Dr Jim Borowczyk. Dr John Robinson. Dr Peter McKenzie. Dr John MacVicar

Transcription

1 Dr Jim Borowczyk Musculoskeletal Physician Christchurch Dr Peter McKenzie Musculoskeletal Physician Nelson Dr John Robinson General Practitioner Otumoetai Doctors Tauranga Dr John MacVicar Medical Director Musculoskeletal Medicine Specialist Southern Rehab Christchurch 8:30-10:30 WS #1: Musculoskeletal Workshop Part 1 11:00 13:00 WS #7: Musculoskeletal Workshop Part 2

2 Lumbar Radiofrequency Neurotomy John MacVicar SouthernRehab Christchurch, NZ South GP CME 2017 South GP CME 2017 meeting 10 th August 2017

3 CONFICTS OF INTEREST Nothing to declare

4

5 LUMBAR ZYGAPOPHYSIAL JOINTS Proven sources of pain Innervation known Nerves accessible Nerves suitable size

6 PHYSICS ANATOMY PATIENT SELECTION TREATMENT TECHNIQUE EVIDENCE OF EFFICACY

7 PHYSICS

8 RF GENERATOR

9 RF GENERATOR

10 RF GENERATOR ground plate electrode

11 RF GENERATOR ground plate electrode

12 RF GENERATOR ground plate electrode

13 RF GENERATOR ground plate + - electrode

14 RF GENERATOR ground plate electrode

15 ELECTRIC FIELD isotherms 55 o C 65 o C 75 o C

16 ZONE OF COAGULATION 65 o C

17 ANATOMY

18 L5 medial branch L5-S1 z joint mal S1 sap communicating branch to S1 L5 dorsal ramus iliac crest Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. J Anat 1982; 134: Bogduk N. The innervation of the lumbar spine. Spine 1983; 8:

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20 PATIENT SELECTION

21 . PATIENT SELECTION

22 . PATIENT SELECTION

23 PATIENT SELECTION NOT: Examination Findings Radiological Findings

24 PATIENT SELECTION Examination findings lumbar spine No correlation between clinical examination findings and the response to controlled blocks

25 PATIENT SELECTION Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N. Pain from the lumbar zygapophysial joints: a test of two models. J Spinal Disord 1994;7: Schwarzer AC, Wang S, Bogduk N, McNaught PJ, Laurent R. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995; 54: Revel M, Poiraudeau S, Auleley GR, Payan C, Denke A, Nguyen M, Chevrot A, Fermanian J. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 1998; 23: Manchikanti L, Pampati VS, Fellows B, Baha A. The inability of the clinical picture to characterize pain from facet joints. Pain Physician 2000; 3: Young SB, Aprill CN, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 2003;3: Laslett M, Oberg B, Aprill CN, McDonald B. Zygapophysial joint blocks in chronic low back pain: a test of Revel s model as a screening test. BMC Musculoskel Disord 2004;5:43. Laslett M, Mcdonald B, Aprill CN, Tropp H, Öberg O. Clinical Predictors of Screening Lumbar Zygapophysial Joint Blocks: Development of Clinical Prediction Rules. The Spine Journal. 2006, 6(4) 370-4

26 PATIENT SELECTION Radiological findings lumbar spine Framingham heart study. CT imaging to assess aortic calcification. Ancillary study to assess radiographic features associated with low back pain. 188 patients LBP in the preceding 12 months was evaluated. The association between FJ OA and low back pain was examined. Kalichman, L. Li, L. Kim, D. Guermazi, A. Berkin, V. O Donnell, C. Hoffmann, U. Cole, R. Hunter, D. Facet Joint Osteoarthritis and Low Back Pain in the Community-Based Population. Spine Volume 33, Number 23, pp

27 PATIENT SELECTION Radiological findings lumbar spine CT imaging revealed a high prevalence of FJ OA Prevalence of FJ OA increases with age. 24.0% of 40 years olds 44.7% of 40 to 49 years olds 74.2% of 50 to 59 years olds 89.2% of 60 to 69 year olds Kalichman, L. Li, L. Kim, D. Guermazi, A. Berkin, V. O Donnell, C. Hoffmann, U. Cole, R. Hunter, D. Facet Joint Osteoarthritis and Low Back Pain in the Community-Based Population. Spine Volume 33, Number 23, pp

28 PATIENT SELECTION Radiological findings lumbar spine CT imaging revealed a high prevalence of FJ OA Prevalence of FJ OA increases with age. 24.0% of 40 years olds 44.7% of 40 to 49 years olds 74.2% of 50 to 59 years olds 89.2% of 60 to 69 year olds No association between FJ OA and low back pain at any spinal level Kalichman, L. Li, L. Kim, D. Guermazi, A. Berkin, V. O Donnell, C. Hoffmann, U. Cole, R. Hunter, D. Facet Joint Osteoarthritis and Low Back Pain in the Community-Based Population. Spine Volume 33, Number 23, pp

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33 VALIDITY OF MEDIAL BRANCH BLOCKS Lumbar intra-articular blocks and medial branch blocks - false positive rate 38% Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58:

34 VALIDITY OF MEDIAL BRANCH BLOCKS Lumbar intra-articular blocks and medial branch blocks - false positive rate 38% Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58: Comparative medial branch blocks Lignocaine Bupivacaine Lord SM, Barnsley L, Bogduk N. The utility of comparative local anaesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain 1995; 11:

35 VALIDITY OF MEDIAL BRANCH BLOCKS Lumbar intra-articular blocks and medial branch blocks - false positive rate 38% Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58: Placebo-controlled cervical medial branch blocks Concordant responses sensitivity 54% specificity 88% (LR 4.5) Concordant + discordant responses sensitivity 100% specificity 65% (LR 2.9) Lord SM, Barnsley L, Bogduk N. The utility of comparative local anaesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain 1995; 11:

36 TREATMENT TECHNIQUE

37 RRE SMK 1mm r w d -2sd +2sd ew 1.6 mm 0.7 mm mean r 1.6 ew = 2.6 mm 2.3 ew = 1.6 m sd 0.3 ew 0.4 ew mean d 0.4 ew = 0.5 mm 1.4 ew = 0.6 mm sd 0.2 ew 0.4 ew

38 RRE 16 G 1mm SMK 22 G r w d -2sd +2sd ew 1.6 mm 0.7 mm range r mm mm range d mm mm

39 RRE 16 G 1mm SMK 22 G r w d -2sd +2sd ew 1.6 mm 0.7 mm range r mm mm range d mm mm

40 RRE 16 G 1mm SMK 22 G r w d -2sd +2sd Based on: Bogduk N. Macintosh J, Marsland A. Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain. Neurosurg.1987; 20: Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophysial joint pain. Neurosurgery Quarterly 1998; 8:

41 1mm

42 DISTAL COAGUATION

43 DISTAL COAGUATION

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47 1mm bone DISTAL COAGUATION

48 1mm

49 1mm

50 Thermal radiofrequency lumbar medial branch neurotomy

51 1.6 mm electrode 5mm With the electrode in contact with the nerve, the lesion easily encompasses the nerve

52 1.6 mm electrode 5mm With the electrode in contact with the nerve, the lesion easily encompasses the nerve

53 1.6 mm electrode 5mm With the electrode in contact with the nerve, the lesion easily encompasses the nerve

54 1.6 mm electrode 5mm Even if the nerve is displaced from the electrode, the lesion still encompasses the nerve

55 0.7 mm electrode 5mm Because the lesion is smaller, the electrode must be in direct contact with the nerve for the lesion to encompass it.

56 SMK electrode 0.7 mm electrode 5mm If the nerve is displaced, only a small distance, from the nerve, the lesion will fail to encompass it.

57 EVIDENCE

58 EVIDENCE SELECTION At least 80% relief of pain following controlled medial branch blocks. n = 15 TECHNIQUE Correct surgical technique. 16G electrodes. 2 lesions parallel to the nerve OUTCOMES 60% of patients obtained at least 90% relief lasting at least 12 months 87% of patients obtained at least 60% relief lasting at least 12 months Pain relief accompanied by clinically and statistically significant improvements in disability Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000;25:

59 EVIDENCE SELECTION 100% relief of pain following controlled medial branch blocks. n = 106 TECHNIQUE Correct surgical technique 16G electrodes. 2 lesions parallel to the nerve, or 10 mm exposed tip OUTCOMES 56% of patients obtained complete relief for at least six months Pain relief corroborated by complete restoration of ADLs, cessation of medication and return to work. Median duration of relief 15 months MacVicar J., Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2013 (in press).

60 Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. There is conflicting evidence on the short-term effect of radiofrequency lesioning on pain and disability in chronic low-back pain of zygapophyseal joint origin.

61 NICE Clinical Guideline 88 Early management of persistent non-specific low back pain Developed by the National Collaborating Centre for Primary Care Do not refer people for any of the following procedures: intradiscal electrothermal therapy (IDET) percutaneous intradiscal radiofrequency thermocoagulation radiofrequency facet joint denervation

62 Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. There is conflicting evidence on the short-term effect of radiofrequency lesioning on pain and disability in chronic low-back pain of zygapophyseal joint origin. Gallagher J, Petriccione di Vadi PL, Wedley JR, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a prospective controlled double-blind study to assess its efficacy. The Pain Clinic 1994;7(3): van Kleef M, Barendse GA, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999;24(18): Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine 2001;26(13):1411-6

63 SUMMARY Patient Selection on the basis of response medial branch blocks 100% relief from pain Positive responses subject to control blocks

64 SUMMARY Patient Selection on the basis of response medial branch blocks 100% relief from pain Positive responses subject to control blocks Treatment technique Correct anatomical electrode placement Electrode parallel to the target nerve Multiple lesions, particularly for small gauge electrodes

65 Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. SELECTION CRITERIA Leclaire Significant pain relief for at least 24 hours during the week after intra-articular facet injection. Gallagher Either good or equivocal response to local anaesthetic injection into and around the appropriate painful joints van Kleef At least 50 per cent pain relief from a single diagnostic dorsal ramus nerve block

66 Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. TREATMENT TECHNIQUE Leclaire Operative technique was not described Gallagher Shealy technique (discredited in 1979) van Kleef Electrodes perpendicular to the nerves

67 Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. RESULTS Leclaire No significant treatment effect Gallagher Results unclear, short-term effect was conflicting van Kleef Mean reduction in VAS 2.0 mm Two month follow-up

68 NICE Clinical Guideline 88 Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine 2001;26(13): van Wijk RMA, Geurts JWM, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain. A randomized, double-blind sham lesion-controlled trial. Clin J Pain 2005;21(4): Nath S, Nath CA, Pettersson K. Percutaneous lumbar zygapophysial (facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain. A randomized double-blind trial. Spine 2008;33:1291 7

69 NICE Clinical Guideline 88 SELECTION Leclaire Significant pain relief for at least 24 hours during the week after intraarticular facet injection. van Wijk at least 50% pain relief following a single intra-articular injection Nath At least 80% relief from controlled medial branch blocks

70 NICE Clinical Guideline 88 TREATMENT TECHNIQUE Leclaire Operative technique was not described van Wijk Electrodes perpendicular to, and lateral to, the location of the target nerves

71 van Wijk RMA, Geurts JWM, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain. A randomized, double-blind sham lesion-controlled trial. Clin J Pain 2005;21(4):335-44

72 van Wijk RMA, Geurts JWM, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain. A randomized, double-blind sham lesion-controlled trial. Clin J Pain 2005;21(4):335-44

73 NICE Clinical Guideline 88 TREATMENT TECHNIQUE Leclaire Operative technique was not described van Wijk Electrodes perpendicular to, and lateral to, the location of the target nerves Nath Correct 22G electrode, multiple lesions

74 NICE Clinical Guideline 88 RESULTS Leclaire No significant treatment effect van Wijk no differences in outcome measures Nath Mean VAS 1.9 compared to 0.4 Multiple sources of pain

75 Tekin I, Mirzai H, Ok G, Erbuyun K, Vatansever D. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clin J Pain 2007;23: RCT, n = 60 SELECTION at least 50% relief of pain following single, uncontrolled, diagnostic blocks TECHNIQUE Patients randomized to thermal RF, pulsed RF or sham treatment For thermal RF, 22G electrode 10 mm tip, single lesion, anatomically correct RESULTS Thermal RF was significantly more effective than pulsed RF and sham treatment at 6 months and at 1 year Analgesic use at 1 year thermal RF 40%, pulsed RF 75%, sham 95%. 65% (44% - 86%) of patients treated with active medial branch neurotomy reported excellent satisfaction with treatment, compared with 20% (2% - 38%) of those who underwent sham treatment.

76 IN SUMMARY Lumbar medial branch radiofrequency neurotomy Provides complete and sustained relief in the majority of patients

77 IN SUMMARY Lumbar radiofrequency medial branch neurotomy Provides complete and sustained relief in the majority of patients, if they are selected on the basis of at least 80% relief from controlled medial branch blocks

78 IN SUMMARY Lumbar radiofrequency medial branch neurotomy Provides complete and sustained relief in the majority of patients, if they are selected on the basis of at least 80% relief from controlled medial branch blocks and meticulous technique is used anatomically correct electrode placement 16G electrodes and/or multiple lesions.