Radiofrequency for chronic lumbosacral and cervical pain: Results of a consensus study using the RAND/UCLA appropriateness method.

BACKGROUND: Despite the routine use of radiofrequency (RF) for the treatment of chronic pain in the lumbosacral and cervical region, there remains uncertainty on the most appropriate patient selection criteria. This study aimed to develop appropriateness criteria for RF in relation to relevant patient characteristics, considering RF ablation (RFA) for the treatment of chronic axial pain and pulsed RF (PRF) for the treatment of chronic radicular pain. METHODS: The RAND/UCLA Appropriateness Method (RUAM) was used to explore the opinions of a multidisciplinary European panel on the appropriateness of RFA and PRF for a variety of clinical scenarios. Depending on the type of pain (axial or radicular), the expert panel rated the appropriateness of RFA and PRF for a total of 219 clinical scenarios. RESULTS: For axial pain in the lumbosacral or cervical region, appropriateness of RFA was determined by the dominant pain trigger and location of tenderness on palpation with higher appropriateness scores if these variables were suggestive of the diagnosis of facet or sacroiliac joint pain. Although the opinions on the appropriateness of PRF for lumbosacral and cervical radicular pain were fairly dispersed, there was agreement that PRF is an appropriate option for well-selected patients with radicular pain due to herniated disc or foraminal stenosis, particularly in the absence of motor deficits. The panel outcomes were embedded in an educational e-health tool that also covers the psychosocial aspects of chronic pain, providing integrated recommendations on the appropriate use of (P)RF interventions for the treatment of chronic axial and radicular pain in the lumbosacral and cervical region. CONCLUSIONS: A multidisciplinary European expert panel established patient-specific recommendations that may support the (pre)selection of patients with chronic axial and radicular pain in the lumbosacral and cervical region for either RFA or PRF (accessible via https://rftool.org). Future studies should validate these recommendations by determining their predictive value for the outcomes of (P)RF interventions.

[Radiofrequency denervation of the spine and the sacroiliac joint : A systematic literature search according to GRADE with new German S3 guideline]. / Radiofrequenzdenervation der Wirbelsäule und des Iliosakralgelenks : Eine systematische Literaturrecherche nach GRADE mit neuer S3-Leitlinie.

BACKGROUND: This article summarizes the results of the German guideline on radiofrequency denervation of the facet joints and the sacroiliac joint. Evidence on the indications, test blocks and technical parameters are presented. OBJECTIVE: The aim is to avoid overtreatment and undertreatment, which is also of socioeconomic importance. MATERIAL AND METHOD: A systematic evaluation of the literature was carried out according to the grading of recommendations assessment, development and evaluation (GRADE) approach. A multidisciplinary guideline group has developed recommendations and statements. RESULTS: Statements and recommendations were given for 20 key questions. There was an 87.5% consensus for 1 recommendation and 100% consensus for all other recommendations and statements. The guideline was approved by all scientific medical societies involved. Specific questions included the value of the medical history, examination and imaging, the need for conservative treatment prior to an intervention, the importance of test blocks (medial branch block and lateral branch block), choice of imaging for denervation, choice of trajectory, the possibility to influence the size of the lesion, stimulation, the possibility of revision, sedation and decision support for patients with anticoagulants, metal implants and pacemakers and advice on how to avoid complications. CONCLUSION: Selected patients can benefit from well-performed radiofrequency denervation. The guideline recommendations are based on very low to moderate quality of evidence.

Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline.

STUDY DESIGN: Systematic review of the literature and subsequent meta-analysis for the development of a new guideline. OBJECTIVES: This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure. METHODS: A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. RESULTS: 20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications. CONCLUSION: Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.

[Evidence-based interventional pain medicine : Progress over the past 10 years]. / Evidenzbasierte interventionelle Schmerztherapie : Fortschritte der letzten 10 Jahre.

Interventional pain medicine plays an important role in pain therapy for neck and back pain. However, spine interventions are characterized by controversy between its proponents and its detractors. Detractors variously assert that the procedures practiced lack validity, are not effective, or produce complications that impugn the procedures. The Spine Intervention Society (SIS) published several articles over the last decade that answer and refute these criticisms.

Coronal oblique orientation of the neural foramen improves cervical spine MRI: A comparison of the sensitivity of different angulations.

OBJECTIVE: Angulated projections are used in radiography to show the cervical neural foramen. Imaging the coronal oblique planes in an MRI of the cervical spine should therefore improve visualization of neural foramen pathology. This has to be demonstrated. PATIENTS AND METHODS: A multi-center investigation of 40 patients with monoradiculopathy and 10 healthy controls was undertaken. T2-weighted sagittal, coronal oblique and axial slices were individually and separately examined by four readers blinded to the diagnosis. The statistical evaluation compared against the clinical gold standard of the neurological diagnosis of a single nerve root irritation or lesion. RESULTS: The sensitivity/specificity required to detect the relevant neural foramen pathology was 0.47/0.60 for axial, 0.57/0.90 for sagittal and 0.55/0.70 for coronal oblique scans. The readers felt significantly more confident in attributing the cause of pathology using coronal oblique planes. Interreader reliability was moderate to substantial, with the highest values for the sagittal planes (0.39-0.76) and lower values for the transversal and coronal oblique planes (0.15-0.63). Intrareader reliability was substantial, with values between 0.53 and 0.88. Reading the axial planes was significantly more time consuming than reading the other planes. CONCLUSION: The use of coronal oblique planes in cervical spine MRIs increases sensitivity and confidence in attributing the cause of neural foramen obstruction. They are easy to interpret and demand less reading time than axial planes, and so the inclusion of coronal oblique planes in the workup of cervical spine MRI is recommended, at least when neural foramen pathology is suspected.

The Frequency of Resurgery after Percutaneous Lumbar Surgery Using Dekompressor in a Ten-Year Period.

To prevent open surgical procedures, minimally invasive techniques, like Dekompressor (PLDD), have been developed. The absence of reherniation is an important factor correlating with clinical success after lumbar surgery. In this retrospective, observational study, the frequency of additional open surgery after PLDD in a long time retrospective was examined. The correlation between clinical symptoms and outcome was assessed, and the time between PLDD and open surgery was analyzed. Consecutive patients after PLDD between 2005 and 2007 were included. MacNab's outcome criteria were used to evaluate patient satisfaction. The need for additional open surgery of the lumbar spine, the period between Dekompressor and resurgery, and the treated levels were analyzed. In total, 73 patients were included in this study. The patients were seen one month after PLDD. The majority of patients (76.7%) had additional radicular pain. The most common level treated was L4-5 (58.9%). The follow-up time was longer than 5 years in 30.1% of the patients and longer than 10 years in 6.82%. The short-term success rate was 67.1%. Additional surgery was performed in 26.0% of patients, with 78.9% of the reoperations undertaken during the first year after PLDD. These patients had a statistically significant worse outcome (P = 0.025). Radicular pain was present in all patients with an early subsequent surgery, but only in 50% of patients with late surgery (P = 0.035). Significantly more patients with poor pain relief had radicular pain (P = 0.04). The short-term success rate was worsened by a resurgery rate of 26.0%. Subsequent surgery, a short time after PLDD, suggests that PLDD is not a replacement for open discectomy. Because patients with radicular pain had a worse outcome and more frequent resurgeries, whether radicular pain is an ideal indication for PLDD should be discussed.

The Frequency of Re-Surgery After Cervical Disc Nucleoplasty.

OBJECTIVE: In percutaneous cervical nucleoplasty (PCN) a portion of the nucleus tissue is ablated using the Coblation technique. Re-surgery is an important factor for the clinical outcome. However, the rate of subsequent surgery after PCN is still unknown. The aim of this study was to investigate the frequency of an additional open surgery after PCN in a retrospective of more than 10 years. METHODS: Retrospective observational study. Consecutive patients with PCN between 2005 and 2007 were included. Patient's satisfaction was evaluated using McNab's outcome criteria. The necessity of an additional open surgery at the cervical spine, the period between PCN and the fusion, and the treated levels were analyzed. RESULTS: One hundred thirty-three patients were included. The follow-up time was longer than 5 years in 31.6% of patients and longer than 10 years in 6.0% of patients. The short-term success rate was 70.7%; however, subsequent surgery was performed in 19.5% of patients. Overall, 57.7 % of reoperations were performed during the first year after PCN. In patients with a good result after PCN, subsequent surgery was less frequent, and the interval between PCN and additional surgery was larger (P < 0.01). CONCLUSIONS: This is the first study reporting the frequency of re-surgery after PCN. Overall, 70.7% patient satisfaction was observed after 1 month. This result is worsened because of a re-surgery rate of 19.5%. The data from this study suggest that PCN is a poor replacement for conventional open surgery. Degeneration of the disc is progressive despite or because of PCN.

Response to Cervical Medial Branch Blocks In Patients with Cervicogenic Vertigo.

BACKGROUND: Among the various causes of vertigo, the so-called cervicogenic vertigo (CV) has been the most controversial. However, perturbations of proprioceptive signals and abnormal activity of the cervical afferents can induce vertigo. Medial branch blocks (MBBs) are a diagnostic tool designed to test whether a patient's neck pain is mediated by one or more of the medial branches of the dorsal rami of the spinal nerve. It is unknown whether MBBs are also suitable for testing symptoms other than pain. OBJECTIVES: The purpose of this study was to test whether MBBs of the cervical spine can be used as a diagnostic tool to identify patients with CV. STUDY DESIGN: A retrospective practice audit (clinical observation). SETTING: An interventional pain management and spine practice. METHODS: An electronic medical record system was used to identify patients in a single spine center. Included were consecutive patients with neck pain and vertigo, who had received cervical MBBs in a period from July 2001 to April 2016. The patients were tested with a MBB of about 1 mL of bupivacaine (0.25%) and 20 mg triamcinolone. Injections were performed with fluoroscopic visualization using established techniques in 2 or 3 levels on one or both sides. Vertigo was analyzed through the global clinical impression of the patient (i.e., "gone," "better," "the same," or "worse"). RESULTS: One-hundred seventy-eight patients met the inclusion criteria. One-hundred eleven patients (62.4%) experienced a significant improvement of the vertigo. In 47 patients (26.4%), no information about the vertigo was available at follow-up; these patients were assumed to have no improvement (worst-case scenario). Hence, altogether 67 patients (37.6%) had a negative result. The median relief of the vertigo was 2 months. Differences in age, gender, level of treatment, or pain duration between patients with relief of the vertigo and without relief were not found. Nine patients with a whiplash injury in their medical history were also tested. They experienced a lower success rate and had longer duration of pain before the treatment; however, these differences are not statistically significant. LIMITATIONS: It was the primary intention to treat neck pain; the assessment of vertigo was an additional aim. Therefore, the history taken and the clinical examination were not targeted specifically to vertigo. A placebo effect cannot be excluded. Further studies with the primary focus on CV are necessary to prove the significance of MBBs. CONCLUSIONS: This is the first study to demonstrate that MBBs of the cervical spine can be a useful tool for the diagnosis of CV, because they temporarily block cervical afferents. In 63.4% of patients with neck pain and suspected CV, the vertigo was significantly improved. Further placebo-controlled studies with the primary intention on CV are necessary to prove the significance of MBBs. KEY WORDS: Cervicogenic vertigo, medial branch block, facet joint, zygapophysial joint, neck pain, differential diagnosis.

The frequency of re-surgery after lumbar disc Nucleoplasty in a ten-year period.

OBJECTIVE: Percutaneous disc nucleoplasty (PDN) is a minimally invasive technique. A portion of the nucleus tissue is ablated using the Coblation technique. Re-surgery is an important factor for the clinical outcome. However, the rate of subsequent surgery after PDN is still unknown. The aim of the present study was to investigate the frequency of an additional open surgery after PDN in a retrospective of more than ten years. PATIENTS AND METHODS: Retrospective observational study. Consecutive patients who underwent PDN between 2005 and 2006 were included. Patient's satisfaction was evaluated using MacNab's outcome criteria. The patient data (age and gender), the MRI findings (annular fissure or contained herniation) and the follow-up time was evaluated. A distinction was made between patients with only lumbago and patients with radiating pain. The focus of this study was to evaluate the necessity of an additional surgery at the same level. The period of time between the PDN and re-surgery was analyzed. RESULTS: In total, 203 patients were included in this study. All patients were seen one month after PDN. The follow-up time was longer than five years in 41 patients (20.2%), and longer than 10 years in 16 patients (7.9%). The short-term success rate was 63.5%; however, 18.7% of all patients had to undergo an additional surgery at the index level. Half of these additional surgeries were performed during the first three months after PDN. If only a poor pain reduction was achieved, re-surgery was significantly more frequent compared to patients with substantial pain relief. An initial surgery at the L4-5 level was associated more often with an additional surgery compared to an initial surgery at the L5-S1 level. CONCLUSION: The present study is the first study to report the frequency of re-surgery after PDN. At first sight, the fact that 63.5% of patients are satisfied seems to be a good result. However, this short-term result was significantly worsened due to a re-surgery rate at the index level of 18.7%. Moreover, it is possible that nucleoplasty has adverse effects resulting from the puncture and progressive degeneration. Therefore, indications for nucleoplasty should be critically reconsidered.

The incidence of dural tears after complete resection of lumbar synovial cysts and the relation to the outcome.

OBJECTIVE: Synovial cysts in the lumbar spine are uncommon causes of radicular pain. In cases where conservative treatment fails, surgical resection is recommended. Dural adhesions are common intraoperative findings; therefore, the removal of the cyst may sometimes result in dural tears. The frequency of dural tears is greater with synovial cysts than in other lumbar surgeries. Clinical parameters and characteristics seen on magnetic resonance imaging were assessed to investigate the correlation between the outcome after surgery of lumbar synovial cysts and dural tears. METHODS: This study was designed as a retrospective practice audit. Patient data were drawn from an electronic medical record system. Included were consecutive patients after microsurgical resection of symptomatic lumbar synovial cysts between May 2013 and November 2015. The surgical report was evaluated retrospectively regarding the extent of decompression and cyst resection as well as surgery-related complications. Pre-operative magnet resonance imaging was assessed concerning the reason for compression of the neural structures, the dimension of the cyst, and the signal of the cyst content in T2 images. In a follow-up examination about four weeks after surgery, the patient satisfaction index was evaluated. RESULTS: Forty-four consecutive patients after resection of a lumbar synovial cyst met the inclusion criteria. The mean patient satisfaction index was 2.0±1.0. Twenty-nine patients of the 38 patients with follow-up (76.3%) with a satisfaction index of 1 or 2 were rated as favorable. One revision surgery was necessary because of a cerebrospinal fluid fistula. Furthermore, in 4 patients an incidental durotomy occurred without any symptoms after surgery. Accordingly, the rate of dural tears was 11.4%. Dural tears were significantly more common in patients with a satisfaction index of 3 or 4 (P=0.04). Sixty percent of the patients with dural tears were operated on in level L5/S1 compared to 3 patients without a dural tear (P=0.008). There was no statistically significant difference between the different patient subgroups in any other analyzed parameter. CONCLUSION: Dural tears were found significantly more often in patients without a good outcome; they appear to portend a poorer prognosis. The level L5/S1 was significantly more often affected. During surgery, it should be considered whether to remove the cyst completely and risk a dural tear, or to leave residuals of the cyst wall if otherwise a good decompression is achieved.

First Report of Recurrent Intramuscular Lipoma after Decompression Surgery of the Lumbar Spine.

Intramuscular or infiltrating lipomas are rare. We present a 58-year-old man with an intramuscular lipoma developing after decompression surgery for lumbar spinal canal stenosis. One year after macroscopically complete lipoma resection, an even bigger recurrent tumor had to be removed. The lumbar paraspinal musculature is a very uncommon site for an intramuscular lipoma. A relation between surgery and the growth and recurrence of an intramuscular lipoma has not been described previously in the literature.

Response to transforaminal injection of steroids and correlation to mri findings in patients with cervical radicular pain or radiculopathy due to disc herniation or spondylosis.

OBJECTIVE: To determine the effectiveness of cervical transforaminal injection of steroids (CTFIS) and to explore possible determinants of response in patients with cervical disc herniation. DESIGN: Retrospective practice audit covering a time period of 6 months. SETTING: Single spine center in which the patients underwent CTFIS, surgery, and subsequent treatment. Magnetic resonance images were reviewed independently by a radiologist and two neurosurgeons. INTERVENTIONS: Consecutive patients with cervical radicular pain and a magnetic resonance imaging demonstrating nerve root affection received CTFIS. Evaluation in terms of pain reduction and in relation to the level and side of the affected nerve root, the duration of pain, neck or radicular pain, and the presence of sensory or motor deficits. The radiological features assessed were the location, grading, and cause of the impingement. RESULTS: Forty-eight patients were included. Only 35.4% of patients achieved at least 50% reduction in pain 1 month after treatment. The initial pain on the numeric rating scale was reduced from 6.8 to 1.8. None of the clinical or radiological features was associated with a successful outcome. 22.9% of the included patients had to undergo an operation. The duration of these patients' symptoms was significantly shorter (P = 0.01) than in patients without operation. CONCLUSION: Only a minority of patients with disc herniation or spondylosis and a proven nerve root compression benefits from CTFIS. The potential advantage for the patient must be compared with the risk of the procedure. Even with the combination of clinical and radiological findings, the prediction of a favorable outcome of CTFIS was not possible.

Zygapophysial joint pain in post lumbar surgery syndrome. The efficacy of medial branch blocks and radiofrequency neurotomy.

OBJECTIVE: To investigate the prevalence of zygapophysial joint pain in patients after disc surgery, and to determine the effectiveness of radiofrequency neurotomy for its treatment. DESIGN: Retrospective practice audit. SETTING: Review of charts of all patients who underwent lumbar disc surgery during a time period of 2 years. INTERVENTIONS: Patients with persistent back pain after surgery were tested with repeated medial branch blocks. Those patients who consistently report at least 80% pain relief underwent radiofrequency neurotomy. A successful outcome was defined as at least 50% pain reduction enduring for 6 months. RESULTS: In a population of 479 patients who underwent microsurgical lumbar disc operations, persistent axial back pain occurred in 120, of whom 34 had positive responses to diagnostic blocks and were treated with radiofrequency neurotomy. Twenty patients (58.8%) achieved at least 50% reduction in pain for a minimum of 6 months. CONCLUSIONS: The prevalence of zygapophysial joint pain appears to be 7% in patients with failed back surgery syndrome. Patients with this condition can be treated with a radiofrequency neurotomy with a success rate of 58.8%.

Radicular pain in post lumbar surgery syndrome: the significance of transforaminal injection of steroids.

OBJECTIVE: The objective of the study was to see if transforaminal injection of steroids might be an effective treatment for persistent radicular pain after disc surgery. DESIGN: The study was designed as a retrospective practice audit covering a time period of 2 years. SETTING: The study was set in a single spine center in which all patients underwent lumbar disc surgery, postoperative follow-up, and subsequent treatment. INTERVENTIONS: Patients with postsurgical radicular pain were treated with a transforaminal injection of a steroid. The effect was evaluated in terms of pain reduction, duration of pain relief, and in relation to a recurrent disc herniation in postperative magnetic resonance imaging. RESULTS: Of 479 patients who underwent microsurgical lumbar disc surgery, 69 had persistent radicular pain. Transforaminal injection of steroid achieved pain reduction of at least 50% in 26.8% of these patients. The success rate was higher (43%) in patients without a recurrent disc herniation. CONCLUSIONS: Transforaminal injection of steroid appears to be effective in only a minority of patients with radicular pain persisting after disc surgery, but is more often effective in patients without recurrent disc herniation.

Radiofrequency neurotomy for treatment of low back pain in patients with minor degenerative spondylolisthesis.

BACKGROUND: Degenerative spondylolisthesis is one of the major causes for low back pain. Morphological abnormalities of the zygapophysial joints are a predisposing factor in the development of degenerative spondylolisthesis. Therefore, radiofrequency neurotomy seems to be a rational therapy. OBJECTIVES: To determine if radiofrequency neurotomy is effective for patients with low back pain and degenerative spondylolisthesis. STUDY DESIGN: Retrospective practice audit. SETTING: Single spine center METHODS: Charts of all patients with degenerative spondylolisthesis who underwent treatment with radiofrequency neurotomy during a time period of 3 years were reviewed. Only patients with magnetic resonance imaging confirming the diagnosis were included. Patients with a lumbar spine operation in their history, patients with neurological deficits, and patients with a follow-up less than 3 months were excluded. Patients were treated with lumbar radiofrequency neurotomy. Positive treatment response was defined as at least a 50% reduction in pain. A radiofrequency neurotomy was only performed after positive diagnostic medial branch blocks. RESULTS: During a time period of 3 years, 1,490 patients were treated with lumbar radiofrequency neurotomy. Forty of these patients with degenerative spondylolisthesis were included. A significant pain reduction was achieved in 65 % of the patients. LIMITATIONS: This audit is retrospective and observational, and therefore does not represent a high level of evidence. However, to our knowledge, since this information has not been previously reported and no specific nonoperative treatment for lumbar pain in patients with degenerative spondylolisthesis exists, it appears to be the best available research upon which to recommend treatment and to plan higher quality studies. CONCLUSION: Zygapophysial joints are a possible source of pain in patients with spondylolisthesis. Radiofrequency neurotomy is a rational, specific nonoperative therapy in addition to other nonoperative therapy methods with a success rate of 65%. This is the first study to determine the effect of radiofrequency neurotomy in patients with minor degenerative spondylolisthesis.

The benefit of therapeutic medial branch blocks after cervical operations.

BACKGROUND: Persistent neck pain is a common problem after surgery of the cervical spine. No therapy recommendation exists for these patients. OBJECTIVE: The objective of this study was to determine if a therapeutic medial branch block is a rational treatment for patients with postoperative neck pain after cervical spine operations. STUDY DESIGN: Retrospective practice audit. SETTING: Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 3 years. METHODS: Patients with persistent postsurgical pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). A positive treatment response was defined if at least 80% reduction of pain could be achieved or if the patient was sufficiently satisfied with the relief. All patients with a minimum follow up time of 6 months were included. RESULTS: Of the 312 operations performed, 128 were artificial disc operations, 125 were stand alone cages, and 59 were fusions with cage and plate. Persistent neck pain occurred in 33.3% of the patients. There was no difference between the patients with neck pain and the whole group of patients. More than half of the patients with neck pain--52.9%--were treated successfully with therapeutic medial branch blocks. Since no further treatment was necessary, the initial treatment was considered successful. Nearly a third--32.2%--of the patients were initially treated successfully, but their pain recurred and further diagnostics and treatments were necessary. In this group of patients, significantly more with double level operations were found (P = 0.003). Patients not responding to the medial branch block were 14.9%. LIMITATIONS: This audit is retrospective and observational, and therefore does not represent a high level of evidence. However, to our knowledge, since this information has not been previously reported and no recommendation for the treatment of post-operative zygapophysial joint pain exists, it appears to be the best available research upon which to recommend treatment and to plan higher quality studies. CONCLUSION: For persistent postsurgical neck pain only limited therapy recommendations exist. This study suggests treating these patients in a first instance with therapeutic medial branch blocks. The success rate is 52.9 %.