Cervical Spine Pain Treatment

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Cervical Median Branch Block and RF

• Dr. Kailash Kothari, MD

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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

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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

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Referred Pain
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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

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Radiological Tests

• X-Ray
• CT Scan
• MRI
• Bone SPECT Scan

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Diagnosis

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

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Anatomy of Median nerve
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CT SCAN

• Anatomy

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Diagnostic Procedure

• Position
• Prone
• Supine with head turned to opposite side
• Lateral

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Skeletal Anatomy
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Median Branch Block
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Three Overlapping Lesions
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X-Ray sites for lesion

• Oblique view

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Anatomy
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Therapeutic Block
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Intra Articular Block
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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

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C1- C2 Pathology
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AA Joint

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

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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

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Is Patient a Good Candidate for RF?

• Proper blocks for diagnostic and therapeutic
• Consistent results
• More than 80 pain relief
• Patient Is motivated

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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 gt60 degree C
• Duration 60-90 sec
• Use fluroscopy, CT

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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 gt45degree
• Pulse RF

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

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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. 2014 Jan15(1)128-41. doi
  10.1111/pme.12262. 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?lt?0.0001)

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Results long term

• Pain Pract. 2014 Jan14(1)8-15. doi
  10.1111/papr.12043. 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 M1, de Meij N, Dortangs E, Kessels
  A, van Zundert J, Lataster A, Patijn J, van 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

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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.

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Results

• Shin 2006.28 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.

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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.

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Guidelines

• (ASA) A 2010 guideline states
• Conventional 80Cor thermal (e.g., 67C)
  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.

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Pulse RF

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

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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 42C for 120
  seconds found that 68 patients had significant
  pain relief (gt 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.

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• Curr Pain Headache Rep. 2008 Jan 12(1) 3741.
  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

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• Eur Spine J. 2014 Sep23(9)1927-32. doi
  10.1007/s00586-014-3412-x. Epub 2014 Jul 6.
• Effect of pulsed radiofrequency in treatment of f
  acet-joint origin back pain in patients with
  degenerative spondylolisthesis.
• Hashemi M, Hashemian M, Mohajerani SA, Sharifi 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.

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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

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THANK YOU