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Lefel N, van Suijlekom H, Cohen SPC, Kallewaard JW, Van Zundert J. 11. Cervicogenic headache and occipital neuralgia. Pain Pract 2024. [PMID: 39219023 DOI: 10.1111/papr.13405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Cervicogenic headache (CEH) and occipital neuralgia (ON) are headaches originating in the occiput and that radiate to the vertex. Because of the intimate relationship between structures based in the occiput and those in the upper cervical region, there is significant overlap between the presentation of CEH and ON. Diagnosis starts with a headache history to assess for diagnostic criteria formulated by the International Headache Society. Physical examination evaluates range of motion of the neck and the presence of tender areas or pressure points. METHODS The literature for the diagnosis and treatment of CEH and ON was searched from 2015 through August 2022, retrieved, and summarized. RESULTS Conservative treatment includes pain education and self-care, analgesic medication, physical therapy (such as reducing secondary muscle tension and improving posture), the use of TENS (transcutaneous electrical nerve stimulation), or a combination of the aforementioned treatments. Injection at various anatomical locations with local anesthetic with or without corticosteroids can provide pain relief for a short period. Deep cervical plexus block can result in improved pain for less than 6 months. In both CEH and ON, an occipital nerve block can provide important diagnostic information and improve pain in some patients, with PRF providing greater long-term pain control. Radiofrequency ablation of the cervical facet joints can result in improvement for over 1 year. Occipital nerve stimulation (ONS) should be considered for the treatment of refractory ON. CONCLUSION The treatment of CEH preferentially consists of radiofrequency treatment of the facet joints, while for ON, pulsed radiofrequency of the occipital nerves is indicated. For refractory cases, ONS may be considered.
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Affiliation(s)
- Nicole Lefel
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hans van Suijlekom
- Anesthesiology and Pain Management, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steven P C Cohen
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology and Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jan Willem Kallewaard
- Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Genk, Limburg, Belgium
- Mental Health and Neuroscience Research Institute, Maastricht University, Maastricht, The Netherlands
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Pareek AV, Edmondson E, Kung D. Cervicogenic Headaches: A Literature Review and Proposed Multifaceted Approach to Diagnosis and Management. Neurol Clin 2024; 42:543-557. [PMID: 38575265 DOI: 10.1016/j.ncl.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Cervicogenic headaches are a secondary headache disorder attributable to cervical spine dysfunction resulting in head pain with or without neck pain. Diagnosis of this condition has been complicated by varied clinical presentations, causations, and differing diagnostic criteria. In this article, we aim to clarify the approach to diagnosing cervicogenic headaches by providing an overview of cervicogenic headaches, clinical case examples, and a practical diagnostic algorithm based on the most current criteria. A standardized approach will aid in confirmation of the diagnosis of cervicogenic headaches and facilitate further research into this condition.
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Affiliation(s)
- Aishwarya V Pareek
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, 7200 Cambridge Street, 9th Floor, Houston, TX 77030, USA
| | - Everton Edmondson
- Department of Neurology, Baylor College of Medicine, 7200 Cambridge Street, 9th Floor, Houston, TX 77030, USA
| | - Doris Kung
- Department of Neurology, Baylor College of Medicine, 7200 Cambridge Street, 9th Floor, Houston, TX 77030, USA.
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Ekhator C, Urbi A, Nduma BN, Ambe S, Fonkem E. Safety and Efficacy of Radiofrequency Ablation and Epidural Steroid Injection for Management of Cervicogenic Headaches and Neck Pain: Meta-Analysis and Literature Review. Cureus 2023; 15:e34932. [PMID: 36938280 PMCID: PMC10016315 DOI: 10.7759/cureus.34932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
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.
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Affiliation(s)
- Chukwuyem Ekhator
- Neuro-Oncology, New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, USA
| | - Alyssa Urbi
- Neuro-Oncology, Brandeis University, Boston, USA
| | - Basil N Nduma
- Internal Medicine, Merit Health Wesley, Hattiesburg, USA
| | - Solomon Ambe
- Neurology, Baylor Scott and White Health, Mckinney, USA
| | - Ekokobe Fonkem
- Neuro-Oncology, Baylor Scott and White Health, Temple, USA
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Hurley RW, Adams MCB, Barad M, Bhaskar A, Bhatia A, Chadwick A, Deer TR, Hah J, Hooten WM, Kissoon NR, Lee DW, Mccormick Z, Moon JY, Narouze S, Provenzano DA, Schneider BJ, van Eerd M, Van Zundert J, Wallace MS, Wilson SM, Zhao Z, Cohen SP. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med 2022; 47:3-59. [PMID: 34764220 PMCID: PMC8639967 DOI: 10.1136/rapm-2021-103031] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Meredith Barad
- Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic, Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrea Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Jennifer Hah
- Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - David Wonhee Lee
- Fullerton Orthopaedic Surgery Medical Group, Fullerton, California, USA
| | - Zachary Mccormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, South Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
- Pain Diagnostics and Interventional Care, Edgeworth, Pennsylvania, USA
| | - Byron J Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee, USA
| | - Maarten van Eerd
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Mark S Wallace
- Anesthesiology, UCSD Medical Center - Thornton Hospital, San Diego, California, USA
| | | | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Hurley RW, Adams MCB, Barad M, Bhaskar A, Bhatia A, Chadwick A, Deer TR, Hah J, Hooten WM, Kissoon NR, Lee DW, Mccormick Z, Moon JY, Narouze S, Provenzano DA, Schneider BJ, van Eerd M, Van Zundert J, Wallace MS, Wilson SM, Zhao Z, Cohen SP. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:2443-2524. [PMID: 34788462 PMCID: PMC8633772 DOI: 10.1093/pm/pnab281] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Meredith Barad
- Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic, Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrea Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Jennifer Hah
- Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - David Wonhee Lee
- Fullerton Orthopaedic Surgery Medical Group, Fullerton, California, USA
| | - Zachary Mccormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, South Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
- Pain Diagnostics and Interventional Care, Edgeworth, Pennsylvania, USA
| | - Byron J Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee, USA
| | - Maarten van Eerd
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Mark S Wallace
- Anesthesiology, UCSD Medical Center - Thornton Hospital, San Diego, California, USA
| | | | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| | - Steven P Cohen
- Anesthesia, WRNMMC, Bethesda, Maryland, USA
- Physical Medicine and Rehabilitation, WRNMMC, Bethesda, Maryland, USA
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Tak HJ, Chang MC. Effect of Pulsed Radiofrequency Therapy on Chronic Refractory Atlanto-Occipital Joint Pain. World Neurosurg 2018; 119:e638-e642. [PMID: 30077747 DOI: 10.1016/j.wneu.2018.07.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Despite several methods of conservative management, many patients with atlanto-occipital (AO) joint pain complain of persistent pain. In the current study, the authors investigated the clinical efficacy of intra-articular pulsed radiofrequency (PRF) therapy for the management of refractory chronic AO joint pain. METHODS Twenty patients with refractory AO joint pain were recruited, and each received intra-articular AO joint PRF stimulation. Pain reduction after PRF therapy was measured using a numerical rating scale (NRS) before and at 1 and 3 months after treatment. Successful pain relief was defined as ≥50% reduction in the NRS score compared with the pretreatment score. At 3 months after treatment, patient satisfaction levels were also examined. Patients reporting very good (score = 7) or good (score = 6) results were considered to be satisfied with the procedure. RESULTS The NRS scores changed significantly over time. At 1 and 3 months after PRF therapy, the NRS scores were significantly reduced compared with pretreatment scores. Sixteen of the 20 (80%) patients reported pain relief and were satisfied with treatment results 3 months after PRF. No adverse effects were reported. CONCLUSIONS Intra-articular PRF therapy is a beneficial treatment tool for managing refractory chronic AO joint pain.
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Affiliation(s)
- Hyeong-Jun Tak
- Department of Physical Medicine and Rehabilitation, Gimcheon Jeil Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu, Republic of Korea.
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Centeno C, Williams CJ, Markle J, Dodson E. A New Atlanto-Occipital (C0-C1) Joint Injection Technique. PAIN MEDICINE 2018; 19:1499-1500. [PMID: 29092046 DOI: 10.1093/pm/pnx256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christopher Centeno
- Centeno-Schultz Clinic, Broomfield, Colorado.,Regenerative Sciences, LLC, Broomfield, Colorado, USA
| | | | | | - Ehren Dodson
- Regenerative Sciences, LLC, Broomfield, Colorado, USA
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Clinical Effectiveness of Intra-articular Pulsed Radiofrequency Compared to Intra-articular Corticosteroid Injection for Management of Atlanto-occipital Joint Pain: A Prospective Randomized Controlled Pilot Study. Spine (Phila Pa 1976) 2018; 43:741-746. [PMID: 28902105 DOI: 10.1097/brs.0000000000002414] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized controlled pilot study. OBJECTIVE We aimed to assess the effectiveness of pulsed radiofrequency (PRF) stimulation on the atlanto-occipital (AO) joint in patients with chronic joint pain. In addition, we compared the effects of AO intra-articular (IA) PRF and AO IA corticosteroid. SUMMARY OF BACKGROUND DATA IA injection of corticosteroids into the AO joint is widely used for the management of head and upper cervical pain, and its effectiveness has been shown in previous studies. However, little is known about the effect of PRF stimulation on the AO joint for controlling chronic head or upper cervical pain. METHODS Twenty-three consecutive patients with chronic upper cervical pain were enrolled according to the inclusion criteria and divided into one of two groups. Twelve patients received PRF stimulation with a PRF needle electrode in the IA space of the AO joint (PRF group) and 11 patients received AO IA corticosteroid injection (ICI group. Pain intensity was assessed using a numeric rating scale (NRS) before treatment and 1, 3, and 6 months afterward. Successful pain relief was defined as ≥50% reduction in NRS score 6 months post-treatment compared to pretreatment. RESULTS Mean NRS scores were significantly reduced compared to those pretreatment (P < 0.001) in both groups. Temporal changes in NRS score were not significantly different between groups (P = 0.227). Successful pain relief was achieved in 66.7% and 63.6% of patients in the PRF and ICI groups, respectively. CONCLUSION IA PRF stimulation significantly relieved AO joint pain and its effect persisted for at least 6 months after treatment. In addition, the degree of pain relief after IA PRF was not significantly different from that after ICI. We think that PRF stimulation of the AO joint could be a useful clinical treatment for patients with AO joint pain. LEVEL OF EVIDENCE 2.
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