Transcript Material and methods Needle positioning under fluoroscopic

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
Disclosure
Consultant of Stryker
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
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
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 to irritation of joint
innervation, because of capsular
distension, inflammatory synovitis,
entrapment of synovial villi between two
articular processes, or actual nerve
impingement by osteophytes
Anatomy:
relevant nerves
L3
DORSAL RAMUS OF SPINAL NERVE
SUPERIOR ARTICOLAR BRANCH
L4
LATERAL BRANCH
MEDIAL BRANCH
INFERIOR ARTICOLAR BRANCH
L5
Radiological signs
Radiological signs
MRI Gd
Enhancing inflammatory soft tissues
changes surrounding facet joints
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
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
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
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
Controindications
- Local or systemic infections
- Coagulation disorders
Material and methods
Angiographic suite
CT suite
Material and methods
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
Material and methods
Targets
Between the transverse and
articular process!
Material and methods
Targets L5S1
(L5 dorsal ramus)
On the ala of the sacrum just lateral to
the articular process!
Material and methods
Needle positioning under fluoroscopic guide
(length 100 mm exposed tip 5-10 mm)
Material and methods
Needle positioning under fluoroscopic guide:
operative position
Material and methods
Needle positioning under fluoroscopic guide:
operative position
Material and methods
Needle positioning under fluoroscopic guide:
operative position
Material and methods
Needle positioning under fluoroscopic guide:
operative position L5S1
Material and methods
Needle positioning under CT guide
Material and methods
Insertion of the electrode
Material and methods
NEUROPHISIOLOGICAL CHECK
Impedence values between 200 e 800 Ohms
are significant for the correct target
Material and methods
NEUROPHISIOLOGICAL CHECK
SENSORIAL STIMULATION TEST
Parameter settings:
Frequency 50hz
Intensity 0,2 – 0,7V
- Confirms proximity of electrode to sensory fibers
- Reproduces patient’s ‘typical pain’
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
Material and methods
Neurotomy
Parameter settings:
90° for 60”
Material and methods
Patients: 45
Mean age: 70.3±13.0
Joints: 54
Fluoroscopic Guide: 44
CT Guide: 10
Material and methods
Follow up
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
Results
PAIN REDUCTION: VAS 0-10
+1,1
(p<0.0001)
+2,1
-1,1
-2,1
Results
PAIN REDUCTION: use of analgesic drugs
Results
Oswestry Disability Index(ODI)
(p<0.0001)
Results
No procedural complications
No infections
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
Thank you
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