Clinical efficacy of radiofrequency cervical zygapophyseal neurotomy in patients with chronic cervicogenic headache

Radiofrequency Ablation for Craniofacial Pain Syndromes

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

Efficacy of interventional treatment strategies in the management of patients with cervicogenic headache- A systematic review

Cervicogenic headache (CeH) is caused by the disorder of the cervical spine and its anatomical structures. Patients who fail to respond to conservative therapies can undergo interventional treatment. The purpose of this review is to describe the various interventions and compare their relative efficacies. Although a few reviews have been published focusing on individual interventions, reviewing studies on other available treatments and establishing the most efficacious approach is still necessary. We performed a systematic review of studies available on the various interventions for CeH. The PubMed, Embase, and Cochrane databases were searched for literature published between January 2001 and March 2021. Based on the inclusion criteria, 23 articles were included. Two reviewers independently extracted the data from the studies and summarized them in a table. Eleven of twenty-three studies evaluated the effect of radiofrequency ablation (RFA), 5 evaluated occipital nerve blocks, 2 each for facet joint injections and deep cervical plexus blocks, and 1 study each evaluated atlantoaxial (AA) joint injections, cervical epidural injection, and cryoneurolysis. Most of the studies reported pain reduction except 2 studies on RFA. In conclusion, based on the available literature, occipital nerve blocks, cervical facet joint injection, AA joint injection, deep cervical plexus block, cervical epidural injection may be reasonable options in refractory cases of CeH. RFA was found to have favorable long-term outcomes, while better safety has been reported with pulsed therapy. However, our review revealed only limited evidence, and more randomized controlled trials are needed to provide more conclusive evidence.

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.

Chronic Headache: a Review of Interventional Treatment Strategies in Headache Management

PURPOSE OF THE REVIEW

To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks.

RECENT FINDINGS

Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI). Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Unusual clinical presentations of cervical or lumbar dorsal ramus syndrome

OBJECTIVE

Patients with cervical (CDRS) or lumbar dorsal ramus syndrome (LDRS) are characterized by neck or low back pain with referred pain to upper or lower extremities. However, we experienced some CDRS or LDRS patients with unusual motor or bladder symptoms. We analyzed and reviewed literatures on the unusual symptoms identified in patients with CDRS or LDRS.

METHODS

This study included patients with unusual symptoms and no disorders of spine and central nervous system, a total of 206 CDRS/LDRS patients over the past 3 years. We diagnosed by using double diagnostic blocks for medial branches of dorsal rami of cervical or lumbar spine with 1% lidocaine or 0.5% bupivacaine for each block with an interval of more than 1 week between the blocks. Greater than 80% reduction of the symptoms, including unusual symptoms, was considered as a positive response. The patients with a positive response were treated with radiofrequencyneurotomy.

RESULTS

The number of patients diagnosed with CDRS and LDRS was 86 and 120, respectively. Nine patients (10.5%) in the CDRS group had unusual symptoms, including 4 patients with motor weakness of the arm, 3 patients with tremors, and rotatory torticollis in 2 patients. Ten patients (8.3%) in the LDRS group showed unusual symptoms, including 7 patients with motor weakness of leg, 2 patients with leg tremor, and urinary incontinence in 1 patient. All the unusual symptoms combined with CDRS or LDRS were resolved after treatment.

CONCLUSION

It seems that the clinical presentationssuch as motor weakness, tremor, urinary incontinence without any other etiologic origin need to be checked for unusual symptoms of CDRS or LDRS.

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.

Managing and treating headache of cervicogenic origin

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

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

In this case series report, two patients with cervicogenic headache were selected. After initial positive response to the greater occipital nerve block, pulse radiofrequency (PRF) was performed on the position of the second cervical ganglion (C2). Two patients reported 100% pain relief lasting for 6 months. The lateral puncture is safer and more comfortable than the posterior site. This case study demonstrates the effectiveness of PRF to treat cervicogenic headache originating from the C2 nerve. However, we need to further evaluate the results using more samples.

Cervicogenic headache: evidence that the neck is a pain generator

This review was developed as part of a debate, and takes the "pro" stance that abnormalities of structures in the neck can be a significant source of headache. The argument for this is developed from a review of the medical literature, and is made in 5 steps. It is clear that the cervical region contains many pain-sensitive structures, and that these are prone to injury. The anatomical and physiological mechanisms are in place to allow referral of pain to the head including frontal head regions and even the orbit in patients with pain originating from many of these neck structures. Clinical studies have shown that pain from cervical spine structures can in fact be referred to the head. Finally, clinical treatment trials involving patients with proven painful disorders of upper cervical zygapophysial joints have shown significant headache relief with treatment directed at cervical pain generators. In conclusion, painful disorders of the neck can give rise to headache, and the challenge is to identify these patients and treat them successfully.

Immunohistochemical and histological study of human uncovertebral joints: a preliminary investigation

STUDY DESIGN

A descriptive cadaveric study.

OBJECTIVE

To investigate the anatomy and innervation of the uncovertebral joint to determine if it is synovial in nature and capable of generating pain.

SUMMARY OF BACKGROUND DATA

There is controversy with regard to the anatomic and histological makeup of the uncovertebral interface with some authors considering it a joint and others disc tissue. No research has investigated the presence of pain generating neurotransmitters within the uncovertebral cartilaginous and capsular tissue.

METHODS

Tissue from uncovertebral capsule and cartilage was harvested for each uncovertebral surface starting at the C2-C3 to the C6-C7 cervical segment. The tissue was placed in 4% paraformaldehyde fixative, then dehydrated and embedded in paraffin. Ten micron sections were cut through the tissue blocks and mounted on slides. The tissue was rehydrated and either stained with hematoxylin and eosin (H and E) or immunostained with antisera against protein gene product 9.5 (PGP 9.5), substance P (SP), neuropeptide Y (NPY), and calcitonin gene-related peptide (CGRP).

RESULTS

The sample consisted of 2 unembalmed fresh male human cadavers of a mean age of 83 years. Chondrocytes and synoviocytes were identified at the capsular tissue of each uncovertebral interface from C2-C3-C6-C7. Immunoreactivity for PGP 9.5, SP, CGRP, and NPY was observed at all uncovertebral interface levels in capsular tissue.

CONCLUSION

The presence of both synoviocytes and chondrocytes has been recorded in the present study, suggesting that the uncovertebral interface is synovial in nature. Immunoreactivity to PGP 9.5, SP, CGRP, and NPY indicates the presence of nerve fibers from both the somatic and autonomic nervous systems. These findings suggest that the uncovertebral joints are potential pain generators in the cervical spine.