INTERVENTIONAL PAIN MEDICINE PAST, PRESENT, FUTURE. No conflicts of interest. The truth does not pay

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1 INTERVENTIONAL PAIN MEDICINE PAST, PRESENT, FUTURE Professor Nikolai Bogduk Emeritus Professor of Pain Medicine University of Newcastle Australia No conflicts of interest The truth does not pay DARK AGES 1

2 Harrison s Principles of Medicine, 7 th edn 1974 BACK PAIN postural strengthening muscle sprain bed rest, ice codeine, aspirin, pentazocine, propoxyphene NECK PAIN osteoarthritis bed rest, traction DIAGNOSIS muscle sprain tension myalgia myofascial trigger point ligament sprain segmental dysfunction osteoarthritis spondylosis degenerative disc disease instabiliy 2

3 DIAGNOSIS muscle sprain tension myalgia myofascial trigger point ligament sprain segmental dysfunction osteoarthritis spondylosis degenerative disc disease instabiliy WORDS DIAGNOSIS muscle sprain tension myalgia myofascial trigger point ligament sprain segmental dysfunction osteoarthritis spondylosis degenerative disc disease instabiliy WORDS GUILD belief Religious belief 3

4 DIAGNOSIS muscle sprain tension myalgia myofascial trigger point ligament sprain segmental dysfunction osteoarthritis spondylosis degenerative disc disease instabiliy WORDS What is the evidence? What is the DIAGNOSTIC TEST DIAGNOSIS muscle sprain tension myalgia myofascial trigger point ligament sprain segmental dysfunction osteoarthritis spondylosis degenerative disc disease instabiliy WORDS What is the evidence? What is the DIAGNOSTIC TEST SCIENCE 4

5 T G B C D 5

6 5 vertebrae 5 discs 10 Z joints 64 muscles 12 ligaments 7vertebrae 7 discs 12 Z joints 6 synovial joints many muscles 3 ligaments 6

7 muscles? muscles? Z joints Z joints discs? ligaments? vertebrae? DARK AGES INTERVENTIONAL PAIN MEDICINE 7

8 DARK AGES ACHIEVEMENTS INTERVENTIONAL PAIN MEDICINE 8

9 CERVICAL ZYGAPOPHYSIAL JOINT PAIN CERVICAL MEDIAL BRANCH BLOCKS From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

10 54 whiplash 1 whiplash 2 pain clinic 3 pain clinic 4 pain clinic PREVALENCE (%) 1. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20: Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21: Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophysial joint blocks for chronic cervical pain. Med J Aust 2001; 174: Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 2002; 5: Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9:

11 THIRD OCCIPITAL HEADACHE THIRD OCCIPITAL NERVE BLOCKS From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

12 THIRD OCCIPITAL NERVE BLOCKS THIRD OCCIPITAL HEADACHE 12

13 THIRD OCCIPITAL HEADACHE Prevalence: 54% Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital nerve headache: a prevalence study. J Neurol Neurosurg Psychiatry 1994; 57: LATERAL ATLANTO-AXIAL JOINT PAIN 13

14 LATERAL ATLANTO-AXIAL JOINT BLOCKS From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 LATERAL ATLANTO-AXIAL JOINT PAIN Prevalence: 9-16% Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral atlantoaxial (C1-2) joint. Cephalalgia 2002; 22: Narouze SN, Casanova J, Mekhail N. The longitudinal effectiveness of lateral atlantoaxial intra-articular steroid injection in the treatment of cervicogenic headache. Pain Med 2007; 8: Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9:

15 CERVICAL DISC PAIN CERVICAL DISC STIMULATION From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

16 CERVICAL DISC STIMULATION From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 CERVICAL DISC PAIN Prevalence: 16% Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9:

17 LUMBAR ZYGAPOPHYSIAL JOINT PAIN 17

18 LUMBAR MEDIAL BRANCH BLOCKS From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 LUMBAR MEDIAL BRANCH BLOCKS 18

19 LUMBAR ZYGAPOPHYSIAL JOINT PAIN Prevalence: 11% MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12: LUMBAR DISC PAIN 19

20 LUMBAR DISC STIMULATION From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 LUMBAR DISC STIMULATION From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

21 CRITERIA Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med 2013; 14: painless control level painless control level CRITERIA Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med 2013; 14: painless control level concordant pain painless control level 21

22 CRITERIA Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med 2013; 14: painless control level concordant pain to 7/10 VAS painless control level CRITERIA Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med 2013; 14: painless control level concordant pain to 7/10 VAS at < 15 psi painless control level 22

23 CRITERIA Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med 2013; 14: painless control level concordant pain to 7/10 VAS at < 15 psi painless control level + Grade III-IV fissure on CT LUMBAR DISC PAIN PREVALENCE 39% 26% 42% Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995; 20: Manchikanti L, Singh V, Pampati V, Damron KS, Barnhill RC, Beyer C, Cash KA. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001; 4: De Palma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med 2011; 12:

24 SACROILIAC JOINT PAIN SACROILIAC JOINT BLOCKS From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

25 SACROILIAC JOINT PAIN PREVALENCE 13% 18% 19% Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996; 21: DePalma MJ, Ketchum JM, Saullo T What is the source of chronic low back pain and does age play a role. Pain Med 2011; 12: LUMBAR MEDIAL BRANCH RF NEUROTOMY 25

26 MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Med 2013; 14: Practice A Practice B Treated Complete relief of pain (VAS = 0) Restoration of all ADLs 58% 53% No need for other health care Return to Work CERVICAL MEDIAL BRANCH RF NEUROTOMY 26

27 PLACEBO CONTROLLED TRIAL OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT 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: Active RF Sham RF Days 27

28 Active RF Sham RF Days Active RF Sham RF Days 28

29 LONG-TERM FOLLOW-UP OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophyseal joint pain. Neurosurgery Quarterly 1998;8: McDonald GJ, Lord SM, Bogduk N. Long term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999;45: Duration of complete relief years 29

30 RECENT STUDIES Macivar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med 2012; 13: Practice A Practice B Treated Complete relief of pain (VAS = 0) Restoration of all ADLs 74% 61% No need for other health care Return To work PRACTICE A Complete relief of pain (VAS = 0) Restoration of all ADLs No need for other health care Return to work From first RFN: Median = 15 m (IQR = m) From all RFNs: Median = 13 m (IQR = 9 26 m) Otherwise, Or 575 months, for a cost of 35 RFNs 16 months per RFN months 30

31 PRACTICE A Complete relief of pain (VAS = 0) Restoration of all ADLs No need for other health care Return to work From first RFN: Median = 15 m (IQR = m) From all RFNs: Median = 13 m (IQR = 9 26 m) Otherwise, Or 575 months, for a cost of 35 RFNs 16 months per RFN months PRACTICE B Complete relief of pain (VAS = 0) Restoration of all ADLs No need for other health care Return to work From first RFN: Median = 15 m (IQR = m) From all RFNs: Median = 13 m (IQR = m) Otherwise, or 1,067 months, for a cost of 66 RFNs 16 months per RFN months 31

32 THIRD OCCIPITAL RADIOFREQUENCY NEUROTOMY LONG-TERM FOLLOW-UP 49 patients with Third Occipital Headache Complete relief: 88% median duration: 297 days ++ Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiat 2003; 74:

33 days SCORE CARD Headache Neck Pain Back Pain Prev Treat Third Occipital 54% TON RFN Lateral AA 9-16% Z joints 54% CMB RFN Disc 16% Z joints 11% LMB RFN Disc 39% Sacroiliac 13 19% 33

34 SCORE CARD Headache Neck Pain Back Pain Prev Treat Path Third Occipital 54% TON RFN *** Lateral AA 9-16% Z joints 54% CMB RFN *** Disc 16% Z joints 11% LMB RFN Disc 39% *** Sacroiliac 13 19% DARK AGES ACHIEVEMENTS INTERVENTIONAL PAIN MEDICINE 34

35 DARK AGES ACHIEVEMENTS TROUBLES INTERVENTIONAL PAIN MEDICINE DARK AGES ACHIEVEMENTS STANDARDS TROUBLES INTERVENTIONAL PAIN MEDICINE 35

36 DARK AGES ACHIEVEMENTS STANDARDS TROUBLES TECHNIQUE DIAGNOSTIC EFFICACY BLOCKS INTERVENTIONAL PAIN MEDICINE Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

37 COMPLIANCE next to ZERO COMPLIANCE next to ZERO REASONS Personal antipathy Too demanding Too strict You wrote them Don t get paid Take short cuts My own way Get paid Still get paid 37

38 DARK AGES ACHIEVEMENTS STANDARDS TROUBLES TECHNIQUE DIAGNOSTIC EFFICACY BLOCKS INTERVENTIONAL PAIN MEDICINE LUMBAR MEDIAL BRANCH RF NEUROTOMY 38

39 LUMBAR MEDIAL BRANCH RF NEUROTOMY HOW TO DO IT PROPERLY Pillar view of block needle 39

40 Pillar view of electrode in place AP view of electrode in place 40

41 First coagulation Oblique view of electrode in place second coagulation 41

42 Pillar view of second electrode placement Oblique view of second electrode placement 42

43 AP view of second electrode placement YET 43

44 LUMBAR MEDIAL BRANCH RF NEUROTOMY HOW OTHERS ARE DOING 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

45 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 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 ? 45

46 Van Wijk RMA, Geurts JWM, Wynne HJ, Hammink E, Buskens E, Lousberg R, Knape JTA, Groen GJ. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain. A randomized, double-blind sham lesioncontrolled trial. Clin J Pain 2004; 21: LEFT RIGHT 46

47 LEFT RIGHT 47

48 where the nerve is 48

49 Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, Aprill C. Complications of spinal diagnostic and treatment procedures. Pain Med 2008; 6:S11-S34. 49

50 DARK AGES ACHIEVEMENTS STANDARDS TROUBLES TECHNIQUE DIAGNOSTIC EFFICACY BLOCKS INTERVENTIONAL PAIN MEDICINE DIAGNOSTIC BLOCKS STANDARDS Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 Engel A, MacVicar J, Bogduk N. A philosophical foundation for diagnostic blocks with criteria for their validation Pain Med. 2014; 15: Engel AJ, Bogduk N. Mathematical validation and credibility of diagnostic blocks for spinal pain. Pain Med 2016; 17:

51 0. COMPLETE RELIEF 1. CORRECT TECHNIQUE 2. Must REPEAT 3. Must CONTROL for placebo 4. Must EVALUATE strictly 0. COMPLETE RELIEF 100% not 50% 51

52 1. CORRECT TECHNIQUE From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

53 From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

54 From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 From: Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco,

55 2. Must REPEAT 2. Must REPEAT Why? 30 40% of patients positive to a first block report NO RELIEF from a 2 nd block Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain 1993; 9:

56 3. Must CONTROL for placebo 3. Must CONTROL for placebo Why? Even positive responses are false according to placebo controls False-positive rate = 25 45% Schwarzer AC et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994; 58: Manchikanti L et al. Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician 1999; 2: Manchikanti L et al. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain 2000; 4: Manchikanti L et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders 2004; 5:15. Manchukonda R et al. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech 2007; 20:

57 OPTIONS FOR CONTROLLED BLOCKS OPTIONS FOR CONTROLLED BLOCKS? 1. Covert placebo Unethical 57

58 OPTIONS FOR CONTROLLED BLOCKS? 1. Covert placebo Unethical 2. Overt placebo Informed consent Could still guess Introduce chance OPTIONS FOR CONTROLLED BLOCKS? 1. Covert placebo Unethical 2. Overt placebo Informed consent Could still guess Introduce chance FIRST BLOCK SECOND BLOCK THIRD BLOCK active agent active agent or placebo or placebo active agent 58

59 OPTIONS FOR CONTROLLED BLOCKS? 3. Comparative local anaesthetic blocks FIRST BLOCK SECOND BLOCK lignocaine or bupivacaine bupivacaine or lignocaine SHORT LONG LONG SHORT The effect of false-positive depends on prevalence Bogduk N. On the rational use of diagnostic blocks for spinal pain. Neurosurgery Quarterly 2009; 19:

60 CRITERION STANDARD + - TEST + - a c b d a / (a + c) = SENSITIVITY CRITERION STANDARD + - TEST + - a c b d d/ (b + d) = SPECIFICITY 60

61 CRITERION STANDARD + - TEST + - a c b d a : b = DIAGNOSTIC CONFIDENCE CRITERION STANDARD + - TEST + a b a : b = DIAGNOSTIC CONFIDENCE - c d DIAGNOSTIC CONFIDENCE = a b = PREVALENCE x 1 - PREVALENCE SENSITIVITY 1 - SPECIFICITY Prevalence as ODDS Positive Likelihood Ratio 61

62 CERVICAL MEDIAL BRANCH BLOCKS PLACEBO CONTROLLED POS NEG COMPARATIVE POS 13 3 BLOCKS NEG SEN = 0.54 SPEC = 0.88 LR = 4.5 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: CERVICAL MEDIAL BRANCH BLOCKS Prev Prev Odds LR DC ODDs DC % 60% 60: : 1 87% 62

63 Blocks in general Prev Prev Odds LR DC ODDs DC % 60% 60: % 50% 50: % 30% 30: % 10% 10: % 5% 5: % Blocks in general Prev Prev Odds LR DC ODDs DC % 60% 60: % 50% 50: % 30% 30: % 10% 10: % 63

64 Blocks in general Prev Prev Odds LR DC ODDs DC % 60% 60: % 50% 50: % 30% 30: % 10% 10: % 5% 5: % Prevalence of Lumbar Z joint pain? 64

65 N = 65 patients with low back pain MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12: N = 65 patients with low back pain FIRST BLOCK 20 positive [ 31% ] MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12:

66 N = 65 patients with low back pain FIRST BLOCK SECOND BLOCK NORMAL SALINE 20 positive [ 31% ] MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12: N = 65 patients with low back pain FIRST BLOCK SECOND BLOCK NORMAL SALINE 20 positive [ 31% ] 9 negative negative [ 45% ] MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12:

67 N = 65 patients with low back pain FIRST BLOCK SECOND BLOCK NORMAL SALINE 20 positive [ 31% ] 9 negative negative [ 45% ] 4 negative positive [ 20% ] MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12: N = 65 patients with low back pain FIRST BLOCK SECOND BLOCK NORMAL SALINE 20 positive [ 31% ] 9 negative negative [ 45% ] 4 negative positive [ 20% ] 7 positive negative [ 35% ] MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12:

68 N = 65 patients with low back pain FIRST BLOCK SECOND BLOCK NORMAL SALINE 20 positive [ 31% ] 9 negative negative [ 45% ] 4 negative positive [ 20% ] 7 positive negative [ 35% ] Prevalence = 7 / 65 = 11% ( 8%) MacVicar J, Bogduk N. Placebo-controlled lumbar medial branch blocks. Pain Med 2011; 12: LUMBAR MEDIAL BRANCH BLOCKS Prev Prev Odds LR DC ODDs DC % 60% 60: % 50% 50: % 30% 30: % 10% 10: % 5% 5: % 68

69 CREDIBILITY of POSITIVE RESPONSES to controlled blocks FIRST BLOCK SECOND BLOCK THIRD BLOCK Lign or Bup or 50% Bup Lig Engel AJ, Bogduk N. Mathematical validation and credibility of diagnostic blocks for spinal pain. Pain Med 2016; 17: CREDIBILITY of POSITIVE RESPONSES to controlled blocks FIRST BLOCK SECOND BLOCK THIRD BLOCK Lign or Bup or 50% Bup Lig Lign or Bup or Placebo Placebo or Bup 75% Bup Lig or Placebo Placebo or Lig Engel AJ, Bogduk N. Mathematical validation and credibility of diagnostic blocks for spinal pain. Pain Med 2016; 17:

70 CREDIBILITY of POSITIVE RESPONSES to controlled blocks FIRST BLOCK SECOND BLOCK THIRD BLOCK Lign or Bup or 50% Bup Lig Lign or Bup or Placebo Placebo or Bup 75% Bup Lig or Placebo Placebo or Lig Lig or Bup Lig or Bup or Lig or Bup or 95% Placebo Placebo Engel AJ, Bogduk N. Mathematical validation and credibility of diagnostic blocks for spinal pain. Pain Med 2016; 17: Must EVALUATE strictly PAIN SCORES COMPLETE RELIEF REAL-TIME ASSESSMENT ACTIVITIES RESTORED 70

71 DIAGNOSTIC BLOCKS STANDARDS Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 Engel A, MacVicar J, Bogduk N. A philosophical foundation for diagnostic blocks with criteria for their validation Pain Med. 2014; 15: Engel AJ, Bogduk N. Mathematical validation and credibility of diagnostic blocks for spinal pain. Pain Med 2016; 17: DARK AGES ACHIEVEMENTS STANDARDS TROUBLES TECHNIQUE DIAGNOSTIC EFFICACY BLOCKS INTERVENTIONAL PAIN MEDICINE 71

72 Relief of Pain (%) after Medial Branch Neurotomy PERPENDICUKLAR LUMBAR MEDIAL BRANCH RF NEUROTOMY Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS til 50 9 til 9 til 72

73 Relief of Pain (%) after Medial Branch Neurotomy Relief of Pain (%) after Medial Branch Neurotomy PARALLEL PERPENDICUKLAR PARALLEL PERPENDICUKLAR Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS til 50 9 til 9 til Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS COMPARATIVE BLOCKS til 50 9 til 9 til 73

74 Relief of Pain (%) after Medial Branch Neurotomy Relief of Pain (%) after Medial Branch Neurotomy PERPENDICUKLAR PARALLEL PERPENDICUKLAR Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS COMPARATIVE BLOCKS Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS COMPARATIVE BLOCKS

75 Relief of Pain (%) after Medial Branch Neurotomy Relief of Pain (%) after Medial Branch Neurotomy PARALLEL PERPENDICUKLAR PARALLEL PERPENDICUKLAR Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS COMPARATIVE BLOCKS ij 6 e Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS COMPARATIVE BLOCKS l 33 ij 6 e 75

76 Relief of Pain (%) after Medial Branch Neurotomy PARALLEL PERPENDICUKLAR Relief of Pain (%) from Diagnostic Blocks SINGLE BLOCKS COMPARATIVE BLOCKS l 33 ij 6 e CERVICAL MEDIAL BRANCH RF NEUROTOMY 76

77 CERVICAL MEDIAL BRANCH RF NEUROTOMY WHEN PERFORMED ACCORDING TO STANDARDS OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT SUCCESS RATE 70% 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: CERVICAL MEDIAL BRANCH RF NEUROTOMY WHEN PERFORMED ACCORDING TO STANDARDS OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT SUCCESS RATE 70% Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophyseal joint pain. Neurosurgery Quarterly 1998;8: McDonald GJ, Lord SM, Bogduk N. Long term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999;45:

78 CERVICAL MEDIAL BRANCH RF NEUROTOMY WHEN PERFORMED ACCORDING TO STANDARDS OUTCOME CRITERIA: COMPLETE RELIEF OF PAIN, FULL RESTORATION OF ADLS, NO NEED FOR OTHER TREATMENT SUCCESS RATE 70% Macivar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med 2012; 13: CERVICAL MEDIAL BRANCH RF NEUROTOMY WHEN PERFORMED ACCORDING TO NO STANDARDS 78

79 CERVICAL MEDIAL BRANCH RF NEUROTOMY WHEN PERFORMED ACCORDING TO NO STANDARDS SUCCESS RATE 0 Sluijter ME, Koetsveld-Baart CC: Interruption of pain pathways in the treatment of the cervical syndrome. Anaesthesia 1980; 35: 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 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: Vervest ACM, Stolker RJ. The treatment of cervical pain syndromes with radiofrequency procedures. Pain Clinic 1991; 4: DARK AGES ACHIEVEMENTS STANDARDS TROUBLES INTERVENTIONAL PAIN MEDICINE FUTURE? 79

80 FUTURE FUTURE STANDARDS 80

81 FUTURE My way An easy way A fast way Not his way STANDARDS FUTURE WON T WORK My way An easy way A fast way Not his way STANDARDS 81

82 FUTURE INSURERS WON T WORK My way An easy way A fast way Not his way STANDARDS FUTURE INSURERS STANDARDS 82

83 FUTURE INSURERS FUTURE INSURERS 83

84 DARK AGES DARK AGES 84