Pulsed radiofrequency of the second cervical ganglion (C2) for the treatment of cervicogenic headache

Pulsed Radiofrequency Neuromodulation of the Greater Occipital Nerve for the Treatment of Headache Disorders in Adults: A Systematic Review

Background

Pulsed radiofrequency neuromodulation (PRFN) of greater occipital nerve (GON) is considered in patients with headaches failing to achieve sustained analgesic benefit from nerve blocks with local anesthetic and steroids. However, the evidence supporting this practice is unclear.

Aims

This narrative systematic review aims to explore the effectiveness and safety of GON PRFN on headaches.

Methods

Databases were searched for studies, published up to February 1, 2024, investigating PRFN of GON for adults with headaches. Abstracts and posters were excluded. Primary outcome was change in headache intensity. Secondary outcomes included effect on monthly headache frequency (MHF), mental and physical health, mood, sleep, analgesic consumption, and side-effects. Two reviewers screened and extracted data.

Results

Twenty-two papers (2 randomized controlled trials (RCT), 11 cohort, and 9 case reports/series) including 608 patients were identified. Considerable heterogeneity in terms of study design, headache diagnosis, PRF target and settings, and image-guidance was noted. PRFN settings varied (38-42°C, 40-60 V, and 150-400 Ohms). Studies demonstrated PRFN to provide significant analgesia and reduction of MHF in chronic migraine (CM) from 3 to 6 months; and significant pain relief for ON from six to ten months. Mild adverse effects were reported in 3.1% of cohort. A minority of studies reported on secondary outcomes. The quality of the evidence was low.

Conclusions

Low-quality evidence indicates an analgesic benefit from PRFN of GON for ON and CM, but its role for other headache types needs more investigation. Optimal PRFN target and settings remain unclear. High-quality RCTs are required to further explore the role of this intervention. PROSPERO ID CRD42022363234.

Neuronavigation-guided Percutaneous Rhizotomies to Trigeminal Neuralgia: A Systematic Review

OBJECTIVE

Neuronavigation improves intraoperative visualization of the cranial structures, which is valuable in percutaneous surgical treatments for patients with trigeminal neuralgia (TN) who are refractory to pharmacotherapy or reluctant to receive open surgery. The objective of this review was to evaluate the available neuronavigation-guided percutaneous surgical treatment modalities with cannulation of foramen ovale to TN, and their relative benefits and limitations.

METHODS

This review was conducted based on the PRISMA statement. An initial search was performed on electronic databases, followed by manual and reference searches. Study and patient characteristics, rhizotomy procedure and neuronavigation details, and treatment outcomes (initial pain relief and pain recurrence within 2 y, success rate of forman ovale cannulation, and complications) were evaluated. The risk of bias was assessed with a quality assessment based on the ROBINS-I tools.

RESULTS

Ten studies (491 operations, 403 participants) were analyzed. Three percutaneous trigeminal rhizotomy modalities identified were radiofrequency thermocoagulation rhizotomy (RFTR), percutaneous balloon compression, and glycerol rhizotomy. Intraoperative computed tomography and magnetic resonance imaging fusion-based RFTR had the highest initial pain relief rate of 97.0%. The success rate of foramen ovale cannulation ranged from 92.3% to 100% under neuronavigation. Facial hypoesthesia and masticatory muscle weakness were the most reported complications.

DISCUSSION

Neuronavigation-guided percutaneous trigeminal rhizotomies showed possible superior pain relief outcomes to that of conventional rhizotomies in TN, with the benefits of radiation reduction and lower complication development rates. The limitations of neuronavigation remain its high cost and limited availability. Higher-quality prospective studies and randomized clinical trials of neuronavigation-guided percutaneous trigeminal rhizotomy were lacking.

Safety and Efficacy of Radiofrequency Ablation and Epidural Steroid Injection for Management of Cervicogenic Headaches and Neck Pain: Meta-Analysis and Literature Review

Dysfunction of the cervical spine and its anatomical features, mostly innervated by the C1, C2, and C3 spinal nerves, can result in a secondary headache known as cervicogenic headache (CHA), mainly characterized by unilateral pain. The usefulness of pharmaceutical medications and physical therapy is currently the subject of scant literature. Interventional pain management techniques can be applied when conservative treatment is unsuccessful. This study looks at radiofrequency ablation (RFA) and epidural steroid injection (ESI) to identify their safety and efficacy in managing patients with cervicogenic headaches and neck pain. Three databases - PubMed, Cochrane CENTRAL Library, and Embase were searched, and 110 studies were identified. Nine screening processes were included for review and meta-analysis. Statistical evaluation was conducted through STATA version 17 (College Station, TX: StataCorp LLC) and effect measures were reported through random effects model risk ratios. The main subject of focus included three following outcomes: incidences of pain relief, degree and duration of pain, and incidences of adverse effects. The findings showed both interventions relieved pain by a factor of >50%, demonstrating a relative effects risk ratio of 1.45 (-0.50, 3.39) for RFA: pain relief, 84.76 (82.82, 86.69) RFA: adverse effects, and 19.46 (18.80, 20.11) ESI: pain relief at 95% confidence interval. The efficacy of RFA and ESI differ. Both interventions are effective in the reduction of cervicogenic headache pain intensity. However, their complication rates and pain duration are considerably different. With ESI, the headaches can still recur weekly, demanding the use of oral analgesics to deal with them. On the other hand, RFA has a low complication rate. Improving guidance from imaging technologies, RFA has the potential to be the most effective interventional treatment.

Computed tomography-guided radiofrequency ablation of cervical intervertebral discs for the treatment of refractory cervicogenic headache: A retrospective chart review

OBJECTIVE

To evaluate the feasibility and efficacy of computed tomography (CT)-guided radiofrequency ablation (RFA) of cervical intervertebral discs for the treatment of discogenic cervicogenic headache (CEH).

BACKGROUND

Some patients with CEH experience no obvious therapeutic effect after conventional therapy, particularly patients with refractory CEH originating from abnormal cervical intervertebral discs. Treatment for this type of CEH remains poorly characterized.

METHODS

Using a single intervention arm, pretest/posttest design, we retrospectively analyzed the data of patients who underwent CT-guided RFA of cervical intervertebral discs for CEH at the Pain Medicine Center of Zhejiang Provincial People's Hospital from January 2017 to April 2021. If conservative treatment failed in patients with discogenic CEH, we classified the patients as having refractory CEH and performed RFA of cervical intervertebral discs. We used a numeric rating scale (NRS) to assess pain intensity for 6 months. We also compared therapeutic outcome of patients with different characteristics.

RESULTS

A total of 44 patients who underwent CT-guided RFA of cervical intervertebral discs were enrolled and 41 of them were analyzed in the present study. The preoperative median (25th, 75th) NRS score was 4 (4, 5), and it was significantly reduced to 1 (0, 4) 6 months after RFA (p < 0.001). The number of patients with ≥50% of their pain relieved after 6 months was 28 of 41 (68%). No serious treatment-related complications occurred in this study. Compared with single-level RFA, multi-level RFA shows greater effects on pain intensity reduction (p = 0.032) and pain relief rate (p = 0.047) of patients.

CONCLUSION

In patients who have discogenic CEH, CT-guided RFA of the cervical intervertebral discs appears to be a promising treatment with no serious complications.

CT-Guided C2 Dorsal Root Ganglion Radiofrequency Ablation for the Treatment of Cervicogenic Headache: Case Series and Clinical Outcomes

Cervicogenic headache is a secondary headache syndrome attributable to upper cervical spine pathology. Osteoarthritis of the lateral atlantoaxial joint with resultant C2 dorsal root ganglion irritation is an important and potentially treatable cause of cervicogenic headache. In this case series, we present 11 patients with cervicogenic headache who underwent C2 dorsal root ganglion thermal radiofrequency ablation. Radiologists should be familiar with this efficacious procedure and technical considerations to avoid complications.

The efficacy of ultrasound-guided multifidus cervicis plane block versus greater occipital nerve block for cervicogenic headache

Introduction

Traditionally, non-invasive and invasive techniques were used for the treatment of cervicogenic headache (CH). Greater occipital nerve block is the most frequent peripheral nerve block invasive technique used for the management of cervicogenic headache. The purpose of this prospective, double-blinded study was to compare the efficacy of two different techniques: multifidus cervicis plane block and greater occipital nerve block in the treatment of refractory cervicogenic headache by using ultrasound.

Methods

Sixty patients with cervicogenic headache were recruited and diagnosed according to the ICHD-III beta version. The patients were divided into two groups, one group was for greater occipital nerve block and the other group was for multifidus cervicis plane block with ultrasound-guided.

Results

Visual analog scale (VAS) was 2.09% in the multifidus cervicis plane block (MCPB) group and was 2.22% in the greater occipital nerve block (GONB) group with a median reduction of − 4.33 and − 3.048, respectively, at 2-week visits with a statistically significant difference better in the MCPB group (P< 0.001). At 4 weeks visits, VAS scale was better in the MCPB group than in the GONB group (3.79 and 4.44, respectively) with a median reduction in VAS scale (− 3.27 and − 3.095, respectively) and statistically significant differences between both groups (P= 0.020).

Conclusion

Both the ultrasound-guided multifidus cervicis plane block and greater occipital nerve block are effective as intervention techniques in the treatment of refractory cervicogenic headache. These techniques are simple, safe, more reliable with less side effects, and often reduce the requirements of analgesic drugs.

Radiofrequency Ablation for Craniofacial Pain Syndromes

Headache disorders and trigeminal neuralgia are common conditions representing the types of craniofacial pain syndrome that can significantly impact quality of life. Many cases are refractory to traditional pharmacologic treatments, whether oral or intravenous. Radiofrequency ablation has been increasingly used as a tool to treat resistant, chronic pain of both of these disorders. Multiple studies have been reported that illustrate the efficacy of radiofrequency ablation in the treatment of the numerous headache subtypes and trigeminal neuralgia.

Spinal manipulation for the management of cervicogenic headache: A systematic review and meta-analysis

BACKGROUND

Spinal manipulative therapy (SMT) is frequently used to manage cervicogenic headache (CGHA). No meta-analysis has investigated the effectiveness of SMT exclusively for CGHA.

OBJECTIVE

To evaluate the effectiveness of SMT for CGHA.

DATABASES AND DATA TREATMENT

Five databases identified randomized controlled trials comparing SMT with other manual therapies. The PEDro scale assessed the risk-of-bias. Pain and disability data were extracted and converted to a common scale. A random effects model was used for several follow-up periods. GRADE described the quality of evidence.

RESULTS

Seven trials were eligible. At short-term follow-up, there was a significant, small effect favouring SMT for pain intensity (mean difference [MD] -10.88 [95% CI, -17.94, -3.82]) and small effects for pain frequency (standardized mean difference [SMD] -0.35 [95% CI, -0.66, -0.04]). There was no effect for pain duration (SMD - 0.08 [95% CI, -0.47, 0.32]). There was a significant, small effect favouring SMT for disability (MD - 13.31 [95% CI, -18.07, -8.56]). At intermediate follow-up, there was no significant effects for pain intensity (MD - 9.77 [-24.21 to 4.68]) and a significant, small effect favouring SMT for pain frequency (SMD - 0.32 [-0.63 to - 0.00]). At long-term follow-up, there was no significant effects for pain intensity (MD - 0.76 [-5.89 to 4.37]) and for pain frequency (SMD - 0.37 [-0.84 to 0.10]).

CONCLUSION

For CGHA, SMT provides small, superior short-term benefits for pain intensity, frequency and disability, but not pain duration, however, high-quality evidence in this field is lacking. The long-term impact is not significant.

SIGNIFICANCE

CGHA are a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short-term effects for pain intensity, frequency and disability when compared with other manual therapies. These findings may help clinicians in practice better understand the treatment effects of SMT alone for CGHA.

Efficacy and safety of pulsed radiofrequency as a method of dorsal root ganglia stimulation for treatment of non-neuropathic pain: a systematic review

BACKGROUND

We systematically reviewed the evidence on the efficacy and safety of dorsal root ganglion (DRG) targeted pulsed radiofrequency (PRF) versus any comparator for treatment of non-neuropathic pain.

METHODS

We searched MEDLINE, CINAHL, Embase, PsycINFO, clinicaltrials.gov and WHO clinical trial register until January 8, 2019. All study designs were eligible. Two authors independently conducted literature screening. Primary outcomes were pain intensity and serious adverse events (SAEs). Secondary outcomes were any other pain-related outcome and any other safety outcome that was reported. We assessed the risk of bias using the Cochrane tool and Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I). We conducted narrative evidence synthesis and assessed the conclusiveness of included studies regarding efficacy and safety.

RESULTS

We included 17 studies with 599 participants, which analyzed various pain syndromes. Two studies were randomized controlled trials; both included participants with low back pain (LBP). Non-randomized studies included patients with the following indications: LBP, postsurgical pain, pain associated with herpes zoster, cervicogenic headache, complex regional pain syndrome type 1, intractable vertebral metastatic pain, chronic scrotal and inguinal pain, occipital radiating pain in rheumatoid arthritis and chronic migraine. In these studies, the PRF was usually initiated after other treatments have failed. Eleven studies had positive conclusive statements (11/17) about efficacy; the remaining had positive inconclusive statements. Only three studies provided conclusiveness of evidence statements regarding safety - two indicated that the evidence was positive conclusive, and one positive inconclusive. The risk of bias was predominantly unclear in randomized and serious in non-randomized studies.

CONCLUSION

Poor quality and few participants characterize evidence about benefits and harms of DRG PRF in patients with non-neuropathic pain. Results from available studies should only be considered preliminary. Not all studies have reported data regarding the safety of the intervention, but those that did, indicate that the intervention is relatively safe. As the procedure is non-destructive and early results are promising, further comparative studies about PRF in non-neuropathic pain syndromes would be welcomed.

The Feasibility and Efficacy of Ultrasound-Guided C2 Nerve Root Coblation for Cervicogenic Headache

OBJECTIVE

The cervicogenic headache is a syndrome caused by dysfunction of the upper cervical spine and its component bony, disc, and/or soft tissue elements. The C2 nerve root may play a pivotal role in cervicogenic headache. In this retrospective study, we evaluated the feasibility and efficacy of ultrasound-guided C2 nerve root coblation in managing 26 patients with cervicogenic headache.

DESIGN AND SETTING

The data were collected retrospectively by reviewing the patient's medical records and pain questionnaires.

SUBJECTS AND METHODS

A total of 109 patients with cervicogenic headache sustained for at least six months were identified. Of those patients, 26 had a visual analog scale score ≥6 and subsequently underwent an ultrasound-guided C2 nerve root coblation.

RESULTS

All 26 patients had >50% pain relief one day after coblation. Twenty-three of the 26 patients (92.31%) had a decrease in their pain score of 50% or more at 24-week follow-up. The mean pain score was 7.38 ± 1.13 before coblation and 1.85 ± 0.83 one day after coblation (Bonferroni-adjusted P < 0.001). At 12 and 24 weeks after coblation, the mean pain scores were 2.96 ± 0.96 (P < 0.001) and 3.08 ± 1.38 (P < 0.008), respectively.

CONCLUSIONS

C2 nerve coblation may provide the majority of patients with a pain relief period as long as 24 weeks. And ultrasound guidance is an efficient method with which to perform coblation.

Pulsed Radiofrequency Ablation of the C2 Dorsal Root Ganglion Using a Posterior Approach for Treating Cervicogenic Headache: A Retrospective Chart Review

OBJECTIVE

To evaluate the efficacy and complications of C2 dorsal root ganglion (DRG) pulsed radiofrequency ablation (RFA) for cervicogenic headache (CEH) and to identify factors related to the outcome of the procedure in this retrospective analysis.

BACKGROUND

Although conventional high-temperature C2 DRG RFA was effective in patients with CEH in previous studies, the effect of pulsed RFA on C2 DRG in cases of CEH has not yet been evaluated.

METHODS

We examined the electronic medical records of consecutive patients who underwent C2 DRG block for CEH from January 2012 to May 2018 at a pain center. Consequent C2 DRG pulsed RFA was performed for patients in whom the headache recurred after an initial period of relief 24 hours after the C2 DRG block. A successful outcome was defined as at least 50% pain relief at 6 months after C2 DRG pulsed RFA. We also examined variables associated with the outcome and prognostic factors of CEH.

RESULTS

Fluoroscopy-guided C2 DRG block was performed in 114 patients with CEH. Forty-five patients received C2 DRG pulsed RFA and 40.0% among them (18/45, success group) had ≥50% pain relief after 6 months. There were no post-procedure complications throughout the study period. Significantly more patients in the success group than in the failure group had a definite positive response (≥50% pain relief) to a previous C2 DRG block (P < .001).

CONCLUSION

C2 DRG pulsed RFA may be an effective treatment for patients with CEH, particularly for patients who have previously experienced definite pain reduction after C2 DRG block. However, the limitations of our study design and small number of patients preclude firm conclusions.

Diagnostic Value of Single-Photon Emission Computed Tomography/Computed Tomography Scans with Tc-99m HDP in Cervicogenic Headache

A cervicogenic headache (CEH) is difficult to diagnose due to its varied pathology. We evaluated the usefulness of single-photon emission computed tomography/computed tomography (SPECT/CT) in diagnosing CEH and its interventional treatment. Retrospectively, 23 patients diagnosed with CEH between March 2016 to August 2018 were allocated to SPECT/CT (n = 11) and control (n = 12) groups. The SPECT/CT group was further stratified into SPECT/CT(+) and SPECT/CT(-) groups according to the presence of positive findings. Patients in the SPECT/CT group underwent an intra-articular injection at a radiologically verified lesion site, whereas those in the control group underwent third occipital nerve block. Clinical outcomes were evaluated with the visual analog scale (VAS), neck disability index (NDI), and global perceived effect (GPE) scale at baseline, and at one, three, and six months postoperatively. The SPECT/CT group showed less VAS, NDI, and GPE scores at six months postoperatively (2.91 ± 2.30 vs. 4.42 ± 1.62, p = 0.08; 38.00 ± 16.54 vs. 48.7 ± 12.40, p = 0.093; 2.00 ± 1.41 vs. 3.17 ± 1.11, p = 0.039). Successful responders at six months postoperatively were higher in the SPECT/CT(+) group than in the control group (75% vs. 0%). SPECT/CT can identify arthritic changes and accurately define therapeutic targets.

CT-Guided Block and Radiofrequency Ablation of the C2 Dorsal Root Ganglion for Cervicogenic Headache

The purpose of this report is to describe the technical aspects of CT-guided C2 dorsal root ganglion diagnostic block and radiofrequency ablation for refractory cervicogenic headache. CT guidance allows precise and safe positioning of a needle adjacent to the C2 dorsal root ganglion. At-risk neural and vascular structures can be avoided with CT, and it can provide a thorough understanding of upper cervical neuroanatomy.

Pulsed radiofrequency of the C2 dorsal root ganglion and epidural steroid injections for cervicogenic headache

BACKGROUND

Cervicogenic headache (CEH) is characterized by unilateral headache symptoms referred to the head from the cervical spine. Few methods have addressed long-term pain relief for CEH. This study was undertaken to evaluate pain control and quality of life after pulsed radiofrequency (PRF) for the C2 dorsal root ganglion and epidural steroid injections (ESI) for CEH.

METHODS

This was a case-control study. One hundred thirty-nine patients suffering from CEH were enrolled in this study. Of these patients, 87 CEH patients underwent PRF for the C2 dorsal root ganglion and ESI therapy, and 52 CEH patients only underwent ESI therapy. Quality of life and pain control were measured with the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and Izbicki pain scores. Kaplan-Meier curve was used to evaluate the efficacy of the treatment in the groups.

RESULTS

Before therapy, the median of Izbicki pain score in PRF+ESI group and ESI group was 78.5 and 72.5, respectively (p = 0.574). After 2 year follow-up, significant reduction was found in the two groups (11.25 versus 40.00, p < 0.001). The two groups demonstrated an equal distribution of age and gender (p > 0.05). SF (68.52 ± 21.50 versus 50.63 ± 15.42), PF (70.61 ± 29.47 versus 47.87 ± 21.53), RF (52.04 ± 17.92 versus 38.13 ± 24.07), EF (61.17 ± 28.41 versus 43.52 ± 25.48), CF (55.36 ± 19.82 versus 46.82 ± 23.54), and QL (59.31 ± 27.44 versus 50.73 ± 21.90) were significantly higher in PRF+ESI group than in ESI group. Kaplan-Meier curve showed that the probability of treatment success in PRF+ESI group was higher than that in ESI group (median pain relief: ESI group, 4 months; PRF+ESI group, 8 months) (Log-Rank test, p < 0. 001). There was no serious side effect in this study.

CONCLUSION

The combination of PRF for the C2 dorsal root ganglion and ESI is a relatively safe therapy for CEH. This technique not only provides the sustained relief of pain symptom but improves the quality of life in patients with CEH.

Systematic Review of Radiofrequency Ablation and Pulsed Radiofrequency for Management of Cervicogenic Headaches

PURPOSE OF REVIEW

Cervicogenic headache (CHA) is a secondary headache which has a source in the upper cervical spine. Many traditional analgesic choices lack good efficacy in managing the associated pain. As a result, in management of CHA, radiofrequency ablation (RFA) or pulse radiofrequency (PRF) has been tried with success. Our study investigated the use of RFA and PRF for the management of CHA.

RECENT FINDINGS

In the present investigation, a review of the literature was conducted using PubMed (1966 to February 2017). The quality assessment was determined using The Cochrane Risk of Bias. After initial search and consultation with experts, 34 articles were identified for initial review and 10 articles met inclusion for review. Criteria for inclusion were primarily based on identification of articles discussing cervicogenic headaches which were previously treatment resistant and occurred without any other pathology of the craniofacial region or inciting event such as trauma. This systematic review demonstrated that RFA and PRFA provide very limited benefit in the management of CHA. At present, there is no high-quality RCT and/or strong non-RCTs to support the use of these techniques, despite numerous case reports which have demonstrated benefit. This review is one of the first to provide a comprehensive overview of the use of RFA and PRF in the management of CHA.

Ultrasound-Guided versus Fluoroscopy-Guided Deep Cervical Plexus Block for the Treatment of Cervicogenic Headache

Objective. The aim of this study was to compare the efficacy of ultrasound-guided deep cervical plexus block with fluoroscopy-guided deep cervical plexus block for patients with cervicogenic headache (CeH). Methods. A total of 56 patients with CeH were recruited and randomly assigned to either the ultrasound-guided (US) or the fluoroscopy-guided (FL) injection group. A mixture of 2–4 mL 1% lidocaine and 7 mg betamethasone was injected along C₂ and/or C₃ transverse process. The measurement of pain was evaluated by patients' ratings of a 10-point numerical pain scale (NPS) before and 2 wks, 12 wks, and 24 wks after treatments. Results. The blocking procedures were well tolerated. The pain intensity, as measured by NPS, significantly decreased at 2 wks after injection treatment in both US and FL groups, respectively, compared with that of baseline (P < 0.05). The blocking procedures had continued, and comparable pain relieving effects appeared at 12 wks and 24 wks after treatment in both US and FL groups. There were no significant differences observed in the NPS before and 2 wks, 12 wks, and 24 wks after treatment between US and FL groups. Conclusions. The US-guided approach showed similar satisfactory effect as the FL-guided block. Ultrasonography can be an alternative method for its convenience and efficacy in deep cervical plexus block for CeH patients without radiation exposure.

Comparison of Transcutaneous Electrical Nerve Stimulation and Pulsed Radiofrequency Sympathectomy for Treating Painful Diabetic Neuropathy

Background:

Painful diabetic peripheral neuropathy (DPN) is a long-term complication of type 1 and type 2 diabetes that majorly impacts quality of life. Its prevalence increases with age and duration of diabetes. It is more common in patients who have suboptimal glycemic control over several years. Because DPN may be resistant to conventional treatments, it is common for patients to only have partial pain relief. Therefore, new therapeutic options are needed for the condition.

Objectives:

The aim of the present study was to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) and pulsed radiofrequency (PRF) lumbar sympathectomy in treating painful DPN.

Patients and Methods:

Sixty-five patients with painful DPN refractory to conventional treatment were randomly and evenly assigned to either the TENS or PRF lumbar sympathectomy groups. Pain evaluations were based on the 10-point numerical rating scale (NRS). Subjects were followed for three months and had a total of four study visits (baseline and 1 week, 1 month, and 3 months after treatment).

Results:

Sixty patients completed all study visits. In both groups, the NRS rating significantly decreased after treatment, with a marked pain reduction observed at the first follow-up evaluation. In the PRF group, the NRS decreased from 6.46 at baseline to 2.76 at the 1 week visit. One and 3 months after treatment, the NRS was 4.30 and 5.13, respectively (P < 0.0001). In the TENS group, the NRS decreased from 6.10 at baseline to 3.96 at the 1 week visit. One and 3 months after treatment, the NRS was 5.23 and 5.90, respectively (P < 0.0001). Unfortunately, the NRS steady increased almost back to baseline levels in the TENS group. The NRS only slightly increased during the follow-up period in the PRF group, but did not reach baseline levels.

Conclusions:

Both TENS and PRF lumbar sympathectomy are promising pain relief treatments for painful DNP. However, PRF lumbar sympathectomy seems to have a superior efficacy. Further studies with a larger sample size and a longer follow-up period are needed.

Successful Treatment of Occipital Radiating Headache Using Pulsed Radiofrequency Therapy

Rheumatoid arthritis (RA) is a chronic inflammatory disease involving multiple joints. The cervical spine is often affected, and cases involving atlantoaxial joint can lead to instability. Anterior atlantoaxial subluxation in RA patients can lead to posterior neck pain or occipital headache because of compression of the C2 ganglion or nerve. Here, we report the successful treatment of a RA patient with occipital radiating headache using pulsed radiofrequency therapy at the C2 dorsal root ganglion.

Efficacy of Pulsed Radiofrequency on Cervical 2-3 Posterior Medial Branches in Treating Chronic Migraine: A Randomized, Controlled, and Double-Blind Trial

Objective. The aim of this study was to examine the efficacy and safety of pulsed radiofrequency (PRF) in the treatment of chronic migraine (CM) on cervical 2-3 posterior medial branches. Methods. This randomized, double-blind, and controlled clinical trial included 40 subjects with CM, who were randomly divided into two groups: treatment (treated by PRF) and sham (treated by sham treatment). Pain intensity, headache duration (days), the Migraine Disability Assessment Questionnaire (MIDAS), and aspirin dose taken by patients were evaluated at 1, 2, and 6 months after the intervention. Side effects were observed from the time of treatment and throughout the follow-up period. Results. During the follow-up, pain intensity, headache duration (days), disability score, and the analgesic dose were significantly improved in the treatment group compared to the sham group (P < 0.001) and the baseline (P < 0.001) at all measured time points after intervention. No serious complications were reported. Conclusion. PRF on the cervical 2-3 posterior medial branches could provide satisfactory efficacy in the treatment of CM without obvious adverse effects.

Pulsed radiofrequency to the great occipital nerve for the treatment of intractable postherpetic itch: a case report

A patient with intractable postherpetic itch lasting for 1 year was reported. The itch was mainly from the left vertex, frontal and ophthalmic regions and extended to the left neck area. The patient had negative response to the ophthalmic nerve block. Under the initial positive response to the great occipital nerve block, pulsed radiofrequency (PRF) was performed on the position of the great occipital nerve. After 4 months treatment, the itch was completely vanished. This case study demonstrates the effectiveness of PRF for intractable postherpetic itch originating in the head and neck. However, more samples needed to verify this management.

Therapeutic options for cervicogenic headache

The term cervicogenic headache (CeH) describes a syndrome originating from the cervical spine. There are a variety of therapeutic approaches used for the management of CeH, but scientific evidence of their effectiveness is scarce. No medication drug has proven to be effective. The evidence for greater occipital nerve blocks, cervical nerve blockades, facet joint injections and surgical procedures is limited. Several physical therapy interventions are proposed for CeH, with spinal manipulation and soft tissue interventions being the most commonly used. However, the lack of solid evidence of positive effects and risks of serious complications for spinal manipulation should be considered in favor of other physical therapy interventions associated with less risk. The inconsistent results in the literature can be related to the fact that maybe not all therapeutic interventions are appropriate for all patients with CeH or maybe not all patients with CeH will benefit from particular interventions.

Managing and treating headache of cervicogenic origin

CGH is a common entity that has been assessed historically in various medical disciplines. Currently, CGH is a controversial topic whose existence has supporters and naysayers. The difficulty evaluating CGH is caused by a lack of objective findings on imaging and biologic tests. Patients present with pain but often with a lack of hard, concrete physical findings. Other clinical diagnoses may confound the clinical presentation of patients. The concomitant presence of ON and migraine headaches has been noted in the literature. Positive analgesia after interventional techniques remains the major way to consider the diagnosis in potential patients with headaches. Although the IHS has acknowledged CGH as a secondary headache in its diagnostic schema, more research, specifically randomized double-blinded evaluations of patients with CGH, are required. These data would be deemed as objective gold-standard evidence to lead us from controversy to collaborative agreement regarding the fate of CGH. What is certain regarding CGH is that a cooperative effort should be considered in the treatment of the patients between evaluating physicians, interventional pain physicians, surgeons, and physical therapy providers. This multidisciplinary effort can lead to the effective management of CGH.

Effect of intradiscal monopolar pulsed radiofrequency on chronic discogenic back pain diagnosed by pressure-controlled provocative discography: a one year prospective study

Objective

To investigate the efficacy and safety of percutaneous intradiscal monopolar pulsed radiofrequency (PRF) in patients with chronic disabling discogenic back pain.

Method

Twenty-six subjects (7 males; mean age 43.2 years) with chronic back pain refractory to active rehabilitative management were recruited. All subjects underwent MRI for evaluation of Modic changes, and monopolar PRF (20 min at 60 V) at the center of target lumbar intervertebral disc confirmed by pressure-controlled provocative discography. Clinical outcomes were measured by the visual analogue scale (VAS), Oswestry disability index (ODI), and sitting tolerance time (ST) for 12 months after treatment. Successful clinical outcome was described as a minimum of 2 point reduction in VAS compared with the baseline at each follow-up period.

Results

The mean VAS for low back pain reduced significantly from 6.4±1.1 at pre-treatment to 4.4±1.9 at 12 months (p<0.05). The mean ODI score was 47.3±15.4 points at pre-treatment and 36.7±19.5 at 12 months (p<0.001). The ST was 27.8±20.4 minutes at pre-treatment and 71.5±42.2 at 12 months (p<0.001). However, successful clinical outcome was achieved at 58%, 50%, and 42%, measured at 3, 6, and 12 months post-treatment. There were no significant relationship between the clinical outcome and Modic changes; no adverse events were recorded.

Conclusion

The results demonstrated that the application of intradiscal monopolar PRF might be relatively effective but limited; successful intervention for chronic refractory discogenic back pain is needed. To achieve the optimal outcome through intradiscal PRF, we suggested further studies about stimulation duration, mode, and intensity of PRF.

Clinical outcomes of pulsed radiofrequency neuromodulation for the treatment of occipital neuralgia

Objective

Occipital neuralgia is characterized by paroxysmal jabbing pain in the dermatomes of the greater or lesser occipital nerves caused by irritation of these nerves. Although several therapies have been reported, they have only temporary therapeutic effects. We report the results of pulsed radiofrequency treatment of the occipital nerve, which was used to treat occipital neuralgia.

Methods

Patients were diagnosed with occipital neuralgia according to the International Classification of Headache Disorders classification criteria. We performed pulsed radiofrequency neuromodulation when patients presented with clinical findings suggestive occipital neuralgia with positive diagnostic block of the occipital nerves with local anesthetics. Patients were analyzed according to age, duration of symptoms, surgical results, complications and recurrence. Pain was measured every month after the procedure using the visual analog and total pain indexes.

Results

From 2010, ten patients were included in the study. The mean age was 52 years (34-70 years). The mean follow-up period was 7.5 months (6-10 months). Mean Visual Analog Scale and mean total pain index scores declined by 6.1 units and 192.1 units, respectively, during the follow-up period. No complications were reported.

Conclusion

Pulsed radiofrequency neuromodulation of the occipital nerve is an effective treatment for occipital neuralgia. Further controlled prospective studies are necessary to evaluate the exact effects and long-term outcomes of this treatment method.

Cervicogenic headaches: an evidence-led approach to clinical management

Cervicogenic headache (CGH), as the diagnosis suggests, refers to a headache of cervical origin. Historically, these types of headaches were difficult to diagnose and treat because their etiology and pathophysiology was not well-understood. Even today, management of a CGH remains challenging for sports rehabilitation specialists. The purpose of this clinical suggestion is to review the literature on CGH and develop an evidence-led approach to assessment and clinical management of CGH.