1. Thermal Radiofrequency Neurotomy of the Cervical Medial Branches of the Dorsal Rami In Whiplash and Related Disorders John MacVicar MB ChB, FAFMM, MPainMed James M Borowczyk BSc, MB ChB, FRCP (Edin), DipMM, FAFMM, MPainMed Anne M MacVicar B Sc (DM), MB ChB Brigid M Loughnan MB ChB, FRNZGP Nikolai Bogduk MD, PhD, DSc

2. Disclosure None of the authors have a financial conflict of interest to declare. This study was supported by a research grant from the International Spine Intervention Society, which subsidised the collection of follow-up data.

3. History of Musculoskeletal Radiofrequency Neurotomy (RFN) in NZ 2004

4. Causes, Incidence and Pathophysiology of Cervical Facet Joint Trauma?

5. Anatomy Medial Branch of the Dorsal Ramus of the Spinal Nerve Medial Branch Block (MBB)

6. Transverse Process Neural Gutter Medial Branch Dorsal Ramus Spinal Nerve Dorsal Ramus

7. Anatomy Lateral Cervical Spine

8. Anatomical Variation C2 C3 C4 C5 C6 C7

9. Each facet joint is innervated by two medial branches, on from above, and one from below The exception is C2/3 which is innervated by the third occipital nerve (TON) alone The target for diagnostic blocks is the mid point of the lateral aspect of the articular pillar

10. Lumbar Spine

11. Anatomical Variation C2 C3 C4 C5 C6 C7

12. Facet Joint Pain Diagnostics

13. Evaluation of Medial Branch Blocks Processes and Pitfalls

14. MBB is performed to obtain information only

15. Patients’ Pain Subjective Identify with the patient exactly where the pain is at the time of blocking Need to get the patient to focus on their pain and discuss with them the possible confusion that may arise afterwards from the needle pain

16. Other factors Occupation Supports Pain management Co-morbidites other injuries Other procedures done

18. Pain Drawing

20. The Pain Ruler

23. ADLs Ordinary daily activities which cant be done or which are limited by the pain and loss of function. Aim to get something which can be measured in the clinic settling. Watch the patient performing these activities so you can have some assessment on return of function.

25. Evaluation Immediate assessment of the VAS and function after patient dressed. 30 minutes VAS score ADLs assessment 60 minutes VAS score ADLs assessment

28. Sources of Errors False Positive (27% cervical, 38% lumbar) Insufficient pain at the time (25/100) Pain confusion / inability to identify pain Patient fabrication??

29. Sources of Error May be more than one level pain Unmasking of other pains No double blinding of the agent Other patient co-morbidities

30. Outcomes A truly positive MBB is one where : Total relief of pain at the treated level Complete restoration of function Duration of pain relief is concordant with the agent used in a minimum of two blocks

31. Imaging

32. The Equipment 16 gauge radiofrequency electrode (six inch nail) 5 or 10mm exposed tip Radiofrequency generator

33. Electrode Thermal RF 16 gauge RF electrodes Bogduk N. Ed: Practice guidelines for spinal diagnostic and treatment procedures. 1st ed. San Francisco (CA): International Spine Intervention Society (ISIS); 2004.

38. Treatment Technique Thermal RF 16 gauge electrodes Lesions parallel to nerves One electrode width apart Multiple lesions ‘Snug’ to bone Bogduk N. Ed: Practice guidelines for spinal diagnostic and treatment procedures. 1st ed. San Francisco (CA): International Spine Intervention Society (ISIS); 2004.

39. Treatment Technique Thermal RF 16 gauge RF electrodes Lesions parallel to nerves Multiple lesions ‘Snug’ to bone Bogduk N. Ed: Practice guidelines for spinal diagnostic and treatment procedures. 1st ed. San Francisco (CA): International Spine Intervention Society (ISIS); 2004.

40. Cervical Spine

44. Lumbar Spine

45. Treatment Technique Thermal RF 16 gauge RF electrodes Lesions parallel to nerves Bogduk N. Ed: Practice guidelines for spinal diagnostic and treatment procedures. 1st ed. San Francisco (CA): International Spine Intervention Society (ISIS); 2004.

48. Data Collected

50. CERVICAL MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY IN NEW ZEALAND Prospective outcome study

51. CERVICAL MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY IN NEW ZEALAND Prospective outcome study All patients treated from June 2004 to December 2009 in 2 separate practices (A and B)

52. CERVICAL MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY IN NEW ZEALAND Prospective outcome study All patients treated from June 2004 to December 2009 in 2 separate practices (A and B) Patients selected for treatment on basis of complete relief of pain following controlled medial branch blocks

53. CERVICAL MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY IN NEW ZEALAND Prospective outcome study All patients treated from June 2004 to December 2009 in 2 separate practices (A and B) Selected on basis of complete relief of pain following controlled medial branch blocks Treated according to the practice guidelines of the International Spine Intervention Society

54. Inception Data

55. Inception Data

56. Inception (Prior to Treatment) Data Index pain and its severity (VAS, NPRS, VRS)

61. Inception (Prior to Treatment) Data Index pain and its severity (VAS, NPRS, VRS) Are there other regional pain problems? Patient Specified Functional Outcome Scale - 4 Compromised Activities of Daily Living Current analgesic medication? Concurrent Health Care for Index Pain? Are they working? (where applicable) Other Health problems?

62. Pain Levels

63. 4 ADLs

64. Medication

65. Concurrent Health Care

66. Work Status

68. What we really want to know... Did the treatment work? Is the patient better? If so, better in what ways, and to what degree?

69. Patient Follow-up

70. Key Follow-up Data 1, 3, 6, 9... Months Has the Index Pain Gone? Have the Four Key ADLs been restored? Is the Patient Taking Analgesics for Pain? If so for what Pain? Is the Patient receiving any other Therapy? Is the Patient Back at Work?

71. Has the Pain Gone?

72. 4 ADLs Restored?

73. Analgesic and Other Health Requirements?

74. Back to Work?

75. Demographics

76. Practices A and B Total Patients - 104 Demographics

77. GENDER

78. AGE

79. WORK STATUS

80. PLACE OF INJURY

81. SITE OF INJURY

82. LUMBAR GENDER

83. LUMBAR AGE

84. LUMBAR WORK STATUS

85. LUMBAR PLACE OF INJURY

86. LUMBAR SITE OF INJURY

87. DURATION OF PAIN BEFORE TREATMENT

88. CLINICAL FEATURES CERVICAL LUMBAR

89. NUMERICAL PAIN RATING

90. CLINICAL FEATURES CERVICAL LUMBAR

91. CRITERIA FOR A SUCCESSFUL OUTCOME Complete relief of pain for at least 6 months

92. CRITERIA FOR A SUCCESSFUL OUTCOME Complete relief of pain for at least 6 months, in association with: Complete restoration of activities of daily living (ADLs) No need for further analgesic medications No need for other health care Return to work (if applicable)

93. CRITERIA FOR A SUCCESSFUL OUTCOME Complete relief of pain for at least 6 months, associated with: Complete restoration of activities of daily living No need for analgesic medications No need for other health care Return to work (if applicable) Patients who failed to meet any of these criteria were deemed to have failed treatment!

94. Overall Results

95. RESULTS 104 patients treated between June 2004 and December 2009 Practice A40 Practice B64 Total104

96. LOW BACK PAIN 56% of patients achieved the prescribed outcomes Practice A 58% Practice B 53%

97. Cervical Pain 68% of patients achieved the prescribed outcome Practice A74% Practice B61%

98. Differences between the two practices were not statistically significant

99. FAILURES Of the patients for whom treatment was categorised as having failed, the largest subgroup were outright failures with no relief

100. FAILURES Of the patients for whom treatment was categorised as having failed, the largest subgroup were outright failures with no relief

101. Duration of Relief

102. CERVICAL PRACTICE A

103. CUMULATIVE RELIEF CERVICAL A Median cumulative duration of relief 29 months Ongoing relief in 60% of patients

104. CERVICAL PRACTICE B

105. CUMULATIVE RELIEF CERVICAL B Median cumulative duration of relief 26 months Ongoing relief in 60% of patients

106. LUMBAR PRACTICE A PRACTICE A

107. CUMULATIVE RELIEF LUMBAR A PRACTICE A Median cumulative duration of relief 17 months Ongoing relief in 66% of patients

108. RELIEF LUMBAR B PRACTICE B

109. CUMULATIVE RELIEF LUMBAR B PRACTICE B Median cumulative duration of relief 33 months Ongoing relief in 66% of patients

110. CRITERIA FOR SUCCESS Complete relief of pain for at least 6 months corroborated by: Complete restoration of activities of daily living No need for analgesic medications No need for other health care Return to work (where applicable)

111. CONCLUSIONS These outcomes are consistent with the results from original bench-mark studies (as below) on cervical and lumbar RFN, using erxactly the same techniques, but... Lord SM, Barnsley L, Wallis B, McDonald GM, Bogduk N. Percutaneous radio ‑ frequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996; 335:1721-1726. Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophyseal joint pain. Neurosurgery Quarterly 1998; 8:288-308. McDonald GJ, Lord SM, Bogduk N. Long term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999; 45:61-68. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25:1270-1277.

112. They stand in contrast to the outcomes of most world-wide studies on thermal RFN!

113. CONCLUSIONS The study perhaps shows what potentially may be achieved if... Patients are carefully selected and, Correct technique according to International Guidelines is followed.

114. Thank You