Cervical Cooled RF Training Presentation

Cervical Cooled RF Training Presentation

Agenda Patient Selection Considerations Diagnostic Block General Considerations COOLIEF* Cooled RF Technique Posterior Lateral Precautions Summary Appendix 2

Disclaimer The information provided in the following presentations is for educational purposes only. Techniques can vary depending on the individual expertise, experience and school-of-thought of the physician using COOLIEF* Cooled RF. Always use your independent medical judgment and discretion when using COOLIEF* Cooled RF. The procedures described herein are not a recommendation by Halyard Health for certain placement techniques and only aim to present information based on current medical literature and clinical data. The following presentations are not intended as a recommendation to purchase or use HALYARD* products. Halyard Health is sponsoring this presentation. The presentation has been reviewed by Halyard Health and is consistent with Halyard Health s product labeling. 3

Patient Selection Considerations

Patient Selection Considerations Prospective Candidate Chronic cervical axial (non-radicular) pain, non-responsive to conservative therapy Greater than 80% pain relief from 2 separate medial branch blocks (no more than 0.3 ml injectate per block) Please see Instructions for Use for detailed information regarding proper use that includes indications and lists of warnings, precautions and contraindications 5

Skeletal Anatomy C3 C6: The bone between the lamina and cervical pedicle is the lateral mass. Due to orientation, the short cervical pedicles are often superimposed over the vertebral body in lateral fluoroscopic view. Superior and inferior surfaces of the lateral mass are cartilaginous. Adjacent superior and inferior articular surfaces of adjacent vertebrae form the zygapophyseal (facet) joint Facet shape and orientation: Superior articular facets: flat and ovoid; directed superoposteriorly Inferior articular facets: directed inferoanteriorly C2-3 z-joint Lamina C4 Lateral mass C5 Body C6 Note C3-4 facets show 2 lucencies height of lateral mass is often asymmetrical. Requires adjustment of c-arm to visualize ipsilateral z-joint space. 6

The Vertebral Artery The V2 segment of the vertebral artery lies anterior to the lateral masses at C2-7 The vertebral artery in the V3 segment passes cephalad and laterally from the C2 foramen transversarium to the C1 foramen transversarium, then turns medially, passing across the dorsal ring of C1 posterior to the AO joint before turning cephalad to enter the foramen magnum Avoid trouble: Direct all implements towards the lateral masses and generally below C1 C2 C1 Tubbs RS, et al. Surgical anatomy and quantitation of the branches of the V2 and V3 segments of the vertebral artery. J Neurosurg Spine 11(1):84-87, July2009. 7

Diagnostic Block

Diagnostic Cervical Medial Branch Block Lateral approach, patient lies on their side with painful side upwards. Stabilize position with foam bolster, pillow or sandbag Obtain true lateral view Superimposition of articular pillars silhouettes (tilting beam cranial-caudal splits the superimposition) Move C-arm or table so target point is in the center of the beam to reduce parallax error Targets: TON caudal aspect of C2 lateral mass and C2-3 facet C3 MB cephalad aspect of the C3 lateral mass C4 MB centroid of the C4 lateral mass C5 MB centroid of C5 lateral mass C6 MB cephalad aspect of C6 lateral mass C7 MB Apex of the C7 SAP, just above the transverse process Bogduk, N. (ed.): Practice Guidelines: Spinal Diagnostic and Treatment Procedures. International Spine Intervention Society, San Francisco, CA, USA, 2004. ( ISIS ) 9

TON Block Tolerable error zone is a rectangular area bounded by the anterior edge of the C3 SAP, upper and lower lines perpendicular passing posteriorly from the apex of the SAP and from the bottom of the C2-3 intervertebral foramen, and posterior line through the posterior edge of the IAP Needle inserted towards the middle of the three target points Progressively insert needle to target point After first target point, the needle may be readjusted to the other target points The three target points are situated at the intersections of the lines. (ISIS p125b). 10

C3-C6 Medial Branch Block Technique Identify centroid of the subject lateral mass. This may be used as a target Select skin entry point overlying the target point avoiding superficial veins, if possible. If possible, avoid piercing the sternocleidomastoid muscle, as subsequent rotation of the patients head will pull the needle off course Align needle coaxially Insert needle through the skin and neck muscles, deep enough to prevent it from swaying if released Check position and orientation to ensure it overlies the target point. Tolerable error should be no greater than the middle half of the area of the articular pillar Progressively insert toward target point and contact bone Inject 0.25-0.3 ml local anesthetic 11

C7 Medial Branch Tolerable insertion zone should be no greater than the triangular silhouette of the C7 SAP Place needle at apex of C7 SAP Confirm placement with AP view. Needle tip lies right against the lateral margin of the SAP 0.3mL at target point, then withdraw 4mm and deliver a second aliquot of 0.3mL. This is due to the variation in the C7 medial branch. Instead of running along the bone, it is displaced by a bundle of the semispinalis capitis 12

General Considerations

Cooled Application 2 mm Active Electrode Oblate spheroid Sphere is flattened in the axial direction 4 6 mm diameter Lesion settings: 60 C for 2:30 min 14

Lesion Characterization Size: 4 6mm Shape: Oblate Spheroid 15

COOLIEF* Cooled RF Posterior Technique

Posterior Approach Cervical Medial Branch Patient prone position Placement of a marker needle Obtain lateral view, identify the center of the neural arch at the target level Insert marker needle and direct under tunnel vision to contact the bone Placement of introducer Rotate to AP view, and identify the waist of the articular pillar Insert introducer under AP guidance to marker needle The introducer should lie at the waist of the vertebra in the AP view, just posterior to the foramen (foraminal view) 17

COOLIEF* Cooled RF Lateral Technique

Cooled RF Technique Lateral Approach Patient in lateral position with sterile prep and drape True lateral fluoroscopic view of target lateral mass Identify centroid of lateral mass Inject local anesthetic and pre-stick skin with 18/19 gauge needle, as desired Insert introducer to contact centroid Stabilize introducer, maintaining depth and orientation Remove stylet and inject 1 2 ml local anesthetic Insert COOLIEF* Cooled RF probe into introducer, maintaining depth and orientation Verify COOLIEF* Cooled RF probe location and set lesion temp at 60 degrees C x 2:30 mins Remove introducer and COOLIEF* Cooled RF probe, repeat at additional levels as indicated 19

C7 Cooled RF Lateral Approach AP View Lateral View Contralateral Oblique Probe 2 mm off of lateral aspect of C7 SAP points to notch Probe appears at apex of C7 SAP but is just above transverse process Probe tip posterior to pedicle. Adequately far from neural foramen 20

Cooled RF Lateral Approach Technique for 3 rd Occipital N./C3 RFL C3 MB Just above the centroid of the lateral mass of C3 At upper portion of lateral concavity of the C3 lateral mass NOTE: Probe tip is 2 mm from bone surface 3 rd Occipital N. Across the C2 3 facet joint space Do not enter the joint space If you enter the joint, withdraw and move 1 2 mm cephalad onto C2 21

Cooled RF Lateral Approach Technique for C4 RFL Probe tip placed at or minimally (1 2 mm) above the centroid of the C4 lateral mass 2 mm gap Correct probe tip position divides lateral mass into two equal anterior and posterior halves Probe tip is 2 mm off of bone surface on AP view C6 technique is identical at or 1 2 mm above the centroid C5 is similar, but directly at the centroid 22

Procedural Video 23

Precautions

Precautions The Vertebral Artery: Direct all implements towards the lateral masses and generally below C1. 25

Summary

Summary Allows user choice of true lateral or posterolateral technique which can coincide with the block injections No known significant complications from procedure reported to Halyard to date Allows the potential for one lesion for the TON compared to the 3 needed for conventional RF The perpendicular approach allow the user the potential to lesion 3 levels with one insertion point utilizing the lateral technique 27

Thank You

Appendix

Anatomy Overview

Cervical Z-Joint Anatomy Zygapophyseal joints: paired posterior diarthrodial joints from C2-S1 Innervation: 1-4 articular nerve branches derived from descending or ascending divisions of the medial branch of the dorsal primary ramus issuing from somatic nerves above and below the joint level Articular nerves issue from the MB in the posterior half of the articular pillar (lateral mass) The dorsal Cruveilhier plexus may provide additional sensory innervation to C2-4 z-joints issuing from the C1 dorsal ramus and the C2-4 medial branches 31

Osseous Anatomy C1 and C2 Vertebra Are Atypical C1 (atlas): 2 lateral masses connected by a short anterior and a longer posterior arch NO vertebral body Lateral masses form the inferior portion of the AO and superior AA joints. Maximum width: 74-95 mm in males, 65-75 mm in females Tip of the transverse process usually palpable between the mastoid process and ramus of the mandible Standring, Gray s Anatomy 2005 C2 (axis): Acts as an axle for rotation of the atlas and head around the odontoid process (dens), which extends superiorly from the C2 vertebral body C2 dens is secured to C1 by several atlantoaxial ligaments Spinous process is large, with a bifid tip, and is concave inferiorly 32

Skeletal Anatomy C7: Most inferior cervical vertebra (vertebra prominens) Prominent non-bifid spinous process is palpable from the skin surface Attaches to the ligamentum nuchae and various muscles Large transverse processes: posterolateral to the transverse foramina Transverse foramen at C7 rarely transmits the vertebral artery (unlike C2-C6 vertebrae) May have transitional variation suggestive of thoracic vertebrae, including vestigial ribs Standring, 2005 33

General Scheme of the Cervical Medial Branches 34

Cervical Medial Branch Neuroanatomy Medial branches are about 1 mm diameter Arise from the posterior primary ramus, travel dorsally and inferiorly around the groove of the lateral mass Often divide into superficial and deep divisions Medial branch or deep division issues the ascending and descending articular nerves posterior to the centroid of the lateral mass and underneath the semispinalis muscle insertions on the lateral masses Superficial division runs through or posterior to the semispinalis to supply cutaneous ipsilateral paramedian sensation Suggested reading: Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982;7:319-330 35

Cervical Medial Branch Neuroanatomy C3: Two divisions of the medial branch Deep division of medial branch innervates C3-4 z- joint (lateral) and upper half of C3 articular pillar Superficial division medial branch becomes the 3rd occipital nerve (TON) and innervates C2-3 z-joint TON includes a contribution from the C2 medial branch C 4 Lang J. Clinical anatomy of the cervical spine. Verlag 1993 36

Exceptions to the Anatomic Rules At C3, the superficial division of the medial branch becomes the third occipital nerve (TON). A branch from the C3 MB can communicate with the C2 dorsal primary ramus. Sensation to the C2-3 facet can originate from the TON or from the C2-3 communicating branches At C7, a slip of muscle may extend laterally, displacing the MB laterally, necessitating an additional slightly lateral lesion at this level *Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. 2017 HYH. All rights reserved. 37