Medial Branch Radiofrequency Neurotomy Research Articles

True lateral imaging during lumbar medial branch radiofrequency neurotomy: Interobserver reliability

BackgroundTrue lateral imaging (TLI), obtained by superimposing bilateral lumbar spine structures and aligning superior endplate cortical bone, requires deliberate rotational adjustments of the laterally positioned fluoroscope in both the axial and longitudinal planes. True lateral segmental imaging is necessary to depict true and accurate radiofrequency (RF) cannula positioning relative to bony anatomy during lumbar medial branch radiofrequency neurotomy (LMBRFN). ObjectiveTo determine the interobserver reliability of TLI during LMBRFN. MethodsThis was a retrospective review of a prospectively generated collection of lateral fluoroscopic images to determine the interobserver reliability of TLI during LMBRFN. Lateral fluoroscopic images were prospectively collected from 34 consecutive L4-5 and L5-S1 LMBRFN procedures during routine clinical practice. Employing International Pain and Spine Intervention Society (IPSIS) LMBRFN and TLI techniques, an RF cannula was positioned parallel to the L3 and L4 medial branches and the L5 dorsal rami. During the normal course of TLI, untrue and final true lateral segmental images were obtained and saved. An original data set of 100 pairs of true and untrue lateral images was reviewed to verify true laterality using established criteria; disagreement was resolved by consensus or discarding ambiguous cases. To measure interobserver reliability (Cohen's Kappa), two blinded expert reviewers independently reviewed the image set, identifying the true lateral image and the plane requiring correction. ResultsThe observers agreed upon 98/98 true lateral RF-segment images (Kappa score 1.0 [1.00,1.00]). The observers agreed upon 86/98 maneuvers to correct the untrue RF-segment image. The Kappa score for determining the most appropriate corrective maneuver was 0.76 (0.63,0.89), showing substantial interobserver agreement. ConclusionsThe true lateral image of the targeted RF segment during LMBRFN was reliably determined with perfect interobserver agreement. Interobserver agreement was substantial regarding the maneuver to achieve TLI.

Asymmetrical atrophy of the paraspinal muscles in patients undergoing unilateral lumbar medial branch radiofrequency neurotomy.

Lumbar medial branch radiofrequency neurotomy (RFN), a common treatment for chronic low back pain due to facet joint osteoarthritis (FJOA), may amplify paraspinal muscle atrophy due to denervation. This study aimed to investigate the asymmetry of paraspinal muscle morphology change in patients undergoing unilateral lumbar medial branch RFN. Data from patients who underwent RFN between March 2016 and October 2021 were retrospectively analyzed. Lumbar foramina stenosis (LFS), FJOA, and fatty infiltration (FI) functional cross-sectional area (fCSA) of the paraspinal muscles were assessed on preinterventional and minimum 2-year postinterventional MRI. Wilcoxon signed-rank tests compared measurements between sides. A total of 51 levels of 24 patients were included in the analysis, with 102 sides compared. Baseline MRI measurements did not differ significantly between the RFN side and the contralateral side. The RFN side had a higher increase in multifidus FI (+4.2% [0.3-7.8] vs +2.0% [-2.2 to 6.2], P = 0.005) and a higher decrease in multifidus fCSA (-60.9 mm 2 [-116.0 to 10.8] vs -19.6 mm 2 [-80.3 to 44.8], P = 0.003) compared with the contralateral side. The change in erector spinae FI and fCSA did not differ between sides. The RFN side had a higher increase in multifidus muscle atrophy compared with the contralateral side. The absence of significant preinterventional degenerative asymmetry and the specificity of the effect to the multifidus muscle suggest a link to RFN. These findings highlight the importance of considering the long-term effects of lumbar medial branch RFN on paraspinal muscle health.

Does medial branch radiofrequency neurotomy accelerate degenerative lumbar spondylolisthesis compared to natural progression? A cross-sectional cohort study

BackgroundLumbar radiofrequency neurotomy (LRFN) effectively treats lumbar zygapophyseal joint pain by coagulating medial branch nerves (MBNs) carrying nociceptive signals. MBNs also innervate deep paraspinal muscles. There is a paucity of literature on whether LRFN accelerates the progression of vertebral displacement in patients with degenerative lumbar spondylolisthesis (DLS). ObjectiveCompare the rate of spondylolisthesis progression in adults with DLS who underwent LRFN to the 2% annual rate of progression expected by natural history. DesignCross-sectional cohort study. MethodsConsecutive patients with pre-existing DLS who underwent LRFN for zygapophyseal joint-mediated low back pain were identified. Patient demographics, LRFN procedure details, and radiographic images confirming Meyerding Grade (I-II) spondylolisthesis were collected from electronic medical records. The quantitative magnitude of spondylolisthesis progression and the annualized rate were calculated from pre-and post-LRFN radiographs. Data were analyzed using Wilcoxon signed-rank tests and a linear regression model. Results152 patients (mean age 65.9 ± 12.3 years; 59.2% female) met eligibility criteria and were included in the analyses. Average time to radiographic follow-up was 35.6 ± 24.7 months post-LRFN. The average spondylolisthesis progression rate of 1.63 ± 2.91% per year calculated for the LRFN cohort was significantly lower than the 2% annual rate of progression associated with natural history (p < 0.001). None of the included covariates, such as age, BMI, LRFN laterality, number of levels denervated, or history of prior lumbar spinal surgery, were significantly associated with the average annual rate of progression. ConclusionsOur results suggest that spondylolisthesis progression rate is no different or worse than the expected natural progression rate in patients with pre-existing DLS who have undergone LRFN.

Randomized controlled trial comparing technical features and clinical efficacy of a multi-tined cannula versus a conventional cannula for cervical medial branch radiofrequency neurotomy in chronic neck pain

ObjectivesCompare procedural characteristics and clinical efficacy of cervical medial branch radiofrequency neurotomy (CMBRFN) using a multi-tined cannula (MTC) versus a conventional cannula (CC) to treat chronic neck pain. DesignProspective, double-blinded randomized controlled trial. MethodsPatients who responded to dual medial branch blocks with ≥75% pain relief were randomized to receive RFN with either the MTC or the CC. Primary outcomes: procedural pain, procedure duration, fluoroscopy time and radiation dose. Secondary outcomes: proportion of patients reporting ≥50% numerical rating scale reduction and ≥30% neck disability index reduction at 3, 6 and 12 months. ResultsForty-two patients underwent treatment. There was no difference in procedural pain between the MTC and CC groups (NRS 4.7 ± 2.0 vs. 4.2 ± 1.8, p = 0.465), but three patients, all in the CC group, could not complete the procedure due to pain. CMBRFN in the MTC group was significantly faster than in the CC group (35.5 ± 7.3 min vs. 58.2 ± 14.8 min, p < 0.001), with less fluoroscopy time (167.6 ± 76.4 s vs. 260.8 ± 123.5 s, p = 0.004). Radiation dose was 8.95 ± 7.9 mGy in the MTC group and 11.53 ± 10.3 mGy in the CC group (p = 0.36). Rates of ≥50% NRS reduction were not significantly different between the two groups at 3 months, but at 6 and 12 months, they were significantly higher in the CC group. At 3, 6 and 12 months, rates of ≥30% NDI reduction were significantly higher in the CC group. ConclusionsThe MTC offers technical advantages compared to the CC for both the operator and the patient. However, CMBRFN with the multi-tined cannula seems less effective to treat neck pain than with the conventional cannula.

FactFinders for patient safety: Understanding potential procedure-related complications: RFN/multifidus atrophy, intradiscal biologics, and facet cyst rupture

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential procedure-related complications.The evidence in support of the following facts is presented: (1) Multifidus Atrophy After Lumbar Medial Branch Radiofrequency Neurotomy (LMBRFN) -- There is no conclusive published literature indicating that LMBRFN leads to increased multifidus atrophy relative to natural history. High-quality prospective studies with a natural history comparison group evaluating immediate pre-procedure as well as post-procedure longitudinal cross-sectional imaging are needed to accurately assess for any possible influence of LMBRFN on multifidus atrophy as well as the clinical relevance. (2) Intradiscal Biologics -- Although the available evidence on intradiscal biologic interventions is limited, it nonetheless shows a non-zero risk of complications. Until larger sample sizes are reported, the actual magnitude of the risk cannot be ascertained. In the meantime, physicians who perform intradiscal injections of biologics should conscientiously consider the risk-benefit of these procedures. (3) Lumbar Facet Synovial Cyst Rupture -- There have been few reports of complications secondary to lumbar facet synovial cyst rupture. Risks of may include increased pain, infection, and nerve root compression.

CRITICAL EVALUATIONS OF INTRA-ARTICULAR PLATELET RICH PLASMA ALONE OR COMBINATION WITH MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY IN PATIENTS WITH LUMBAR FACET JOINT ARTHROPATHY: A PROSPECTIVE OUTCOME STUDY

Background: Common cause of chronic low back pain is lumbar facet joint arthropathy. Radiofrequency ablation (RFA) of medial branch currently preferred treatment in facet joint pain syndrome. Platelet-rich plasma (PRP) is known to initiate mesenchymal tissue healing by concentration of several fundamental protein growth factors. Our aim in this study is to evaluate the effect of co-administration of autologous PRP in lumbar facet and RFA of the medial branch of the dorsal ramus for lumbar facet arthropathy. Methodology: This was a prospective randomised study with a blind assessor. Eighty-one consecutive patients who complained of low back pain secondary to lumbar facet joint arthropathy were randomly allocated into three-groups: Group RF: only RFA done. Group PR: received both PRP plus RFA. Group PL: received only PRP. Primary outcome of the study was assessment of pain intensity using visual analogue scale (VAS). Result: The patients who had both RFA and PRP therapy had significant decrease in VAS score as compared to its baseline in the immediate and long term follow up period ([Formula: see text] &lt; 0.001). However, for those who received only PRP, the decrease in VAS was more significant at 1 and 4 months. Similarly, there was a significant improvement in ODI score in patients who received both RFA and PRP ([Formula: see text] &lt; 0.001). There was a gradual improvement in ODI in PRP group at 4-month interval. Rescue analgesics requirement was reduced and patients were better satisfied in those who received both RFA and PRP therapy. ([Formula: see text] &lt; 0.05). Conclusion: The combined administration of RFA and PRP proved to provide better analgesia in both short-term follow up and long-term follow up than treatment with either method in patients with lumbar facet syndrome.

Are There Optimal Prognostic Block Selection Criteria for Predicting Treatment Success Following Cervical Medial Branch Radiofrequency Neurotomy? A Real-world Cohort Study

Are There Optimal Prognostic Block Selection Criteria for Predicting Treatment Success Following Cervical Medial Branch Radiofrequency Neurotomy? A Real-world Cohort Study

The Effectiveness of Cervical Medial Branch Radiofrequency Neurotomy Using a Perpendicular Approach with a Multi-tined Probe: A Single-Arm, Retrospective Cohort Study

The Effectiveness of Cervical Medial Branch Radiofrequency Neurotomy Using a Perpendicular Approach with a Multi-tined Probe: A Single-Arm, Retrospective Cohort Study

Are There Optimal Prognostic Block Selection Criteria for Predicting Treatment Success Following Lumbar Medial Branch Radiofrequency Neurotomy? A Cohort Study

Are There Optimal Prognostic Block Selection Criteria for Predicting Treatment Success Following Lumbar Medial Branch Radiofrequency Neurotomy? A Cohort Study

Brown-Sequard Syndrome After Radiofrequency Therapy of the Left C3 Medial Branch

&lt;p&gt;A 59-year-old woman presented with a 5-year history of neck pain and intractable headache radiating from the occipital region to the supra-orbital region. Magnetic resonance imaging demonstrated a C5&amp;ndash;6 herniated intervertebral disc and bulging disc at C4&amp;ndash;5. Left C3 medial branch radiofrequency neurotomy was performed. Although the procedure was uneventful, the patient developed a cervical spinal cord haemorrhage that caused Brown&amp;ndash;S&amp;eacute;quard syndrome. The haemorrhage was presumably caused by iatrogenic injury of a radicular artery during the procedure.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Factfinders for patient safety: Anticoagulant and antiplatelet agents and cervical medial branch procedures

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of anticoagulant and antiplatelet agents for cervical medial branch blocks and cervical medial branch radiofrequency neurotomy.The evidence in support of the following facts is presented: (1) In patients maintained on therapeutic anticoagulant (AC) and/or antiplatelet (AP) therapy, for whom cervical medial branch blocks (CMBBs) are being considered, there is strong evidence to guide decisions on continuing or discontinuing these AC/AP agents in preparation for the procedure. (2) Therapeutic anticoagulation (AC) and antiplatelet (APT) agents should be discontinued prior to cervical medial branch radiofrequency neurotomy (CMBRFN) due to serious hemorrhagic risks.

Virtual reality for procedural education: Lumbar medial branch radiofrequency neurotomy

Virtual reality (VR) simulation is an emerging tool in medical education. Simulation conducted in VR can reproduce procedural scenarios and allow for immersive interaction with anatomic models. This has the potential to improve understanding of anatomy and concepts relevant to interventional procedures.Here, we present a “proof-of-concept” modeling of lumbar thermal radiofrequency neurotomy through cost-effective, commercially available VR hardware and software. With this technology, we can demonstrate key fluoroscopic views and needle trajectories based on specific recommendations from Spine Intervention Society guidelines. Furthermore, the learner can manipulate the model in multiple 3-dimensional axes to visualize anatomy relevant to key fluoroscopic views. Finally, the content can be exported by recording a live casting stream, thus offering an approach for future content creation and collaboration.VR technology is an emerging educational modality that offers immersive and interactive features that may offer advantages to traditional visual teaching modalities.

Characterizing an angle of cannula insertion for Lumbar Medial Branch Radiofrequency Neurotomy: A retrospective observational study

ObjectiveEvidence characterizing a starting angle of radiofrequency (RF) cannula insertion during radiofrequency neurotomy is lacking. Using computerized tomography (CT), this retrospective observational study attempts to establish a starting angle for RF cannula placement parallel to the transverse process (TP) at the junction of the superior articular process (SAP) near the targeted medial branch. MethodsThis retrospective observational study utilized lumbar spine CT scans performed on adult cancer patients from January 2016 to May 2021 ​at a single center. No significant lumbar pathology was present on the included CT studies. For each patient, medial branches were assumed to lie at the junction of the right and left TP and SAP at each lumbar level. The angle of insertion from each segment’s “squared” superior end plate needed for RF cannula placement parallel to the surface of the TP next to the SAP was calculated. ResultsImages obtained from fifty patients were analyzed. Mean angle of insertion for L1 was 20.15 ​± ​1.82°, L2 was 20.95 ​± ​2.07°, L3 was 25.54 ​± ​1.76°, L4 was 31.01 ​± ​1.83°, and L5 was 40.74 ​± ​1.86°. ConclusionThis study demonstrates variations in inserting angle for RF cannula placement parallel to the surface of the transverse process at each lumbar level. To our knowledge, there are no studies in the current literature that have described an entry angle for RF cannula positioning parallel to lumbar medial branches using CT images.

FactFinders for patient safety: Antithrombotics and interventional pain procedures -- lumbar transforaminal epidural steroid injections and lumbar medial branch radiofrequency neurotomy

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of antithrombotics and two interventional pain procedures — lumbar transforaminal epidural steroid injections and lumbar medial branch radiofrequency neurotomy.The evidence in support of the following facts is presented: (1) The decision to withhold antiplatelet therapy prior to lumbar transforaminal epidural steroid injections should be made on a case-by-case basis, weighing the relative risk of hemorrhage versus the risk of thrombosis for each patient. (2) A clinically significant hemorrhagic complication has never been reported in the medical literature in association with a lumbar medial branch radiofrequency neurotomy procedure. (3) Discontinuing antithrombotics for lumbar radiofrequency neurotomy procedures, even for a short period of time, may lead to an increased incidence of cardiovascular and cerebrovascular events.

Combined thoracic medial branch radiofrequency and chemical neurotomy

ObjectiveExplore the effectiveness of thoracic medial branch neurotomy (MBN) using combined radiofrequency neurotomy and neurolytic lesioning. DesignA retrospective cohort of consecutive patients with chronic thoracic axial pain treated in a community setting. InterventionsWe included all patients who underwent MBN between 2010 and 2016, selected for MBN primarily based on 70% relief following single or dual diagnostic medial branch blocks. Using 18-gauge cannulas, we placed electrodes and made lesions at the suspected location of the thoracic medial branch based on anatomic knowledge at the time; the thermal lesions were supplemented with 50% dextrose to enhance the lesion radius. MeasuresWe defined success as ≥50% relief of their index thoracic pain not returning to baseline for at least six months. Patients not reached for follow-up were considered failures for worst-case analysis. ResultsTwenty-eight patients underwent an initial MBN between 2010 and 2016: Twenty-five of twenty-eight (89%) patients reported ≥70% pain reduction not returning to baseline for six months or longer. Using a worst-case analysis (WCA), patients reported average pain relief of 73% CI (63%,84%) with a mean duration of relief following the initial MBN of 9.9 months CI (6, 13.5). Seventeen of the initial 28 patients had a total of 31 repeat MBNs, 13/17 (76%) having pain relief reinstated after one or more repeat MBNs with an average duration of relief following a first repeat MBNs of 10.9 months CI (6.6,15.2). ConclusionThoracic MBN combined with a mild neurolytic is a potentially effective treatment for thoracic pain in patients selected with positive diagnostic MBB. There were no complications noted. One can reinstate pain relief with repeated MBN in most patients should their symptoms return.

Single Entry Posterior Parasagittal Approach Radiofrequency Neurotomy of Cervical Medial Branch: A Feasible Alternative to Conventional Approaches in the Treatment of Cervical Facet Pain.

Cervical facet joint pain is an important cause of chronic neck pain. The recommended treatment for this condition is radiofrequency (RF) neurotomy of the medial branch of dorsal rami. There have been attempts to find safe and effective ways to perform this procedure. The objective of this study is to describe the single entry posterior parasagittal approach and to evaluate the efficacy and safety of this approach compared to the conventional posterolateral approach of RF neurotomy of cervical medial branch. The record of all patients with cervical facet pain who were treated with RF neurotomy medial branch of dorsal rami between January 2016 and December 2019 were reviewed retrospectively. Comparisons were made between patients who underwent RF neurotomy with multiple skin entry posterolateral approach and those who underwent RF neurotomy with single entry posterior parasagittal approach. The primary outcome was measured as the mean changes in numerical rating scale (NRS), and the secondary outcomes were duration and complications related to both approaches. Thirty-one patients who underwent RF neurotomy via posterolateral approach were compared with 40 patients who underwent the procedure via posterior parasagittal approach. Both approaches showed a significant decrease in the NRS from baseline values. However, the differences in the NRS lowering effect at 3 and 12 months between these 2 approaches were not statistically significant. The duration of the procedure was significantly shorter with posterior parasagittal approach (44.13 ± 4.72 minutes vs 54.68 ± 7.39 minutes; P < 0.001). There were no serious complications encountered in both approaches. With comparable efficacy and safety profile between the posterior parasagittal and the conventional posterolateral approaches, the former single skin entry approach offers the added advantage of being less time-consuming. Further randomized prospective studies are necessary to validate these findings.

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.

96. Dual medial branch blocks and progression to radiofrequency neurotomy for zygapophysial arthropathy

96. Dual medial branch blocks and progression to radiofrequency neurotomy for zygapophysial arthropathy

Development and Description of a New Multifidus-Sparing Radiofrequency Neurotomy Technique for Facet Joint Pain.

The technique of radiofrequency neurotomy (RFN) of the facet joints has been used for decades to treat persistent low back pain to good effect in carefully selected patients. Traditionally, the target is the medial branches of the dorsal root supplying the facet joint. An alternative denervation target is the facet joint capsule. Capsule-targeting techniques may spare the multifidus muscle, a possible unintended target of traditional RFN that is thought to be important in recovering from low back pain, and have shown promising results. A modified RFN technique that targets the capsule and spares the multifidus (multifidus-sparing RFN) is described here, along with a brief report of its application in patients with symptomatic facet joint low back pain as compared to traditional medial branch RFN (MBRF). Over a 2-year period, a total of 401 initial multifidus-sparing RFN and 94 initial MBRF procedures were performed on patients attending a multidisciplinary pain clinic. The proportion of repeat procedures was similar: 28.4% of multifidus-sparing procedures and 23.4% of MBRF procedures. The median repeat interval was 12months for both groups and interquartile range was 10 months (8-18 months) for multifidus-sparing RFN and 4 months (11-15 months) for MBRF. Effectiveness and safety profiles appear to be similar, although limited, retrospective outcome information prevented robust analysis. Multifidus-sparing RFN represents an intriguing technique to denervate the facet joint pain generator while maintaining normal multifidus function. Further study is warranted, particularly in order to identify the appropriate patient criteria and long-term outcomes.

"True" Lateral Imaging for Cervical Medial Branch Radiofrequency Neurotomy.

"True" Lateral Imaging for Cervical Medial Branch Radiofrequency Neurotomy.