Percutaneous Radiofrequency Neurotomy for Chronic Neck Pain: Outcomes in a Series of Consecutive Patients

Sudden Death Due to Necrotizing Fasciitis After Routine Cervical Radiofrequency Ablation Treatment

ABSTRACT

Cervical facet joint neurotomy, also known as cervical radiofrequency ablation (RFA) or cervical facet rhizotomy, is a medical procedure aimed at alleviating chronic neck pain caused by issues related to the cervical facet joints through ablation of neurons (J Pain Res 2021;14:2807-2831). Although generally safe, adverse events can occur. Infection is a rare consequence of this procedure. Most injection-site infections related to cervical RFA occur spontaneously and resolve with oral antibiotics without sequelae (World Neurosurg 2018;111:e644-e648). We report a case in which a cervical RFA injection resulted in the development of necrotizing fasciitis and ultimately death. To our knowledge, this has not been previously reported and is the first documented fatality due to infectious sequelae of a cervical RFA procedure.

Dropped head syndrome after bilateral cervical radiofrequency ablation. A case report and literature review

Introduction

Cervical medial branch radiofrequency ablation is an effective treatment for cervical facet joint pain. It is considered a safe procedure, and permanent complications are very rare. We report a case of a patient who developed dropped-head syndrome (DHS) after bilateral treatment.

Case report

An 86-year-old man was referred to our pain clinic because of neck pain. One year before, he underwent bilateral multi-level cervical medial branch radiofrequency ablation. Within the next 24 hours, he experienced progressive neck extensor muscle weakness. After a comprehensive examination, he was diagnosed with dropped head syndrome as a complication of the radiofrequency procedure. Conservative management was chosen, resulting in partial improvement of the muscular weakness.

Conclusion

The present case, along with others reviewed in this article, supports the recommendation against performing bilateral and multilevel cervical medial branch radiofrequency ablation.

End-on versus parallel radiofrequency lesioning for neurotomy of the cervical medial branch nerves: a study protocol of a prospective, randomized, double-blind clinical trial: the "EndPaRL" study

BACKGROUND

Cervical facet joint disease is a common source of neck pain and its prevalence increases with aging. Conservative multimodal management options (e.g., strengthening of neck muscles, non-steroidal anti-inflammatory medications, massage, and thermal modalities) often fail to relieve pain. Cervical medial branch nerve (CMBN) radiofrequency neurotomy (RFN) is an effective minimally invasive technique for treating chronic neck pain secondary to facet joint disease. An end-on approach for this procedure has been proposed that may be technically easier and require less time while reducing post-procedural discomfort. The protocol presented here is for a study that aims to compare the efficacy of a new end-on approach using multi-tined cannulae, against the conventional parallel technique that employs straight cannulae for RFN of the CMBN in patients with chronic neck pain due to cervical facet joint disease.

METHODS

A multicentre randomized, non-inferior, active comparator-controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessor. The study will include 72 adults with chronic neck pain secondary to facet joint disease who are candidates for RFA of the CMBN. Participants will be randomized to either the conventional parallel or the end-on approach in a 1:1 ratio. The intensity of pain and pain-related domains (function, quality of life, sleep, adverse effects of the interventions, analgesic intake) will be measured at 1, 3, 6, and 12 months after the procedure.

DISCUSSION

Neck pain secondary to cervical facet joint disease is prevalent and RFA of the CMBN is a validated treatment for relieving it. The conventional parallel technique can be technically challenging, and it can be associated with adverse effects while the newer end-on approach has the potential of being a simpler technique with less adverse effects. This trial will be the first non-inferiority study to compare the clinical efficacy of the end-on approach against the conventional parallel approach for RFN of CMBN in patients with chronic neck pain due to cervical facet joint disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05818774. Registered on April 20, 2023.

Randomized controlled trial comparing technical features and clinical efficacy of a multi-tined cannula versus a conventional cannula for cervical medial branch radiofrequency neurotomy in chronic neck pain

Objectives

Compare procedural characteristics and clinical efficacy of cervical medial branch radiofrequency neurotomy (CMBRFN) using a multi-tined cannula (MTC) versus a conventional cannula (CC) to treat chronic neck pain.

Design

Prospective, double-blinded randomized controlled trial.

Methods

Patients who responded to dual medial branch blocks with ≥75% pain relief were randomized to receive RFN with either the MTC or the CC. Primary outcomes: procedural pain, procedure duration, fluoroscopy time and radiation dose. Secondary outcomes: proportion of patients reporting ≥50% numerical rating scale reduction and ≥30% neck disability index reduction at 3, 6 and 12 months.

Results

Forty-two patients underwent treatment. There was no difference in procedural pain between the MTC and CC groups (NRS 4.7 ± 2.0 vs. 4.2 ± 1.8, p = 0.465), but three patients, all in the CC group, could not complete the procedure due to pain. CMBRFN in the MTC group was significantly faster than in the CC group (35.5 ± 7.3 min vs. 58.2 ± 14.8 min, p < 0.001), with less fluoroscopy time (167.6 ± 76.4 s vs. 260.8 ± 123.5 s, p = 0.004). Radiation dose was 8.95 ± 7.9 mGy in the MTC group and 11.53 ± 10.3 mGy in the CC group (p = 0.36). Rates of ≥50% NRS reduction were not significantly different between the two groups at 3 months, but at 6 and 12 months, they were significantly higher in the CC group. At 3, 6 and 12 months, rates of ≥30% NDI reduction were significantly higher in the CC group.

Conclusions

The MTC offers technical advantages compared to the CC for both the operator and the patient. However, CMBRFN with the multi-tined cannula seems less effective to treat neck pain than with the conventional cannula.

Spinal Injections: A Narrative Review from a Surgeon's Perspective

Spinal pain is one of most frequent complaints of the general population, which can cause decreased activities of daily living and absence from work. Among numerous therapeutic methods, spinal injection is one of the most effective treatments for spinal pain and is currently widely applied in the clinical field. In this review, spinal injection is discussed from a surgeon's perspective. Recently, although the number of spinal surgeries has been increasing, questions are arising as to whether they are necessary. The failure rate after spinal surgery is high, and its long-term outcome was reported to be similar to spinal injection. Thus, spinal surgeries should be performed conservatively. Spinal injection is largely divided into diagnostic and therapeutic blocks. Using diagnostic blocks, such as the diagnostic selective nerve root block, disc stimulation test, and diagnostic medial branch block (MBB), the precise location causing the pain can be confirmed. For therapeutic blocks, transforaminal nerve root injection, therapeutic MBB, and percutaneous epidural neuroplasty are used. When unbearable spinal pain persists despite therapeutic spinal injections, spinal surgeries can be considered. Spinal injection is usefully used to identify the precise location prior to a patient undergoing injection treatment or surgery and can reduce pain and improve quality of life, and help to avoid spinal surgery. Pain physicians should treat patients with spinal pain by properly utilizing spinal injection.

Combined Continuous Radiofrequency Ablation and Pulsed Neuromodulation to Treat Cervical Facet Joint Pain and Alleviate Postcervical Radiofrequency Side Effects

Background

Continuous radiofrequency ablation (RFA) can effectively manage cervical facet joint pain related to neuropathic symptoms in the post-radiofrequency period. Additionally, pulse radiofrequency (PRF) provides relief of neuropathic symptoms. However, the effect of combined RFA and PRF has yet to be determined.

Objectives

The study aimed to compare the effectiveness and safety of RFA (CRF group) and combined RFA and PRF (CPRF group).

Methods

The study retrospectively reviewed the charts of patients with cervical facet joint pain undergoing RFA between June 1, 2014, and June 1, 2017, or combined RFA and PRF between June 1, 2017, and June 1, 2020, at a pain research center. Thirty-nine consecutive patients identified from charts meeting the inclusion criteria were included and classified in CRF (n = 22) and CPRF groups (n = 17). The results were evaluated using a Visual Analog Scale (VAS) and neck pain disability index (NDI) before procedures and 1, 3, and 6 months after the injections. Successful treatment was expressed as at least 80% pain relief from baseline and NDI score <15 points. The duration of pain relief was expressed as the period between pain relief and pain reoccurrence to 50% of the preprocedural pain level. The primary outcome was successful treatment in the groups, and the secondary outcome was the duration of pain relief and post-cervical radiofrequency side effects in the groups.

Results

Fourteen (66.7%) patients in the CRF group and 12 (66.7%) in the CPRF group experienced successful treatment at three and six-month follow-ups (P > 0.05). The median time to the reoccurrence of at least 50% of preprocedural pain level was 303.8 days in the CRF group and 270 days in the CPRF group (P = 0.395). However, the CPRF group showed significantly less postoperative numbness, dysesthesia, and hypersensitivity syndrome than the CRF group (P < 0.05).

Conclusions

Combined RFA and PRF can be complementary treatment for cervical facet joint pain, providing an adequate success rate and duration of pain relief as RFA alone but with significantly fewer post-radiofrequency side effects.

A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain

Background

Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks.

Study Design

Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis.

Objective

The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain.

Methods

Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined.

Results

Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions.

Limitations

There was a paucity of literature and heterogeneity among the available studies.

Conclusion

This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-022-00455-0.

A comparison of the effectiveness of cervical medial branch radiofrequency ablation for chronic facet joint syndrome in patients selected by two common medial branch block paradigms

Background

Cervical medial branch radiofrequency ablation (CMBRFA) is effective when patients are selected by dual medial branch blocks (MBBs). SIS guidelines recommend 100% pain improvement after dual comparative MBBs before CMBRFA; however, our prior investigation showed similar outcomes in those selected by a lesser strict paradigm.

Objective

Compare pain and patient impression of improvement after CMBRFA in individuals stratified by a less stringent (80-99%) dual MBB response than those selected by the 100% criteria.

Design

Cross-sectional study.

Methods

Follow-up was conducted via standardized telephone survey at ≥6 months post-CMBRFA to obtain Numerical Rating Scale (NRS) pain and Patient Global Impression of Change (PGIC) scores. Primary and secondary outcomes were within-group and between-group differences in the proportions of patients reporting ≥50% NRS score reduction and PGIC scores.

Results

Medical records of 195 consecutive patients were reviewed; 100 individuals were analyzed. 48% (95% CI 35-61%) and 52% (95% CI 37-67%) of the 80-99% and 100% MBB groups, reported ≥50% pain reduction at ≥6 months post-CMBRFA. 74% (95% CI 63-85%) and 67% (95% CI 52-81%) of the 80-99% and 100% MBB groups reported a PGIC score consistent with "improved" or "very much improved." There were no significant between-group differences in any outcome at any time point.

Conclusions

We observed similar rates of pain relief and global improvement after CMBRFA in patients selected by dual MBBs with ≥80% symptom relief versus 100% relief. This provides evidence that a more practical criteria, compared to a more strict selection paradigm, may result in similar clinical outcomes.

Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of short-term outcomes

Objective

To explore the safety and feasibility of a single autologous injection of platelet-rich plasma (PRP) in cervical facet joints of people with chronic WAD and facet-mediated pain, and explore the association between pain relief reported with diagnostic medial branch blocks (MBBs) and 3-months post-PRP.

Design

A prospective case series of people with chronic whiplash-associated disorders and cervical facet joint mediated pain in a community setting.

Interventions

A single autologous PRP injection was provided to cervical facet joints under ultrasound and fluoroscopic guidance.

Measures

Adverse events were recorded one-week, and measures of pain (numerical pain rating scale - NPRS) and disability (Neck Disability Index - NDI) were collected prior to and 3-months following cervical facet joint PRP. People not reached for follow-up were considered failures for worst-case analysis. The correlation between percentage response to diagnostic cervical medial branch blocks (MBBs) and percentage pain relief reported at 3-months was also investigated.

Results

Forty-four people (82% female; mean age (SD): 45.2 (10.8) years) underwent cervical facet joint PRP. There was a significant improvement in pain and disability following PRP. Seventy percent of people exceeded MCID for pain. For NDI scores, 80% of people exceeded MCID. Forty-one percent of people reported greater than 50% relief of pain 3-months post-cervical facet joint PRP.There was no significant correlation between percentage relief of pain with cervical MBBs and percentage relief of pain 3-months post-PRP (r ​= ​0.06, p ​= ​0.73).There were no adverse events reported.

Conclusion

In people with chronic WAD and facet-mediated pain, preliminary data suggests that PRP is safe and it is feasible to move forwards with randomized studies to further investigate efficacy and effectiveness.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BACKGROUND

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

METHODS

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

RESULTS

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

CONCLUSIONS

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BACKGROUND

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

METHODS

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

RESULTS

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

CONCLUSIONS

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN)

Radiofrequency neurotomy (RFN), also known as radiofrequency ablation (RFA), is a common interventional procedure used to treat pain from an innervated structure. RFN has historically been used to treat chronic facet-joint mediated pain. The use of RFN has more recently expanded beyond facet-joint mediated pain to peripherally innervated targets. In addition, there has also been the emergence of different radiofrequency modalities, including pulsed and cooled RFN. The use of RFN has been particularly important where conservative and/or surgical measures have failed to provide pain relief. With the emergence of this therapeutic option and its novel applications, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidance. The authors formed a multidisciplinary work group tasked to examine the latest evidence-based medicine for the various applications of RFN, including cervical, thoracic, lumbar spine; posterior sacroiliac joint pain; hip and knee joints; and occipital neuralgia. Best practice guidelines, evidence and consensus grading were provided for each anatomical target.

The Effectiveness of Cervical Medial Branch Radiofrequency Ablation for Chronic Facet Joint Syndrome in Patients Selected by a Practical Medial Branch Block Paradigm

BACKGROUND

Cervical medial branch radiofrequency ablation (CMBRFA) is an effective treatment for facetogenic pain in patients selected by Spine Intervention Society (SIS) guidelines of 100% symptom improvement with dual medial branch blocks (MBBs) ± placebo block. Patient selection for CMBRFA using ≥80% symptom improvement after dual concordant MBBs is common; however, this has not been studied.

OBJECTIVE

To evaluate the effectiveness of CMBRFA and compare outcomes in individuals selected by 80-99% vs 100% symptom improvement with dual concordant MBBs.

DESIGN

Cross-sectional cohort study.

METHODS

Medical records of 87 consecutive patients were reviewed; 50 met inclusion criteria. A standardized telephone survey was performed at six or more months post-CMBRFA to query numerical rating scale (NRS) pain and patient global impression of change (PGIC) scores. The primary outcomes were the proportion of patients reporting ≥50% reduction of index pain.

RESULTS

At a mean follow-up time of 16.9 ± 12.7 months, 54% (95% confidence interval [CI] = 35-73%) and 54% (95% CI = 32-74%) of the 80-99% and 100% MBBs groups, respectively, reported ≥50% pain reduction. Between-group comparison showed a relative risk of 0.99 (95% CI = 0.59-1.66) for meeting the primary outcome. Seventy percent (95% CI = 56-81%) of patients reported a PGIC score consistent with "improved or very much improved" at follow-up.

CONCLUSIONS

CMBRFA is an effective treatment in patients who report ≥80% symptom relief with dual concordant MBBs. The present study demonstrated an overall ≥50% pain reduction rate of 54% and no significant difference between those selected by 80-99% vs 100% symptom relief with dual concordant MBBs.

Incidence, Diagnosis, and Management of Neuromas Following Radiofrequency Ablation Treatment: a Narrative Review

OBJECTIVE

To determine the epidemiology of neuroma formation as a complication following radiofrequency ablation for chronic pain conditions as well as reviewing the diagnosis and management of neuromas.

DESIGN

Evidence-based narrative review and critical appraisal of literature.

RESULTS

A comprehensive review of the literature generated one case report describing neuroma formation following lumbar facet medial branch radiofrequency denervation. The rare incidence may be explained by neuroma pathophysiology and peripheral nerve injury produced by radiofrequency ablation, in combination with its asymptomatic nature. Diagnosis of neuromas is predominantly confirmed by clinical history and physical exam with potential for nerve blocks or imaging. Ultrasound has been suggested as a primary imaging modality with magnetic resonance imaging as a secondary option. Neuroma management ranges from conservative therapy to surgery with varying success rates.

CONCLUSIONS

Neuroma formation following radiofrequency ablation procedures is exceedingly rare and could be a hypothetical concern in clinical practice. However, the true incidence may be inaccurate given the asymptomatic nature of neuromas.

The Effectiveness of Cervical Medial Branch Thermal Radiofrequency Neurotomy Stratified by Selection Criteria: A Systematic Review of the Literature

Objective

To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria.

Design

Comprehensive systematic review.

Methods

A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.

Outcome Measures

The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief.

Results

Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used.

Conclusions

Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief.

Cervical Medial Branch Block Volume Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

BACKGROUND

Neck pain is one of the most common causes of chronic pain and the fourth leading cause of disability worldwide; it is estimated that between 36% and 67% of this pain is due to facet arthropathy. For patients who have pain refractory to conservative treatments literature supports management with diagnostic cervical medial branch blocks (MBBs) to identify the associated facet innervation as the source of pain followed by therapeutic radiofrequency ablation (RFA) of the identified nerves. Cervical RFA has good published outcomes; however, the procedure is dependent upon the specificity of the diagnostic block to achieve maximal success. Currently, this prerequisite test has false positive rates between 27% and 63% and recent studies have shown that this may, in part, be a consequence of currently accepted injection volumes of 0.50 mL or more, which may decrease the sensitivity of MBBs.

OBJECTIVE

To evaluate the possible differences in volume dispersion between 0.25 and 0.50 mL of injectate during cervical MBBs.

STUDY DESIGN

Cadaveric study.

SETTING

An academic medical center in the United States.

PATIENTS

Not applicable.

METHODS

This was a cadaveric study in which six subjects were chosen with intact cervical spines. Cervical MBB were performed bilaterally at the midcervical spine, using a posterior approach under fluoroscopic guidance. 0.25 or 0.50 mL of a 9:1 solution of Omnipaque 180 mg iodine/mL and 1% medical grade methylene blue were administered on the left and right sides, respectively. Postinjection computed tomography (CT) imaging and gross dissection were performed to assess injectate spread.

MAIN OUTCOME MEASURES

Outcome measures after using commonly injected volumes for cervical MBB, included visualized and measured spread (by CT and gross dissection) of cervical medial branch blocks, coating adjacent structures not targeted by RFA.

RESULTS

Postinjection CT imaging and cadaveric dissection demonstrated that, although both volumes adequately coated the medial branches, the 0.50 mL cohort reliably spread dorsally to superficial muscles (splenius) and nerves distant from the targeted nerves (dorsal motor branches to splenius), whereas the 0.25 mL injectate cohort was contained in the deep and intermediate muscular cervical layers directly juxtaposed to the targeted cMBBs.

CONCLUSION

Results suggest that 0.50 mL injections of local anesthetic during cervical MBBs contacts many nonintended targets, thus decreasing the specificity of a targeted diagnostic cervical MBB. Furthermore, we demonstrated that 0.25 mL of injectate reliably bathed the cervical medial branches without extensive extravasation. This indicates that there would potentially be fewer local anesthetic effects on distant tissues, increasing the specificity of cervical MBBs and likely improving RFA planning.

Prognostic Factor Analysis for Management of Chronic Neck Pain: Can We Predict the Severity of Neck Pain with Lateral Cervical Curvature?

Objective

Although little is known about its origins, neck pain may be related to several associated anatomical pathologies. We aimed to characterize the incidence and features of chronic neck pain and analyze the relationship between neck pain severity and its affecting factors.

Methods

Between March 2012 and July 2013, we studied 216 patients with chronic neck pain. Initially, combined tramadol (37.5 mg) plus acetaminophen (325 mg) was administered orally twice daily (b.i.d.) to all patients over a 2-week period. After two weeks, patients were evaluated for neck pain during an outpatient clinic visit. If the numeric rating scale of the patient had not decreased to 5 or lower, a cervical medial branch block (MBB) was recommended after double-dosed previous medication trial. We classified all patients into two groups (mild vs. severe neck pain group), based on medication efficacy. Logistic regression tests were used to evaluate the factors associated with neck pain severity.

Results

A total of 198 patients were included in the analyses, due to follow-up loss in 18 patients. While medication was successful in reducing pain in 68.2% patients with chronic neck pain, the remaining patients required cervical MBB. Lateral cervical curvature, such as a straight or sigmoid type curve, was found to be significantly associated with the severity of neck pain.

Conclusion

We managed chronic neck pain with a simple pharmacological management protocol followed by MBB. We should keep in mind that it may be difficult to manage the patient with straight or sigmoid lateral curvature only with oral medication.

Pharmacological and Interventional Management of Pain After Whiplash Injury

Synopsis Whiplash-associated disorder (WAD) is a group of symptoms and clinical manifestations resulting from rear-end or side impact. Despite the wide use of medications in WAD, the published research does not allow recommendations based on high evidence level. It may be meaningful to use nonsteroidal anti-inflammatory drugs in the acute posttraumatic phase. In chronic WAD, the use of nonsteroidal anti-inflammatory drugs is more concerning due to potential gastrointestinal and renal complications with prolonged use and lack of evidence for long-term benefits. Antidepressants can be used in patients with clinically relevant hyperalgesia, sleep disorder associated with pain, or depression. Anticonvulsants are unlikely first-choice medications, but can be considered if other treatments fail. The use of opioids in patients with chronic pain has become the object of severe concern, due to the lack of evidence for long-term benefits and the associated risks. Extreme caution in prescribing and monitoring opioid treatment is mandatory. Nerve blocks of the zygapophyseal (facet) joints have validity for the diagnosis of facet joint pain, which is one of the possible manifestations of WAD. One randomized sham-controlled trial and several high-quality prospective studies support the efficacy of radiofrequency neurotomy for the treatment of facet joint pain. The efficacy of trigger point treatments is uncertain. They can be offered due to possible efficacy and limited risks. Any medication or procedure has to be considered in the frame of a comprehensive patient evaluation. As for any chronic pain condition, concomitant consideration of rehabilitation and psychosocial interventions is mandatory. J Orthop Sports Phys Ther 2016;46(10):845-850. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6906.

The Effectiveness and Risks of Fluoroscopically-Guided Cervical Medial Branch Thermal Radiofrequency Neurotomy: A Systematic Review with Comprehensive Analysis of the Published Data

OBJECTIVE

To determine the effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy (CMBTRFN) for treating chronic neck pain of zygapophysial joint origin.

DESIGN

Systematic review of the literature with comprehensive analysis of the published data.

INTERVENTIONS

Four reviewers formally trained in evidence-based medicine searched the literature on CMBTRFN. Each assessed the methodologies of studies found and appraised the quality of evidence presented.

OUTCOME MEASURES

The primary outcomes assessed were 100% relief of pain 6 and 12 months after treatment. Other outcomes were noted if reported. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The searches yielded eight primary publications on the effectiveness of the procedure. The evidence shows a majority of patients were pain free at 6 months and over a third were pain free at 1 year. The number needed to treat for complete pain relief at 6 months is 2. The evidence of effectiveness is of high quality according to the GRADE system. Twelve papers were found reporting unwanted effects, most of which are minor and temporary. No serious complications have ever been reported from procedures performed according to the published guidelines. The evidence of risks is of low quality according to the GRADE system.

CONCLUSIONS

If performed as described in the International Spine Intervention Society Guidelines, fluoroscopically-guided CMBTRFN is effective for abolishing zygapophysial joint pain and carries only minor risks.

Treatment of Cervicogenic Headache: New Insights on the Treatment of Pain in the Neck

This manuscript served as a companion piece for the original article “Pregabalin for the Management of Cervicogenic Headache; A Double Blind Study” by Guy P. Boudreau and Luc Marchand, which was published in the September 2014 issue ofThe Canadian Journal of Neurological Sciences.1

Modulation of Cervical Facet Joint Nociception and Pain Attenuates Physical and Psychological Features of Chronic Whiplash: A Prospective Study

OBJECTIVE

To investigate changes in clinical (physical and psychological) features of individuals with chronic whiplash-associated disorder who had previously undergone cervical radiofrequency neurotomy at the time point when the effects of radiofrequency neurotomy had dissipated and pain returned.

DESIGN

Prospective cohort observational trial of consecutive patients.

SETTING

Tertiary spinal intervention centre in Calgary, Alberta, Canada.

PATIENTS

A total of 53 consecutive individuals with chronic whiplash-associated disorder.

METHODS

Individuals underwent radiofrequency neurotomy and were assessed before radiofrequency neurotomy, at 1 and 3 months postprocedure, and then after the return of pain (approximately 10 months postprocedure).

MAIN OUTCOME MEASUREMENTS

Quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement; craniocervical flexion test) were measured. Self-reported disability, psychological distress, pain catastrophization, and posttraumatic stress disorder symptoms also were measured.

RESULTS

Upon the return of pain after radiofrequency neurotomy, levels of disability increased (P < .0001), and were no different to those before radiofrequency neurotomy (P = .99). There also was a significant deterioration in quantitative sensory testing measures and reduced cervical range of motion after the return of pain (all P < .05); all approaching values were recorded before radiofrequency neurotomy (P > .22). There were no significant changes in pressure hyperalgesia (P > .054) or craniocervical flexion test performance (P > .07) after the return of pain. Psychological distress and pain catastrophizing increased significantly after the return of pain (P < .01), and again were no different than measures taken prior to radiofrequency neurotomy (P > .13). However, there was no difference in number or severity of posttraumatic stress symptoms after the return of pain (P > .30).

CONCLUSIONS

Physical and psychological features of chronic whiplash-associated disorder are modulated dynamically with cervical radiofrequency neurotomy. These findings indicate that peripheral nociception is involved in the manifestations of chronic whiplash-associated disorder in this cohort of individuals.

Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve

The purpose of this study was to identify the incidence of neuropathic pain occurring after radiofrequency neurotomy of the third occipital nerve (TON). This study was conducted at a teaching hospital from January 1, 2008, to March 31, 2010. With institutional review board approval, Current Procedural Terminology codes were used to identify patients who received radiofrequency ablation (RFA) of the nerves supplying the C2-3 facet joint and the TON. The C3 dorsal ramus provides innervation to the C2-3 facet joint and the suboccipital cutaneous region, and procedures that included ablation to this region were reviewed for complications. Postprocedural data were collected by reviewing follow-up appointment notes and telephone calls. Included were patients who had new neuropathic pain in the distribution of the TON after RFA. They described what they were feeling as burning, tingling, or numbness. All patients who presented with complaints had normal neurologic findings and no secondary cause for their symptoms. The included patient medical records were then reviewed for severity and duration of symptoms and the need for treatment with pain medication. Sixty-four patients underwent C2-3 RFA or TON RFA, and 12 patients were identified as experiencing ablation-induced third occipital neuralgia, an incidence rate of 19%. This finding suggests that patients undergoing RFA of the nerves supplying the C2-3 joint or TON are at risk for postprocedural third occipital neuralgia. This possibility may affect providing informed consent as well as anticipating and managing postprocedural pain.

A comparison of physical and psychological features of responders and non-responders to cervical facet blocks in chronic whiplash

Background

Cervical facet block (FB) procedures are often used as a diagnostic precursor to radiofrequency neurotomies (RFN) in the management of chronic whiplash associated disorders (WAD). Some individuals will respond to the FB procedures and others will not respond. Such responders and non-responders provided a sample of convenience to question whether there were differences in their physical and psychological features. This information may inform future predictive studies and ultimately the clinical selection of patients for FB procedures.

Methods

This cross-sectional study involved 58 individuals with chronic WAD who responded to cervical FB procedures (WAD_R); 32 who did not respond (WAD_NR) and 30 Healthy Controls (HC)s. Measures included: quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test); nociceptive flexion reflex (NFR); motor function (cervical range of movement (ROM); activity of the superficial neck flexors during the cranio-cervical flexion test (CCFT). Self-reported measures were gained from the following questionnaires: neuropathic pain (s-LANSS); psychological distress (General Health Questionnaire-28), post-traumatic stress (PDS) and pain catastrophization (PCS). Individuals with chronic whiplash attended the laboratory once the effects of the blocks had abated and symptoms had returned.

Results

Following FB procedures, both WAD groups demonstrated generalized hypersensitivity to all sensory tests, decreased neck ROM and increased superficial muscle activity with the CCFT compared to controls (p < 0.05). There were no significant differences between WAD groups (all p > 0.05). Both WAD groups demonstrated psychological distress (GHQ-28; p < 0.05), moderate post-traumatic stress symptoms and pain catastrophization. The WAD_NR group also demonstrated increased medication intake and elevated PCS scores compared to the WAD_R group (p < 0.05).

Conclusions

Chronic WAD responders and non-responders to FB procedures demonstrate a similar presentation of sensory disturbance, motor dysfunction and psychological distress. Higher levels of pain catastrophization and greater medication intake were the only factors found to differentiate these groups.

Long-term follow-up of cervical facet medial branch radiofrequency treatment with the single posterior-lateral approach: an exploratory study

BACKGROUND

Over 50% of patients presenting to pain clinic with neck pain have the cervical facet joints as the source of pain. Radiofrequency (RF) treatment of the medial branch, innervating the facet joint, is a therapeutic option. The objectives of this study were to evaluate the therapeutic effect and its duration of RF treatment, using the single posterior-lateral approach in patients suffering from facet joint degeneration and to identify predictors for a long-term effect.

METHODS

Of the 130 consecutive patients with axial neck pain referred to the University Pain Center Maastricht, 67 fulfilled the inclusion criteria. The therapeutic effect was measured using the Patients' Global Impression of Change (PGIC) scale. Retrospective data were made complete using newly collected PGIC follow-up data. A Kaplan-Meier curve evaluated the long-term therapeutic effect. Possible predictors of outcome were evaluated.

RESULTS

Two patients refused to participate and in the remaining 65 patients, overall pain relief was reported in 55.4% at 2-month follow-up. Moderately, important change of improvement and substantial change of improvement were seen in 50.8% of patients. At 3-year follow-up, 30% still reported pain reduction. Spinal treatment level was the only predictor found.

CONCLUSIONS

Radiofrequency treatment of the cervical facet joints using a single posterior-lateral approach is a promising technique in patients with chronic neck pain due to facet degeneration. The short-term and long-term therapeutic effects of this intervention justify a randomized controlled trial to estimate the efficacy of cervical facet joint RF treatment in a chronic neck pain population.

Success of initial and repeated medial branch neurotomy for zygapophysial joint pain: a systematic review

OBJECTIVES

To review the duration of pain relief after initial and repeated radiofrequency neurotomy (RFN) for cervical and lumbar zygapophysial joint pain.

METHODS

We searched PubMed to identify all articles that met review criteria for in-depth analysis, synthesis, and review.

RESULTS

Data from 16 articles are reported in this review, including 8 cervical studies, 7 lumbar studies, and 1 study of both cervical and lumbar treatment. Overall, methodology and design quality of cervical studies exceeded that of lumbar studies. For initial cervical RFN, average range duration of >50% pain relief was 7.3-8.6 months. Repeated cervical RFN was successful 67%-95% of the time when the first RFN procedure was successful. When the first RFN procedure was unsuccessful, repeated RFN was successful 0%-67% of the time. The average range duration of pain relief after successful repeated RFN was 6.0-12.7 months. For initial lumbar RFN, the average duration of >50% pain relief was 9.0 months. Repeated lumbar RFN was successful 33%-85% of the time when the first RFN procedure was successful. The average duration of pain relief after successful repeated lumbar RFN was 11.6 months.

CONCLUSIONS

The results of this review indicate that pain relief after initial RFN generally ends after 7-9 months and that repeating RFN is likely to provide additional pain relief if initial RFN was successful. Results are similar between cervical and lumbar spine studies.

Correlation of lumbar medial branch neurotomy results with diagnostic medial branch block cutoff values to optimize therapeutic outcome

OBJECTIVE

We sought an optimal medial branch block (MBB) cutoff value for both single and double MBB protocols that would best correlate with a positive outcome of medial branch neurotomy (MBN).

OUTCOME MEASURES

We analyzed the percentage of subjective pain relief following MBB, confirmed by numerical rating scale (NRS) in aggravating positions before and 45 minutes after MBB. The percentage of overall pain relief following MBB was plotted against the following outcome variables: degree of subjective pain relief, duration of relief, patient satisfaction and activity level, no other doctor's visits, and reduction in medications use.

RESULTS

Using the percent of pain relief post-MBB plotted in 10% increments in the double-MBB group, patients reporting 70% or greater pain relief following MBB showed statistically favorable outcome for the following four criteria: percentage of pain relief, duration of relief, patient satisfaction, and pain medications reduction. In the single MBB group, patients reporting 80% or greater pain relief following MBB had favorable outcomes for improvement in activity level and patient satisfaction.

CONCLUSIONS

The double MBB protocol better correlated with favorable MBN outcomes compared with a single MBB protocol. Using a double MBB protocol, a 70% cutoff value for reported subjective pain relief post-MBB best predicted overall outcome following MBN. Without a confirmatory MBB, an 80% cutoff value was the optimal value.

Cervical medial branch radiofrequency neurotomy in New Zealand

OBJECTIVE

The objective of this study was to determine the effectiveness of cervical medial branch radiofrequency neurotomy (RFN) performed by two practitioners trained according to rigorous guidelines.

DESIGN

The study was designed as a prospective, outcome study of consecutive patients with chronic neck pain treated in a community setting.

INTERVENTIONS

A total of 104 patients, selected on the basis of complete relief of pain following controlled, diagnostic, medial branch blocks, were treated with RFN according to the guidelines of the International Spine Intervention Society.

OUTCOME MEASURES

Successful outcome was defined as complete relief of pain, or at least 80% relief, for at least 6 months, with complete restoration of activities of daily living, no need for any further health care, and return to work. Patients who failed to meet any of these criteria were deemed to have failed treatment.

RESULTS

In the two practices, 74% and 61% of patients achieved a successful outcome. Relief lasted 17-20 months from the first RFN, and 15 months for repeat treatments. Allowing for repeat treatment, patients maintained relief for a median duration of 20-26 months, with some 60% still having relief at follow-up.

CONCLUSION

Cervical RFN can be very effective when performed in a rigorous manner in appropriately selected patients. Chronic neck pain, mediated by the cervical medial branches, can be temporarily, but completely, relieved and patients fully restored to desired activities of daily living, if treated with RFN.

The role of tissue damage in whiplash-associated disorders: discussion paper 1

STUDY DESIGN

Nonsystematic review of cervical spine lesions in whiplash-associated disorders (WAD).

OBJECTIVE

To describe whiplash injury models in terms of basic and clinical science, to summarize what can and cannot be explained by injury models, and to highlight future research areas to better understand the role of tissue damage in WAD.

SUMMARY OF BACKGROUND DATA

The frequent lack of detectable tissue damage has raised questions about whether tissue damage is necessary for WAD and what role it plays in the clinical context of WAD.

METHODS

Nonsystematic review.

RESULTS

Lesions of various tissues have been documented by numerous investigations conducted in animals, cadavers, healthy volunteers, and patients. Most lesions are undetected by imaging techniques. For zygapophysial (facet) joints, lesions have been predicted by bioengineering studies and validated through animal studies; for zygapophysial joint pain, a valid diagnostic test and a proven treatment are available. Lesions of dorsal root ganglia, discs, ligaments, muscles, and vertebral artery have been documented in biomechanical and autopsy studies, but no valid diagnostic test is available to assess their clinical relevance. The proportion of WAD patients in whom a persistent lesion is the major determinant of ongoing symptoms is unknown. Psychosocial factors, stress reactions, and generalized hyperalgesia have also been shown to predict WAD outcomes.

CONCLUSION

There is evidence supporting a lesion-based model in WAD. Lack of macroscopically identifiable tissue damage does not rule out the presence of painful lesions. The best available evidence concerns zygapophysial joint pain. The clinical relevance of other lesions needs to be addressed by future research.

On cervical zygapophysial joint pain after whiplash

STUDY DESIGN

Narrative review.

OBJECTIVE

To summarize the evidence that implicates the cervical zygapophysial joints as the leading source of chronic neck pain after whiplash.

SUMMARY OF BACKGROUND DATA

Reputedly a patho-anatomic basis for neck pain after whiplash has been elusive. However, studies conducted in a variety of disparate disciplines indicate that this is not necessarily the case.

METHODS

Data were retrieved from studies that addressed the postmortem features and biomechanics of injury to the cervical zygapophysial joints, and from clinical studies of the diagnosis and treatment of zygapophysial joint pain, to illustrate convergent validity.

RESULTS

Postmortem studies show that a spectrum of injuries can befall the zygapophysial joints in motor vehicle accidents. Biomechanics studies of normal volunteers and of cadavers reveal the mechanisms by which such injuries can be sustained. Studies in cadavers and in laboratory animals have produced these injuries.Clinical studies have shown that zygapophysial joint pain is very common among patients with chronic neck pain after whiplash, and that this pain can be successfully eliminated by radiofrequency neurotomy.

CONCLUSION

The fact that multiple lines of evidence, using independent techniques, consistently implicate the cervical zygapophysial joints as a site of injury and source of pain, strongly implicates injury to these joints as a common basis for chronic neck pain after whiplash.

Diagnosis of altered central pain processing

STUDY DESIGN

Nonsystematic review.

OBJECTIVE

To review the current knowledge on detecting altered central pain processing in individual patients with chronic pain.

SUMMARY OF BACKGROUND DATA

Alterations in central pain processing are mainly characterized by hyperexcitability of the central nervous system and disturbances in endogenous pain modulation. Although these mechanisms are widely recognized as important determinants of pain and disability, there is need for translation of this knowledge into benefits for patients. To this purpose, the first step is the detection of abnormalities in pain processing in individual patients. Quantitative sensory tests (QST) explore aspects of nociception and pain perception, and are therefore potentially useful for diagnostic purposes.

METHODS

Nonsystematic review of the reliability, validity and reference values of QST for the assessment of altered central pain processing in chronic pain patients.

RESULTS

The reliability of QST is generally high. However, most studies have been performed on healthy volunteers, and few reliability data in patients are available. Furthermore, little is known on the reliability of measures of endogenous pain modulation. The face validity of QST is acceptable. The construct validity cannot be tested, because there is no gold standard for the detection of altered central pain processing in humans. Reference values of different types of QST for applications in neuropathic and musculoskeletal pain have been determined in large samples of pain-free subjects.

CONCLUSION

QST can be used in clinical practice to assess the presence of sensory abnormalities in individual patients. Because information on the reliability and validity of the tests is incomplete, the findings should be interpreted with caution. It is still unclear to what extent disturbances in central pain processing are relevant for the determination of symptoms in individual patients. Furthermore, the therapeutic consequences of these assessments remain undetermined. These are challenges of future translational research.

Diagnostic blocks for chronic pain

Many conditions associated with chronic pain have no detectable morphological correlate. Consequently, the source of pain cannot be established by clinical examination or medical imaging. However, for some such conditions, the source of pain can be established using diagnostic blocks. The aim of this paper is to review the available evidence concerning the validity and utility of diagnostic blocks, and to identify areas where research is needed. Diagnostic blocks for cervical and lumbar zygapophysial joint pain have been extensively studied. Single blocks are associated with about 30% false-positive responses. Patients can report relief of pain for reasons other than the effect of a local anaesthetic injected during a diagnostic block, e.g. as the result of placebo effect. Therefore, in order to be valid, diagnostic blocks must be controlled in each patient. Many practitioners find limitations in the clinical applicability of placebo-controlled blocks. Comparative blocks (comparison lidocaine-bupivacaine for each block within each patient) have been investigated as alternatives to placebo-controlled blocks. A positive response requires short-lasting relief when lidocaine is used, and long-lasting relief when bupivacaine is used. The validity of comparative blocks is high when the disease under investigation is common. This is the case for zygapophysial joint pain after whiplash injury. However, the validity of comparative blocks strongly decreases with decreasing prevalence of the condition. This is the case for lumbar zygapophysial joint pain in young subjects: in these patients, the expected false-positive rate with comparative blocks is unacceptably high. Diagnostic blocks for cervical and lumbar zygapophysial joint have therapeutic utility. When positive, radiofrequency denervation is expected to produce substantial pain relief in 60-80% of patients. For all other types of blocks, very little research has been conducted. The few studies that have been published did not use controlled blocks. This may have produced a high rate of false-positive responses. Some data on spinal nerve root blocks suggest that these procedures may be valid for the diagnosis of radicular pain and are perhaps predictive for the success of surgery. The validity of diagnostic sympathetic blocks and their prognostic value in relation to outcomes of sympathectomy are unclear. There is lack of data on the validity of diagnostic intra-articular blocks. Discogenic pain is typically diagnosed by provocative discography, but this procedure remains controversial. Intradiscal and sinuvertebral nerve blocks with local anaesthetics are possible alternatives to provocation discography. At present, the sparse data available on these procedures do not allow an estimation of their validity. In conclusion, nerve blocks have an important potential role in the management of chronic pain. These procedures are not suitable to identify the pathology that is the cause of the pain (e.g. inflammatory, neuropathic, etc.). However, they can reveal the anatomical source of pain, thereby allowing the development of targeted treatments. Unfortunately, there is currently very little research on the validity and prognostic value of blocks. The potential usefulness of this practice remains therefore largely unexplored.

Radiofrequency neurotomy for the treatment of therapy-resistant neck pain after ventral cervical operations

OBJECTIVE

The objective of this study was to determine if radiofrequency neurotomy is effective for patients with postoperative neck pain after cervical spine operations.

DESIGN

The study design used was a retrospective practice audit.

SETTING

Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 2.5 years.

INTERVENTIONS

Patients with persistent postsurgical neck pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). If pain recurred, diagnostic medial branch blocks were performed. Patients with at least 80% relief following both the therapeutic and the diagnostic block underwent radiofrequency neurotomy. Positive treatment response was defined for at least 50% reduction of pain or sufficiently satisfaction of the patient.

RESULTS

Two hundred forty-two operations were performed, 125 of which were artificial disc operations, 66 were stand alone cages, and 51 were fusions with cage and plate. Two patients were lost to follow-up. Persistent neck pain occurred in 31% of the patients. The prevalence of zygapophysial pain after surgery was 13.2%. These 32 patients were treated with radiofrequency neurotomy because of recurrent neck pain. The average follow-up time was 15 months. A significant pain reduction was achieved in 59.4%. Significantly, after a double-level operation, more patients suffered persisting neck pain (P=0.002) compared with all patients being operated.

CONCLUSIONS

Zygapophysial joints are a possible source of postoperative pain after anterior cervical spine surgery. Persistent and therapy-resistant neck pain occurs more often in patients after double-level operation. Radiofrequency neurotomy can provide an effective treatment for persistent neck pain after ventral cervical spine surgery.

Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment

Cervicogenic headache is characterised by pain referred to the head from the cervical spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.

Pathoanatomy of the lower cervical spine facet joints in motor vehicle crash fatalities

Non-lethal injuries to the cervical spine facet joints have previously been described in decedents from motor vehicle crashes and in clinical settings these joints have been identified as potential culprits in chronic neck pain syndromes. The aim of this study was to conduct a detailed examination of the lower cervical spine facet joints in a forensic cohort of motor vehicle crash victims and controls using comparable data from medicolegal autopsy, stereomicroscopy and histological evaluations. Injuries to the cervical spine facet joints were common in the trauma cases and included facet fractures, haemarthrosis, and disruption and bleeding in the synovial folds. The injuries could not be reliably verified on stereomicroscopic evaluation, and routine autopsy procedures did not reveal any of the injuries to the facet joints. Despite the presence of these pathoanatomical lesions in road traffic crash fatalities their prevalence and potential clinical implications in survivors from motor vehicle crashes is unknown.

Destructive procedures for the treatment of nonmalignant pain: a structured literature review

OBJECT

Nonmalignant pain has been treated in the past century with ablative, or more appropriately, destructive procedures. Although individual outcomes for these procedures have previously been described in the literature, to the authors' knowledge this is the first comprehensive and systematic review on this topic.

METHODS

A US National Library of Medicine PubMed search was conducted for the following ablative procedures: cingulotomy, cordotomy, DREZ (also input as dorsal root entry zone), ganglionectomy, mesencephalotomy, myelotomy, neurotomy, rhizotomy, sympathectomy, thalamotomy, and tractotomy. Articles related to pain resulting from malignancy and those not in peer-reviewed journals were excluded. In reviewing pertinent articles, focus was placed on patient number, outcome, and follow-up.

RESULTS

A total of 146 articles was included in the review. The large majority of studies (131) constituted Class III evidence. Eleven Class I and 4 Class II studies were found, of which nearly all (13 of 15) evaluated radiofrequency rhizotomies for different pain origins, including lumbar facet syndrome, cervical facet pain, and Type I or typical trigeminal neuralgia. Overall, support for ablative procedures for nonmalignant pain is derived almost entirely from Class III evidence; despite a long history of use in neurosurgery, the evidence supporting destructive procedures for benign pain conditions remains limited.

CONCLUSIONS

Newly designed prospective standardized studies are required to define surgical indications and outcomes for these procedures, to provide more systematic review, and to advance the field.