AJCC October 2000

Percutaneous Radiofrequency Neurotomy

Is It Right For Your Chronic Neck Pain Patient?

 

By Daniel J. Murphy, D.C.

 

            In 1988, an article from SPINE(1), showed that 71% of patients with

neck pain, shoulder pain, or headache could be relieved with diagnostic

medial branch blocks of the cervical zygapophysial joints.

 

            In 1992, a prospective article from SPINE(2) involving 318 patients

concluded that “cervical zygapophysial joint pain is not rare.”

 

            In 1993, an article from PAIN(3) determined that in chronic

post-traumatic neck pain patients, that:

            41% of the pain was from both a disc and a zygapophysial joint at the

same segmental level.

            23% of the pain was from a zygapophysial joint only.

            20% of the pain was from a disc only.

            Therefore, 64% of the pain was from zygapophysial joint involvement,

and 61% was from disc involvement.  However, it is important to note

that only 23% of the patient’s pain came solely from the zygapophysial

joint alone.

 

            In 1995, a double-blind study from SPINE(4) using diagnostic blocks of

the cervical zygapophysial joints, concluded that the “cervical

zygapophysial joint pain was the most common source of chronic neck pain

after whiplash.”

 

            In 1996, a double-blind placebo-controlled study from SPINE(5) using

diagnostic blocks of the cervical zygapophysial joints, concluded that

“For patients with chronic neck pain after whiplash injury, cervical

zygapophysial joint pain is extraordinarily common.”

 

            These studies clearly indicate the the primary source of chronic neck

pain, including post-whiplash chronic neck pain, is the zygapophysial

joints.  The question of how to best treat the involved zygapophysial

joint remains.

 

            In 1994, an article from THE NEW ENGLAND JOURNAL OF MEDICINE(6)

concluded that intraarticular injection of corticosteroids was “not

effective therapy for pain in the cervical zygapophysial joints after a

whiplash injury.”  Consequently, another approach to treatment is necessary.

 

            In 1996, an article from THE NEW ENGLAND JOURNAL OF MEDICINE(7)

concluded that a procedure termed “percutaneous radiofrequency

neurotomy” on chronic zygapophysial joint pain whiplash patients, could

achieve at least 50% of subjective pain relief for an average of about 9

months. 

 

            I found a chapter in a book (8) detailing the percutaneous

radiofrequency neurotomy procedure, including pictures.

 

From these references, several key points should be made concerning the

percutaneous radiofrequency neurotomy procedure:

 

1.         The percutaneous radiofrequency neurotomy treatment is only

applicable to those whose pain arises solely from a single zygapophysial

joint.  Recall (from ref. 3) that this represents approximately 23% of

those with chronic neck pain.

 

2.         Recall that the only way to determine if a patient’s chronic neck

pain arises form a single zygapophysial joint is to use a protocol of

two different blinded diagnostic nerve blocks to the zygapophysial

joints, and have the patient respond appropriately in terms of both pain

relief and  appropriate window for that anesthetic.  This also requires fluoroscopy

 

3.         For the percutaneous radiofrequency neurotomy procedure to work

successfully, multiple (9-12) lesions to the nerve must be made.

 

4.         The percutaneous radiofrequency neurotomy procedure is a three hour

hospital operative neuroablative procedure done with a local anesthetic.

 

5.         The procedure does not cure the patient, but gives the patients

longer lasting relief.  The patient’s pain recurs as the coagulated

nerve heals, usually in 9-15 months.

 

            Two recent review articles include sections on percutaneous

radiofrequency neurotomy for chronic whiplash patients.

            David Ketroser, MD, notes:

 

1.         Chronic whiplash injury neck pain is caused by zygapophyseal joint damage.

 

2.         Technology advances with cineradiography on human volunteers has

shown that the zygapophysial joint is injured because the vertebrae

rotate backward in extension without the backward translation on the

subjacent vertebra that would occur during normal cervical extension.

“The [facet joint] collision occurs because there is no backward

translation of each vertebra as it rotates backward.”

 

3.         Using fluoroscopy to verify placement, one can diagnostically

anesthetize the z-joints individually.

 

4.         Once a painful z-joint is identified, the patients are referred for

repeat blocks using a different anesthetic agent.  Because of their

significantly different durations of anesthesia, lidocaine is often used

for one test and marcaine for the other.

 

5.         “Whiplash-injured patients commonly have pain from more than one z-joint.”

 

6.         Radiofrequency z-joint blocks have been found to provide pain relief

for the majority of patients who have been properly evaluated as having

z-joint pain.

 

7.         “The radiofrequency blocks are performed by inserting a small probe

beside the z-joint nerve and inducing a roughly 2 mm by 5 mm burn that

interrupts the nerve.”  This provides pain relief for an average of 9

months to 15 months.

 

            Bogduk and Teasell (10) note:

 

1.         “The international literature on the symptoms of whiplash is

remarkably consistent.” The symptoms defy language barriers, which

argues in favor of a genuine pathology. “It is hard to accept that the

symptoms of whiplash are the result of an international, translingual

conspiracy among malingerers.”

 

2.         Epidemiological studies, using double-blind, controlled, diagnostic

blocks, have shown that zygapophysial joint pain is the single most

common basis for chronic neck pain after whiplash, accounting for at

least 50%, and up to 80% of patient’s pain.

 

3.         Experiments on healthy volunteers indicate that during whiplash

motion, the lower cervical vertebrae undergo extension without

translation, causing impact injury to the zygapophysial joints.

 

4.         Zygapophysial joint pain cannot be diagnosed clinically or by medical

imaging. The diagnosis relies on fluoroscopically guided, controlled

diagnostic blocks of the painful joint.

 

5.         The percutaneous radiofrequency neurotomy therapy for cervical facet

joint pain targets the medial branches of the cervical dorsal rami that

innervate the painful facet joint. The procedure has been validated in a

randomized double-blind controlled trial, and yet the “pain recurs as

the nerves regenerate, over a period of just less than 1 year.”

 

            In a very recent review article (11), Bogduk notes:

 

1.         “Percutaneous radiofrequency medial branch neurotomy is the one

invasive treatment for neck pain that has been subjected to a

double-blind, controlled trial, and is the only treatment for chronic

neck pain after whiplash that has been rigorously tested and reported.

The procedure confers complete relief in some 70% of patients diagnosed

as suffering from cervical zygapophyseal joint pain on the basis of

placebo-controlled, diagnostic blocks of the painful joint, and

therefore its efficacy is not due to placebo.”

 

2.         “The pain-relief is not permanent.”

 

3.         “The procedure, however, is limited by its ardor and the possibility

of technical failures. Its utility can be corrupted if used by untrained

or inexperienced operators.”

 

            Based on the above, I believe that before one of us decides that

percutaneous radiofrequency neurotomy is appropriate for one of our

patients, one should consider:

 

1.         Percutaneous radiofrequency neurotomy is only affective therapy on

those who have then shown to have 100% of their pain arising from a

single zygapophysial joint.  Studies indicate that this would amount to

approximately 23% of those with chronic neck pain following whiplash

trauma. 

 

2.         One can only determine if a patient's chronic neck pain is arising

from a single zygapophysial joint by employing a rigorous double

anesthetic joint block at different times, and both the under

fluoroscopy.  This is both invasive and results in exposure to ionizing

radiation.

 

3.         Of the 23% of chronic whiplash neck pain patients whose blinded

diagnostic blocks have shown that they are appropriate candidates for

this procedure, the procedure is helpful in approximately 70% of such

patients.  This would represent approximately 16% of the total patient's

who are suffering from chronic post-whiplash neck pain. 

 

4.         The procedure itself is three hours in duration at a hospital.

During this time the patient is being exposed to flouroscopic ionizing

radiation.  The procedure is invasive and expensive. 

 

5.         The procedure is complicated and a froth with technical failures. 

 

6.         When the procedure works properly, it is not considered a cure.

The patient's pain will return in an average time of between 9 to 15

months.

 

Consequently, do not let anyone convince you that this procedure is a

panacea for your chronic whiplash neck pain patients.  

 

Respectfully submitted.

 

Dan Murphy, D.C.

 

 

References

 

1.         Bogduk N, Marsland A; The cervical zygapophysial joints as a source

of neck pain;Spine; 1988Jun; 13(6):610-7.

 

2.         April C, Bogduk N; The prevalence of cervical zygapophysial joint

pain. A first approximation;Spine; 1992Jul; 17(7):744-7.

 

3.         Bogduk N, April C; On the nature of neck pain, discography, and

cervical zygapophysial joint blocks; Pain; 1993Aug; 54(2):213-7.

 

4.         Barnsley L, Lord SM, Wallis BJ, Bogduk N; The prevalence of chronic

cervical zygapophysial joint pain after whiplash;Spine; 1995Jan; 20(1):20-

5.

 

5.         Barnsley L, Lord SM, Wallis BJ, Bogduk N; Chronic cervical

zygapophysial joint pain after whiplash.  A placebo-controlled

prevalence study;Spine; 1996Aug; 21(15):1737-44.

 

6.         Barnsley L, Lord SM, Wallis BJ, Bogduk N; Lack of effect of

intraarticular corticosteroids for chronic pain in the cervical

zygapophysial joints;NEJM; 1994Apr 14; 330(15):1047-50.

 

7.         Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N; Percutaneous

radio-frequency neurotomy for chronic cervical zygapophysial joint pain;

NEJM; 1996Dec 5; 335(23):1721-6.

 

8.         Bogduk N; “Cervical Zygapophysial Joint Pain and Percutaneous

Neurotomy”; Chapter 22 in Whiplash Injuries, Ganaburg R and Szpalski M;

Lipponcott-Raven, 1998.

 

9.         Ketroser DB;  Whiplash, Chronic Neck Pain, and Zygapophyseal Joint

Disorders.  A Selective Review;  Minnesota Medicine, February 2000,

Volume 83, pp 51-54.

 

10.       Bogduk N, Teasell R; Controversies in Neurology: Whiplash: The

Evidence for an Organic Etiology; Arch Neurol, Vol. 57 No. 4, April

2000, 590-91.

 

11.       Bogduk N, Whiplash:  “Why Pay for What Does not Work?”; J of

Musculoskeletal Pain; Vol. 8(1/2) 2000, 29-53.

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Attitude Adjustment

Biomechanical & Neuro responses to Adjustment

Communicating From the Inside Out

Normal Values in Anatomy, Physiology, Disease and Chiropractic

Thermography Mis-Education

Attitude Adjustment

2nd CBP® Seminar in Japan

Financial Repriortization

Ambulatory Translational Traction

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