PERCUTANEOUS RF NEUROTOMY IS EFFECTIVE IN THE TREATMENT OF FACET JOINT SYNDROME

1. Radiology University of Cagliari, Italy San Giovanni di Dio Hospital Chairman: Prof. Giorgio Mallarini PERCUTANEOUS RF NEUROTOMY IS EFFECTIVE IN THE TREATMENT OF FACET JOINT SYNDROME Stefano Marcia, MD, A. Cauli, S. Marini, E. Piras, M. Marras

2. Disclosure Consultant of Stryker

3. INTRODUCTION Facet Joint Syndrome is a mechanical chronic low back pain characterised by stiffness and pain that increase with twisting and bending backwards It affects mainly adult subjects and its precise incidence is not defined Its main cause is osteoarthritis of the zygapophysial joints

4. FACET JOINT SYNDROME • Mechanical back pain • Low back stiffness • Aggravated by rest, worse in the morning, and relived by repeated gentle motion • Pain is centered in the hips, buttocks or thights, does not extend below knees, has no radicular pattern, and is aggravated by hyperextension • Straight leg raise usually negative

5. FACET JOINT SYNDROME Poor correlation between duration and severity of pain and extent of facet degeneration Facet disease may be asymptomatic incidental finding on imaging Pain is related toirritation of joint innervation, because of capsular distension, inflammatory synovitis, entrapment of synovial villi between two articular processes, or actual nerve impingement by osteophytes

6. Anatomy: relevant nerves L3 DORSAL RAMUS OF SPINAL NERVE SUPERIOR ARTICOLAR BRANCH LATERAL BRANCH L4 MEDIAL BRANCH INFERIOR ARTICOLAR BRANCH L5

7. Radiological signs

8. Radiological signs MRI Gd Enhancing inflammatory soft tissues changes surrounding facet joints

9. Percutaneous radiofrequency neurotomy heat ablation of the lumbar medial branch responsible for the sensitivity of facet joints, in order to interrupt nerve conduction, using an electrode needle positioned under CT or fluoroscopic guide

10. Percutaneous radiofrequency neurotomy • Leclaire R, Fortin L, Lambert R, Bergeron YM, Rossignol M: Radiofrequency facet joint denervation in the treatment of low back pain.Spine 2001; 26(13):1411-7 • Schoffermann J, Kine G: Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain.Spine 2004; 29(21):2471-3 • Nath S, Nath CA, Pettersson K: Percutaneous lumbar zygapophisial joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial.Spine 2008; 33(12):1291-7 • Cohen SP, Raja SN: Pathogenesis, diagnosis, and treatment of lumbar zygapophysial(facet) joint pain. Anesthesiology 2007; 106:591-614 • Chou R, Atlas SJ, Stanos SP, Rosenquist RW: Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical pratice guideline.Spine 2009

11. PURPOSE Radiofrequency denervation of the lumbar medial branch after accurate selection of patients and after precise positioning of the electrode-needle by means of neurophisiological testing long term pain relief

12. Patients selection • Lumbar pain with typical signs of facet joint syndrome for at least 6 months • Little response to pharmacological and physiotherapic treatment • Degeneration of zygapophysial joints detected by Xray, CT and MRIGd • Absence of neurological signs • EMG negative • Anesthetic block

13. Controindications - Local or systemic infections - Coagulation disorders

14. Material and methods Angiographic suite CT suite

15. Material and methods

16. Material and methods Technique: - Prone position - Choice of the cutaneous site - Local anestesia - Introduction of the needle and insertion of the electrode - Verification of the correct position - Neurotomy

17. Material and methods Targets Between the transverse and articular process!

18. Material and methods Targets L5S1 (L5 dorsal ramus) On the ala of the sacrum just lateral to the articular process!

19. Material and methods Needle positioning under fluoroscopic guide (length 100 mm exposed tip 5-10 mm)

20. Material and methods Needle positioning under fluoroscopic guide: operative position

21. Material and methods Needle positioning under fluoroscopic guide: operative position

22. Material and methods Needle positioning under fluoroscopic guide: operative position

23. Material and methods Needle positioning under fluoroscopic guide: operative position L5S1

24. Material and methods Needle positioning under CT guide

25. Material and methods Insertion of the electrode

26. Material and methods NEUROPHISIOLOGICAL CHECK Impedence values between 200 e 800 Ohms are significant for the correct target

27. Material and methods NEUROPHISIOLOGICAL CHECK SENSORIAL STIMULATION TEST Parameter settings: Frequency 50hzIntensity 0,2 – 0,7V - Confirms proximity of electrode to sensory fibers - Reproduces patient’s ‘typical pain’

28. Material and methods NEUROPHISIOLOGICAL CHECK MOTORIAL STIMULATION TEST Parameter settings: Frequency 2hz Intensity 0,2 – 1V - Confirms lesion will not damage motor nerves - No limb motion

29. Material and methods Neurotomy Parameter settings: 90° for 60”

30. Material and methods Patients: 45 Mean age: 70.3±13.0 Joints: 54 Fluoroscopic Guide: 44 CT Guide: 10

31. Follow up Material and methods Clinical evaluation • VAS 0-10 analysis baseline and 1w, 1m, 6m, 12m after the procedure • ODI 0-100% questionnaire baseline and 1m, 6m, 12m after the procedure

32. Results PAIN REDUCTION: VAS 0-10 +1,1 (p<0.0001) +2,1 -1,1 -2,1

33. Results PAIN REDUCTION: use of analgesic drugs

34. Results Oswestry Disability Index(ODI) (p<0.0001)

35. Results • No procedural complications No infections

36. Conclusions Lumbar medial branch neurotomy by means of RFD is an effective and safe procedure in reducing chronic back pain in patients with facet joint syndrome

37. Thank you stefanomarcia@aoucagliari.it