Dr. Kailash Kothari, MD

History  Patients are presented with pain in neck  Morning stiffness of neck  Gets better with heating pad, activities  Intermittent flare ups.  Frequent radiation in to neck, shoulder

Symptoms and Signs Unilateral or bilateral paravertebral neck pain Upper cervical facet joint that cause not only neck pain but also headaches and cutaneous pain Pain frequently referred into the shoulder girdle. Pain can extend to the elbow but is rarely distal to the elbow The pain should not follow a radicular pattern

Referred Pain

Physical Examination  Normal Power  Limited ROM of cervical spine in extension  Tenderness over facet joint area  Decreased range of motion of the neck  Local tenderness over affected facet joints

Radiological Tests  X-Ray  CT Scan  MRI  Bone SPECT Scan

Diagnosis  Based on history, Physical Examination and reviewing the radiological tests.  Confirmed by diagnostic and confirmatory blocks of median nerve branch.

Anatomy of Median nerve

CT SCAN  Anatomy

Diagnostic Procedure  Position:  Prone  Supine with head turned to opposite side  Lateral

Skeletal Anatomy

Median Branch Block

Three Overlapping Lesions

X-Ray sites for lesion  Oblique view

Anatomy

Therapeutic Block

Intra Articular Block

Cervicogenic Headache  Cervical C1-2 facet joint can be culprit for chronic occipital cervical area headache.  Proper diagnosis including X-Ray, CT Scan, Bone Scan is helpful  Diagnostic block is helpful

C1- C2 Pathology

AA Joint  Headache is a symptom  Rheumatoid Arthritis  Subluxation  Neurological sequel  Lateral approach to block joint.  Surgical correction and fusion

Follow Up  Diagnostic Median Branch Block  Differentiate Nerve Blocks  Intra articular Facet Joint Injection  Length of time of pain relief  Repeat procedure  Additional PT etc

Is Patient a Good Candidate for RF?  Proper blocks for diagnostic and therapeutic  Consistent results  More than 80% pain relief  Patient Is motivated

Indications  Thermal radiofrequency ablation of facet joint nerves is proven for chronic cervical, thoracic and lumbar pain when confirmed by:  Positive response to diagnostic and confirmatory median nerve branch block or intra-articular block  Temp >60 degree C  Duration sec  Use fluroscopy, CT

RF  Size of needle tip  Single or multiple needles up to 3 in parallel  Curved or Straight needle  Patient position  Minimum length of time for RF lesion  Minimum Temperature >45degree  Pulse RF

C4 C5 C6 3 lesions at C4 2 lesions at C5 3 lesions at C6

results  Manchikanti et al. (2003)  There was strong evidence for short-term pain relief  Moderate evidence for long-term pain relief of chronic low back, thoracic, and neck facet joint pain.

Results  Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash. Smith AD, Jull G, Schneider G, Frizzell B, Hooper RA, Sterling M. Pain Med Jan;15(1): doi: /pme Epub 2013 Oct 18.  53 patients with whiplash 30 healthy controls  Significant early (within 1 month) and sustained (3 months) improvements in pain, disability, local and widespread hyperalgesia to pressure and thermal stimuli, nociceptive flexor reflex threshold, and brachial plexus provocation test responses as well as increased neck range of motion (all P < )

Results – long term  Pain Pract Jan;14(1):8-15. doi: /papr Epub 2013 Mar 18. Long-term follow-up of cervical facet medial branch radiofrequency treatment with with the single posterior-lateral approach: an exploratory study van Eerd M 1, de Meij N, Dortangs E, Kessels A, van Zundert J, Lataster A, Patijn J, van Kleef M. Pain Pract.van Eerd Mde Meij NDortangs EKessels Avan Zundert JLataster APatijn Jvan Kleef M  130 pat  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 patients

Results  Barnsley (2005). 35 patients Retrospective  Twelve patients had 2 procedures.  80% achieved significant relief of pain.  Pain relief continued after a median follow-up of 35 weeks.

Results  Shin patients with chronic cervicobrachialgia  6 months following RFA, 19 (68%) patients reported successful outcome and 8 (42%) of these patients reported complete pain relief.  Four patients had recurrence of pain between 6 and 12 months.

Results  American Society of Interventional Pain Physicians (ASIPP): A 2009 practice guideline states (Manchikanti et al. 2009)  suggested therapeutic frequency for medial branch neurotomy should remain at intervals of at least 6 months or longer per each region (maximum of 2 times per year) between each procedure.  Provided that 50% or greater relief is obtained for 10 to 12 weeks.

Guidelines  (ASA): A 2010 guideline states  Conventional 80°Cor thermal (e.g., 67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief.  Conventional radiofrequency ablation may be performed for neck pain.  Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain.  Conventional or thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain.

Pulse RF  PRFA delivers short bursts of radiofrequency (RF) current, of 2Hz with temperatures not exceeding 42°C  This allows the tissue to cool between bursts.  Lower maximum temperatures as compared with the continuous mode.  Lesser the risk of surrounding tissue destruction.

Results Pulse RF  A retrospective study by Mikeladze et al. (2003) of 114 patients cervical or lumbar facet joint pain  responsive to diagnostic medial branch blocks and subsequently treated with PRF at 42°C for 120 seconds found that 68 patients had significant pain relief (> 50% pain reduction) that lasted an average of nearly 4 months. Eighteen patients had the procedure repeated with the same duration of pain relief that was achieved initially.  The authors concluded that due to the short duration of pain relief with pulse radiofrequency therapy, this therapy is less effective than standard thermal radiofrequency ablation and improvement following pulsed radiofrequency therapy lasting more than 4 months is possibly the result of the natural course of the disease rather than the procedure itself.

 Curr Pain Headache Rep Jan; 12(1): 37–41. Pulsed Radiofrequency for Chronic Pain David Byrd, MD, MPH and Sean Mackey, MD, PhD  Various articles using pRF in different condition were discussed, and concluded that pRF may be an effective treatment option for chronic pain conditions

 Eur Spine J Sep;23(9): doi: /s x. Epub 2014 Jul 6. Eur Spine J. Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis.  Hashemi M, Hashemian M, Mohajerani SA, Sharifi G. Hashemi MHashemian MMohajerani SASharifi G  Patients were randomly assigned to - group one received pulsed RF, and group 2 received injection by steroids (triamcinolone) and bupivacaine.  80 patient  Results - PRF more effective than steroid and bupivacaine injection in decreasing back pain due to degenerative facet pain and improvement in function of patients.

Conclusion  Facet pain is clinical diagnosis  Diagnostic block is gold standard  RF ablation is proven therapy and gives lasting relief in most patients  RF ablation is easily repeatable procedure  Post procedure rehabilitation programme helps improving outcome