INTERVENTIONAL TREATMENT FOR PAIN OF SPINAL ORIGIN Dr John MacVicar, Medical Director Southern Rehab, Christchurch, NZ AOCPRM Nov 23 rd 2018 INTERVENTIONAL TREATMENT FOR PAIN OF SPINAL ORIGIN An evidence-based approach 1
DISCLOSURES No conflicts of interest INTERVENTIONAL TREATMENT FOR PAIN OF SPINAL ORIGIN SUMMARY Cervicogenic headache Neck pain Lower back pain 2
INTERVENTIONAL TREATMENT FOR PAIN OF SPINAL ORIGIN SUMMARY Cervicogenic headache Neck pain Lower back pain Third occipital nerve RF neurotomy Cervical medial branch RF neurotomy Lumbar medial branch RF neurotomy INTERVENTIONAL TREATMENT FOR PAIN OF SPINAL ORIGIN SUMMARY Cervicogenic headache Neck pain Lower back pain Indications Technique Effectiveness Safety 3
Guidelines Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 Cervicogenic headache Moderator John MacVicar MB ChB 4
Radiofrequency third occipital nerve neurotomy Third occipital nerve ANATOMY Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982; 7:319-330. 5
Third occipital nerve ANATOMY Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982; 7:319-330. Third occipital nerve ANATOMY Innervation of C2-3 zygapophysial joint suboccipital skin semispinalis capitis 6
C2-3 zygapophysial joint pain PREVALENCE Headache dominant Overall 53% 67% 27% 39% 31% Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital headache: a prevalence study. J Neurol Neurosurg Psychiat 1994; 57:1187-1190. Govind J, King W, Giles P, Bailey B, Bogduk N. Headaches and the cervical zygapophysial joints: a prevalence study. Syllabus of the 14th Annual Scientific Meeting of the International Spine Intervention Society, Utah, 13-16 July, 2006, pp 169-171. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007; 8:344-353. MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical Medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. Third occipital nerve radiofrequency neurotomy INDICATIONS Neck pain Headache > 4 months Third occipital nerve blocks 100% relief control blocks Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4), 344 353. 7
Third occipital nerve blocks Third occipital nerve blocks 8
Third occipital nerve blocks Third occipital nerve blocks ASSESSMENT OF THE RESPONSE REAL TIME ASSESSMENT Pain drawing VAS/NRS Four ADLs Duration of relief. 9
Third occipital nerve radiofrequency neurotomy TECHNIQUE 5 mm Third occipital nerve radiofrequency neurotomy TECHNIQUE... Oblique pass 80 0 for 90 seconds 10
Third occipital nerve radiofrequency neurotomy TECHNIQUE... sagittal pass 85 0 for 90 seconds Third occipital nerve radiofrequency neurotomy SUCCESS RATES Lower cervical RF TON RF Success 7 4 Failure 3 6 Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophyseal joint pain: a caution. Neurosurgery 1995; 36:732-739. 11
Third occipital nerve radiofrequency neurotomy SUCCESS RATES 86% of 49 patients obtained complete relief of pain median duration of relief 297 days Eight patients experiencing ongoing, complete relief. 14 patients underwent repeat neurotomy when their pain recurred. Twelve (86%) regained complete relief. 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. Third occipital nerve radiofrequency neurotomy SUCCESS RATES Govind et al technical details 1. 16G electrode 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. 12
Third occipital nerve radiofrequency neurotomy SUCCESS RATES Govind et al technical details 1. 16G electrode 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. Third occipital nerve radiofrequency neurotomy SUCCESS RATES Govind et al technical details 1. 16G electrode 2. Electrode held firmly throughout procedure 3. Check position every 30 seconds and restart procedure if the electrode has moved 4. At least 3 parallel lesions 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. 13
Third occipital nerve radiofrequency neurotomy SUCCESS RATES Govind et al technical details 1. 16G electrode 2. Electrode held firmly throughout procedure 3. Check position every 30 seconds and restart procedure if the electrode has moved 4. At least 3 parallel lesions Bogduk N (Ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures 2 nd edn. International Spine Intervention Society, San Francisco, 2013 Third occipital nerve radiofrequency neurotomy SUCCESS RATES 35 consecutive patients Third occipital nerve RF 49% Selection - 100% relief of pain following controlled medial branch blocks. 16 G electrodes. Sagittal and oblique passes, 2 or 3 parallel lesions 74% of patients had complete pain relief Mean duration of relief 36 weeks Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain: outcomes in a series of consecutive patients. Pain Medicine 2005; 6:282 286. 14
Third occipital nerve radiofrequency neurotomy SUCCESS RATES Prospective audit, n = 104 Third occipital nerve RF 31% Selection - 100% relief of pain following controlled medial branch blocks. 16 G electrodes. Sagittal and oblique passes, 2 or 3 parallel lesions Practice A - 74% of patients obtained complete relief for at least 6 months Median duration of relief 17 months Practice B - 61% of patients obtained complete relief for at least 6 months Median duration of relief 20 months MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. Third occipital nerve radiofrequency neurotomy SAFETY 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. Gazelka HM, Knievel S, Mauck WD, Moeschler SM, Pingree MJ, Rho RH, et al. Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve. Journal of Pain Research 2014;7:195-98. 15
Third occipital nerve radiofrequency neurotomy SAFETY Gazelka et al: Third occipital neuralgia 12/64 19% Duration: 5/12 < 1 month 7/12 1-6 months, mean 2.6 months 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. Gazelka HM, Knievel S, Mauck WD, Moeschler SM, Pingree MJ, Rho RH, et al. Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve. Journal of Pain Research 2014;7:195-98. Third occipital nerve radiofrequency neurotomy SAFETY Gazelka et al: Third occipital neuralgia 12/64 19% Duration: 5/12 < 1 month 7/12 1-6 months, mean 2.6 months 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. Gazelka HM, Knievel S, Mauck WD, Moeschler SM, Pingree MJ, Rho RH, et al. Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve. Journal of Pain Research 2014;7:195-98. 16
Neck pain Moderator John MacVicar MB ChB Radiofrequency cervical medial branch neurotomy 17
Cervical medial branches ANATOMY Cervical medial branches ANATOMY 18
Cervical medial branches ANATOMY Nerves cross the articular pillars Diameter 0.5 0.9 mm Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982; 7:319-330. Cervical medial branches ANATOMY Nerves cross the articular pillars Diameter 0.5 0.9 mm Innervation of C3-4 to C6-7 zygapophysial joints each joint innervated by 2 nerves multifidus semispinalis capitis 19
Cervical zygapophysial joint pain PREVALENCE 1. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20:20-26. 2. Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21:1737-1745. 3. Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophysial joint blocks for chronic cervical pain. Med J Aust 2001; 174:174-176. 4. Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 2002;5:243-249. 5. Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9:196-203. 6. Gibson T, Bogduk N, Macpherson J, McIntosh A. Crash characteristics of whiplash associated chronic neck pain. J Musculoskeletal Pain 2000; 8:87-95. 20
Cervical medial branch radiofrequency neurotomy INDICATIONS Neck pain +/- headache +/- shoulder pain Medial branch blocks 100% relief control blocks Cervical medial branch blocks SELECTION OF LEVEL 21
Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4), 344 353. Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4), 344 353. 22
Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4), 344 353. Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4), 344 353. 23
Cervical medial branch blocks TECHNIQUE 24
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C5,6 MEDIAL BRANCH BLOCKS C5,6 MEDIAL BRANCH BLOCKS 27
Left C5,6 medial nerve blocks ASSESSMENT OF THE RESPONSE REAL TIME ASSESSMENT Pain drawing VAS/NRS Four ADLs Duration of relief. Cervical medial nerve blocks VALIDITY False positive rate 27% Placebo-controlled cervical medial branch blocks Concordant responses sensitivity 54% specificity 88% LR 4.5 Discordant responses sensitivity 100% specificity 65% LR 2.9 Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain 1993; 9:124-130 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; 11:208-213. 28
Cervical medial branch radiofrequency neurotomy TECHNIQUE Cervical medial branch radiofrequency neurotomy TECHNIQUE 29
Cervical medial branch radiofrequency neurotomy SUCCESS RATES 24 patients, selected on the basis of 100% relief from placebo-controlled cervical medial 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 radiofrequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:1721 1726. 30
Cervical medial branch radiofrequency neurotomy SUCCESS RATES The criteria for a successful outcome were complete relief of pain for at least three months restoration of activities of daily living 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 radiofrequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:1721 1726. Cervical medial branch radiofrequency neurotomy SUCCESS RATES Prospective outcome study All patients treated from June 2004 to December 2009 Selected on basis of complete relief of pain following controlled medial branch blocks Treated according to the practice guidelines of the International Spine Intervention Society MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. 31
Cervical medial branch radiofrequency neurotomy SUCCESS RATES Complete relief of pain for at least 6 months corroborated by: Complete restoration of activities of daily living No need for analgesic medications No need for other health care Return to work (if applicable) MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. OUTCOME CERVICAL RF NEUROTOMY PRACTICE A PRACTICE B FAILURE Outright; no relief 5 12 Other pain 1 5 Pain relieved; activities not restored Pain recurred, before 6 months 0 3 4 1 Not complete relief of pain 0 3 Lost to follow-up 0 2 Not yet reached 6 months 1 0 SUCCESS Complete relief of pain Activities restored No other health care Return to work 31 74% (61 87) 40 61% 49 72) MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. 32
MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654. 33
Cervical medial branch radiofrequency neurotomy SUCCESS RATES Our outcomes are consistent with the results from bench-mark studies on cervical RFN 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. 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; 8:288-308. 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. Govind J, King, Bailey B. Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiat 2003; 74:88-93. Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain: outcomes in a series of consecutive patients. Pain Med 2005; 6:282-286. Cervical medial branch radiofrequency neurotomy SAFETY 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. 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; 8:288-308. 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. 34
Lower back pain Moderator John MacVicar MB ChB Radiofrequency lumbar medial branch neurotomy 35
Lumbar medial branches ANATOMY Innervation of lumbar zygapophysial joints each joint innervated by 2 nerves multifidus Lumbar zygapophysial joint pain PREVALENCE? 36
Lumbar medial branch radiofrequency neurotomy TECHNIQUE 37
Lumbar medial branch radiofrequency neurotomy TECHNIQUE Lumbar medial branch radiofrequency neurotomy MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Med 2013; 14:639-645. 38
MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Med 2013; 14:639-645. MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Med 2013; 14:639-645. 39
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 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 40
Lumbar medial branch radiofrequency neurotomy SAFETY Safe! Interventional treatment of spine pain TAKE HOME MESSAGES Cervical zygapophysial joint pain is common particularly C2-3 and C5-6 41
Interventional treatment of spine pain TAKE HOME MESSAGES Cervical zygapophysial joint pain is common particularly C2-3 and C5-6 Cervical medial branch RF neurotomy is highly effective when patients are correctly selected treatment performed according to guidelines Interventional treatment of spine pain TAKE HOME MESSAGES Cervical zygapophysial joint pain is common particularly C2-3 and C5-6 Cervical medial branch RF neurotomy is highly effective when Lumbar medial branch RF neurotomy is highly effective when patients are correctly selected treatment performed according to guidelines The prevalence of lumbar zygapophysial joint pain is low Cervical and lumbar RFN is safe, if performed according to Guidelines 42
Interventional treatment of spine pain TAKE HOME MESSAGES Cervical zygapophysial joint pain is common particularly C2-3 and C5-6 Cervical medial branch RF neurotomy is highly effective when Lumbar medial branch RF neurotomy is highly effective when patients are correctly selected treatment performed according to guidelines The prevalence of lumbar zygapophysial joint pain is low Cervical and lumbar RFN is safe, if performed according to Guidelines Come and visit the South Island! Lake Wanaka 43
Thank you for your attention 44