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Dr Jim BorowczykMusculoskeletal Physician
Christchurch
8:30 - 10:30 WS #1: Musculoskeletal Workshop Part 1
11:00 13:00 WS #7: Musculoskeletal Workshop Part 2
Dr Peter McKenzieMusculoskeletal Physician
Nelson
Dr John RobinsonGeneral Practitioner
Otumoetai Doctors
Tauranga
Dr John MacVicarMedical Director
Musculoskeletal Medicine Specialist
Southern Rehab
Christchurch
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Thermal cervical medial branch radiofrequency neurotomy
JOHN MACVICAR
28.05.15
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CERVICAL AND LUMBAR
ZYGAPOPHYSIAL “FACET” JOINTS
Proven sources of pain
Innervation known
Nerves accessible
Nerves suitable size
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PHYSICS
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RF GENERATOR
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RF GENERATOR
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RF GENERATOR
ground plate
electrode
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RF GENERATOR
ground plate
electrode
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RF GENERATOR
ground plate
electrode
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RF GENERATOR
ground plate
electrode
-+
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RF GENERATOR
ground plate
electrode
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ELECTRIC FIELD
isotherms
55o C
65o C
75o C
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ZONE OF COAGULATION
65o C
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PATIENT SELECTION
100% relief from controlled medial branch blocks
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PATIENT SELECTION
NOT:
Examination Findings
Radiological Findings
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TREATMENT TECHNIQUE
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TREATMENT TECHNIQUE
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1mm
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1mm
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1mm
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medial branch
anterior
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30o
30o
oblique
path
medial branch
anterior
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30o
30o
oblique
path
medial branch
anterior
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30o
30o
sagittal path
oblique
path
medial branch
anterior
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30o
30o
sagittal path
oblique
path
medial branch
anterior
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30o
medial branch
anterior
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PAlateral
lateral PA
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EVIDENCE
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EVIDENCE
RCT
24 patients, selected on the basis of 100% relief from placebo-controlled cervical medial branch blocks
Randomised to:
RF neurotomy
Sham treatment
22G electrodes
Sagittal and oblique passes, 2 or 3 parallel lesions
Lord SM, Barnsley L, Wallis B, McDonald GM, Bogduk N. Percutaneous radio‐frequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:1721‐1726.
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EVIDENCE
The criteria for a successful outcome were
•complete relief of pain for at least three months
•restoration of activities of daily living, and
•no need for continuing health care for neck pain.
By 27 weeks, complete relief from pain:
Treatment group – seven
Control group – one
Median duration of complete relief:
RF neurotomy – 263 days
Sham treatment – 8 days
Lord SM, Barnsley L, Wallis B, McDonald GM, Bogduk N. Percutaneous radio‐frequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:1721‐1726.
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EVIDENCE
Case series
18/28 (64%) patients obtained complete relief of pain that lasted for a median duration of 421.5 days 1
22G electrodes. Sagittal and oblique passes, 2 or 3 parallel lesions
42/49 (86%) of patients obtained complete relief of pain
median duration of relief 297 days 2
16 G electrodes. Sagittal and oblique passes, at least 3 parallel lesions
21/35 (60%) obtained complete relief of pain for at least 12 weeks
median duration of relief 44 weeks 3
16 G electrodes. Sagittal and oblique passes, 2 or 3 parallel lesions
1. McDonald GJ, Lord SM, Bogduk N. Long term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999;45:61-68.
2. Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiat 2003; 74:88‐93.
3. Barnsley L. Percutaneous radiofrequency neurotomy for chornic neck pain: outcomes in a series of consecutive patients. Pain Medicine 2005; 6:282‐286.
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EVIDENCE
Case series
Prospective audit, n = 104
Selection - 100% relief of pain following controlled medial branch blocks.
16 G electrodes. Sagittal and oblique passes, 2 or 3 parallel lesions
OUTCOMES
Practice A - 74% of patients obtained complete relief for at least six months
Median duration of relief 17 months
Practice B - 61% of patients obtained complete relief for at least six months
Median duration of relief 20 months
Pain relief corroborated by complete restoration of ADLs, cessation of medication and return to work.
MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain
Medicine 2012;13:647-654.
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EVIDENCE
Case series
Poor patient selection
Incorrect surgical technique
22G electrodes, single lesions
Schaerer JP: Radiofrequency facet rhizotomy in the treatment of chronic neck and low back pain. Int Surg 1978; 63:53‐59.
Schaerer JP. Radiofrequency facet denervation in the treatment of persistent headache associated with chronic neck pain. J Neurol Orthop Surg 1980; 1:127‐130.
Sluijter ME, Koetsveld‐Baart CC: Interruption of pain pathways in the treatment of the cervical syndrome. Anaesthesia 1980; 35:302‐307.
Sluijter M E, Mehta M: Treatment of chronic back and neck pain by percutaneous thermal lesions. In: Lipton S, Miles J (eds) Persistent pain. Modern methods of treatment, Vol. 3. Academic Press, London, 1981, pp 141‐179.
Hildebrandt J. Argyrakis A. Percutaneous nerve block of the cervical facets – a relatively new method in the treatment of chronic headache and neck pain. Man Med 1986; 2:48‐52.
Schaerer JP. Treatment of prolonged neck pain by radiofrequency facet rhizotomy. J Neurol Orthop Med Surg 1988; 9:74‐76.
Vervest ACM, Stolker RJ. The treatment of cervical pain syndromes with radiofrequency procedures. Pain Clinic 1991; 4:103‐112.