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

Thermal cervical medial branch radiofrequency neurotomy

JOHN MACVICAR

28.05.15

CERVICAL AND LUMBAR

ZYGAPOPHYSIAL “FACET” JOINTS

Proven sources of pain

Innervation known

Nerves accessible

Nerves suitable size

PHYSICS

RF GENERATOR

RF GENERATOR

RF GENERATOR

ground plate

electrode

RF GENERATOR

ground plate

electrode

RF GENERATOR

ground plate

electrode

RF GENERATOR

ground plate

electrode

-+

RF GENERATOR

ground plate

electrode

ELECTRIC FIELD

isotherms

55o C

65o C

75o C

ZONE OF COAGULATION

65o C

PATIENT SELECTION

100% relief from controlled medial branch blocks

PATIENT SELECTION

NOT:

Examination Findings

Radiological Findings

TREATMENT TECHNIQUE

TREATMENT TECHNIQUE

1mm

1mm

1mm

medial branch

anterior

30o

30o

oblique

path

medial branch

anterior

30o

30o

oblique

path

medial branch

anterior

30o

30o

sagittal path

oblique

path

medial branch

anterior

30o

30o

sagittal path

oblique

path

medial branch

anterior

30o

medial branch

anterior

PAlateral

lateral PA

EVIDENCE

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.

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.

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.

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.

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.