interventional treatment for pain of … dr john...scientific meeting of the international spine...

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INTERVENTIONAL TREATMENT FOR PAIN OF SPINAL ORIGIN

Dr John MacVicar, Medical Director

Southern Rehab, Christchurch, NZ

AOCPRM

Nov 23rd 2018


An evidence-based approach

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DISCLOSURES

No conflicts of interest


Cervicogenic headache

Neck pain

Lower back pain

SUMMARY

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Neck pain

Lower back pain

Third occipital nerve RF neurotomy

Cervical medial branch RF neurotomy

Lumbar medial branch RF neurotomy

SUMMARY



Neck pain

Lower back pain

Indications

Technique

Effectiveness

Safety

SUMMARY

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Guidelines

Bogduk N (Ed).

Practice Guidelines for Spinal Diagnostic and Treatment Procedures

2nd edn.

International Spine Intervention Society, San Francisco, 2013


Moderator – John MacVicar MB ChB

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Radiofrequency third occipital nerve neurotomy

Third occipital nerve

ANATOMY

Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982; 7:319-330.

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ANATOMY



Innervation of

C2-3 zygapophysial joint

suboccipital skin

semispinalis capitis

ANATOMY

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C2-3 zygapophysial joint pain

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.

PREVALENCE

Third occipital nerve radiofrequency neurotomy

INDICATIONS

Neck painHeadache> 4 months

Third occipital nerve blocks100% reliefcontrol blocks

Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4), 344–353.

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Third occipital nerve blocks


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ASSESSMENT OF THE RESPONSE

.

REAL TIME ASSESSMENT

Pain drawing

VAS/NRS

Four ADLs

Duration of relief

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TECHNIQUE

5 mm


TECHNIQUE

.

.

.Oblique pass 800 for 90 seconds

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TECHNIQUE

.

.

.sagittal pass 850 for 90 seconds


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.

SUCCESS RATES

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SUCCESS RATES

86% of 49 patients obtained complete relief of painmedian 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.


SUCCESS RATES

Govind et al – technical details1. 16G electrode


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SUCCESS RATES

Govind et al – technical details1. 16G electrode



SUCCESS RATES

Govind et al – technical details1. 16G electrode2. Electrode held firmly throughout procedure3. Check position every 30 seconds and restart procedure if the

electrode has moved4. At least 3 parallel lesions


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SUCCESS RATES

Govind et al – technical details1. 16G electrode2. Electrode held firmly throughout procedure3. Check position every 30 seconds and restart procedure if the

electrode has moved4. At least 3 parallel lesions

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


SUCCESS RATES

Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain: outcomes in a series of consecutive patients. Pain Medicine 2005; 6:282‐286.

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

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SUCCESS RATES

MacVicar J, Borowczyk J, MacVicar A, Loughnan B, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2012;13:647-654.

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


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.

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SAFETY

Gazelka et al:

Third occipital neuralgia

12/64 – 19%

Duration: 5/12 < 1 month

7/12 1-6 months, mean 2.6 months



SAFETY

Gazelka et al:

Third occipital neuralgia

12/64 – 19%

Duration: 5/12 < 1 month

7/12 1-6 months, mean 2.6 months


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Neck pain


Radiofrequency cervical medial branch neurotomy

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Cervical medial branches

ANATOMY


ANATOMY

MBBP.ppt#1. Slide 1

MBBP.ppt#1. Slide 1

MBBP.ppt#1. Slide 1

MBBP.ppt#1. Slide 1

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ANATOMY

Nerves cross the articular pillars

Diameter 0.5 – 0.9 mm



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

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Cervical zygapophysial joint pain

PREVALENCE

1. Barnsley L, Lord SM,Wallis BJ, BogdukN. 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. YinW, Bogduk N. The nature of neck pain in a private pain clinic in the United States. PainMed 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.

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Cervical medial branch radiofrequency neurotomy

INDICATIONS

Neck pain+/- headache+/- shoulder pain

Medial branch blocks100% reliefcontrol blocks

Cervical medial branch blocks

SELECTION OF LEVEL

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Cervical medial branch blocks

TECHNIQUE

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C5,6 MEDIAL BRANCH BLOCKS

C5,6 MEDIAL BRANCH BLOCKS

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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 blocksConcordant responses sensitivity 54% specificity 88% LR 4.5Discordant 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.

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TECHNIQUE


TECHNIQUE

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SUCCESS RATES

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.

24 patients, selected on the basis of 100% relief from placebo-controlled cervical medial blocks

Randomised to:RF neurotomy Sham treatment

22G electrodesSagittal and oblique passes, 2 or 3 parallel lesions

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SUCCESS RATES

The criteria for a successful outcome were complete relief of pain for at least three monthsrestoration of activities of daily livingno need for continuing health care for neck pain.

Median duration of complete relief:RF neurotomy – 263 daysSham treatment – 8 days

By 27 weeks, complete relief from pain:Treatment group – sevenControl group – one

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.

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


SUCCESS RATES


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Complete relief of pain for at least 6 months corroborated by:

Complete restoration of activities of daily living

No need for analgesic medicationsNo need for other health care

Return to work (if applicable)

SUCCESS RATES



OUTCOME – CERVICAL RF NEUROTOMY PRACTICE A PRACTICE

B

FAILURE Outright; no relief 5 12

Other pain 1 5

Pain relieved;

activities not restored0 3

Pain recurred,

before 6 months4 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)


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Our outcomes are consistent with the results from bench-mark studies on cervical RFN

SUCCESS RATES


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.

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.

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Lower back pain


Radiofrequency lumbar medial branch neurotomy

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Lumbar medial branches

ANATOMY

Innervation of

lumbar zygapophysial joints

each joint innervated by 2 nerves

multifidus

Lumbar zygapophysial joint pain

PREVALENCE

?

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Lumbar medial branch radiofrequency neurotomy

TECHNIQUE

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TECHNIQUE

MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Med 2013; 14:639-645.


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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

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SAFETY


Safe!

Interventional treatment of spine pain

TAKE HOME MESSAGES

Cervical zygapophysial joint pain is commonparticularly C2-3 and C5-6

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TAKE HOME MESSAGES


Cervical medial branch RF neurotomy is highly effective when

patients are correctly selectedtreatment performed according to guidelines


TAKE HOME MESSAGES


Cervical medial branch RF neurotomy is highly effective whenLumbar medial branch RF neurotomy is highly effective when


The prevalence of lumbar zygapophysial joint pain is lowCervical and lumbar RFN is safe, if performed according to Guidelines

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TAKE HOME MESSAGES


Cervical medial branch RF neurotomy is highly effective whenLumbar medial branch RF neurotomy is highly effective when


The prevalence of lumbar zygapophysial joint pain is lowCervical and lumbar RFN is safe, if performed according to Guidelines

Come and visit the South Island!

Lake Wanaka

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Thank you for your attention

interventional treatment for pain of … dr john...scientific meeting of the international spine...

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