the electrocoagulation. Eight of the remaining 25 patients had satisfactory relief of pain at follow-up. The failures included all patients with previous multiple lumbar operations except for three.

Radiofrequency Facet Denervation: A Treatment Alternative in Refractory Low Back Pain with or without Leg Pain

Summary In summary, there exists a definite clinical syndrome marked by worsening subjective complaints associated with increased activity, especially those activities that unduly stress the lumbar articulations and their soft tissue investitures. The complaint of low back pain is frequently associated with pain of a referred nature into one or both legs, usually limited to an area above the knee. Unusual areas of pain perception have been described as emanating from noxious stimuli to the periarticular nerves, which are branches of the posterior primary ramus. Objective findings are scarce, with the x-ray studies of myelography and CT scanning being normal. These patients are refractory to time-honored conservative methods of treatment such as bracing, bed rest, analgesics, and physical therapy. A treatment alternative exists that employs, as its basis of approach, known anatomic facts. It relies on the fact that certain miniscule nerves and their branches bear a constant and reproducible location with respect to bony landmarks of the spine. By virtue of this anatomy, these nerves are readily accessible to percutaneous destruction. The procedure of radiofrequency denervation is safe, and in my experience, it has yet to cause permanent worsening of a patient's clinical condition, a claim that cannot often be made for spine fusion or laminectomy. The procedure of radiofrequency denervation has been shown to be effective in satisfactorily reducing pain perception in greater than 70 per cent of patients, provided that those patients were screened first with preoperative facet blocks. For a patient to be considered a candidate for the procedure, pain relief from the blocks must be substantial and reproducible. Consideration of the procedure as a denervation of the motion segment must be disposed of. At best, I have come to think of it as a desensitizing procedure, a concept for which I am indebted to Dr. Vert Mooney. I seek to reduce the sensory input from the only nociceptive site accessible to percutaneous destruction. There still remain the innervations to the neural contents of the spinal canal, the annulus fibrosis, and the posterior longitudinal ligament made via the sinuvertebral nerve with this being multisegmental in its innervation.23 It is possible that this nociceptive input is responsible for the tendency toward partial relief of symptoms and a seemingly time dependent deterioration of relief following facet denervation procedures. No alteration is being made in the stability of the motion segments, so as such, the pathologic process continues, labeled by many as “mechanical instability.” All that I have attempted to do is to modify the host response to the noxious stimulation from one area of the spine. As degeneration of the motion segment continues, made possible by vocational stress, body habitus, or decreased muscle conditioning, further segmental instability ensues. The part played by the sinovertebral nerve may then become more important, thus explaining these late failures. The procedure of radiofrequency facet denervation should be applied only in a well thought out treatment program and should never act as a substitute for the time honored treatment modality of rest, immobilization, analgesia, weight reduction, graduated exercise, and spinal education.

Radiofrequency Facet Denervation in Treating Headache Associated with Chronic Neck Pain

AbstractThis article is concerned with patients whose chief complaint of headache was found to originate in facet joints of the upper cervical spine, usually as a result of trauma. Eighty-four patients who had suffered severe chronic headache associated with neck pain for periods ranging from two months to thirty years (with an average of two years and nine months) were treated with radiofrequency facet denervation or rhizotomy. The results of the procedure are evaluated based on an average follow-up of close to two years. The results of this study suggest that when severe and persistent headache can be shown to originate in painful facet joints of the upper cervical spine (with or without co-existing discopathy), facet denervation is a valid treatment method, with a reasonable chance for success.

Facet Denervation in the Management of Back and Sciatic Pain

Back pain, with or without sciatic radiation, may come from a number of anatomical sites. Radiofrequency facet denervation suggests that a majority of patients seem to have pain referred from distress of the facet joints or the sacro-iliac joints. In those patients who are properly selected and have not had previous surgical treatment, radiofrequency denervation of the appropriate facet joints yields partial to total relief of pain in 82% of cases. The technique for doing this procedure and for selection of patients must be followed very closely but in over 800 patients surveyeyed for this report no neurologic complications have been reported. Facet denervation, when indicated, is proposed as a safe alternative to either chemonucleolysis or surgery.