Literature References Supporting the Technique RF Literature Supporting the Use of Facet and other RF THERMOCOAGULATION Spine. 2004 Nov 1;29(21):2471-3. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Schofferman J, Kine G. SpineCare Medical Group, San Francisco Spine Institute, Daly City, California, USA. jschofferman@spinecare.com STUDY DESIGN: Retrospective chart review. OBJECTIVES: To determine the success rate and duration of relief of repeat radiofrequency neurotomy for lumbar facet joint pain. SUMMARY OF BACKGROUND DATA: Radiofrequency neurotomy is an effective but temporary management of lumbar facet pain. When pain recurs, radiofrequency neurotomy is usually repeated, but the outcome and duration of relief for repeat radiofrequency neurotomies are unknown. METHODS: Record review of consecutive patients who had an initial successful radiofrequency neurotomy, subsequent recurrence of pain, and then repeat radiofrequency neurotomy. Responses of repeat radiofrequency neurotomies were compared with initial radiofrequency neurotomy for success rates and duration of relief. RESULTS: There were 16 women and 4 men. Mean age was 48 years (range, 26-63). Radiofrequency neurotomy denervated one segment in two patients, two segments in 16 patients, and three or more in two patients. There were 10 bilateral and 10 unilateral radiofrequency neurotomies. Mean duration of relief after initial radiofrequency neurotomy was 10.5 months (range, 4-19). To date, two patients had a series of two radiofrequency neurotomies performed, six had three, five had four, three had five, and four had seven or more. Twenty patients had a second radiofrequency neurotomy, which was successful in 17 (85%) but unsuccessful in two. The mean duration of relief in 16 of these 17 patients was 11.6 months (range, 6-19), and relief is continuing in one. Sixteen patients had a third radiofrequency neurotomy, of which 15 were successful and one was unsuccessful. The mean duration of relief in nine of the 15 was 11.2 months (range, 5-23), and relief is continuing in the other six. Eight patients had a fourth radiofrequency neurotomy, which was successful in seven but unsuccessful in one. The mean duration of relief was 9 months (range, 5-14) in three patients, and relief is continuing in the other four. None of these differences is significant. The frequency of success and durations of relief remained consistent after each subsequent radiofrequency neurotomy. CONCLUSIONS: Repeated radiofrequency neurotomies are an effective long-term palliative management of lumbar facet pain. Each radiofrequency neurotomy had a mean duration of relief of 10.5 months and was successful more than 85% of the time. Pain Med. 2001 Sep;2(3):249-50. (224) retrospective study of efficacy of radiofrequency neurolysis for facet arthropathy. Royal M, Wienecke G, Movva V, Ward S, Bhakta B, Jensen M, Gunyea I. Oklahoma University College of Medicine. In 1933, Ghormley proposed facet arthropathy as a source of chronic back pain [1]. In 1971, Bogduk demonstrated that the median branches could be easy targets for percutaneous denervation due to their relative constant position in relation to bone [2-4]. Over the last 4 years, we performed 230 radiofrequency thermocoagulation (RFTC) median branch neurolytic procedures on 148 patients with refractory cervical or lumbar facet arthropathy as documented by diagnostic fluoroscopically-directed facet nerve or joint blocks. Of the 148 patients, 63 had cervical and 85 had lumbar RFTC procedures performed using a Leibinger radiofrequency generator according to the technique described by Kline (2 lesions at each median branch location at 85 degrees C. for 60 seconds) [5]. Subjective patient responses were graded as follows: excellent-greater than 70% improvement, good-50-70% improvement, fair-30-49%, and poor-less than 30%. One hundred six RFTC procedures were performed in the 63 cervical cases and 124 in the 85 lumbar cases with those patients who had good to excellent responses undergoing repeat procedures. No significant side effects were experienced (short-term neuritis was seen in 2 patients who had cervical and 1 who had lumbar RFTC, but resolved after a few weeks). In summary, 85% of cervical and 71% of lumbar RFTC cases had at least a 50% improvement in symptoms for extended periods. RFTC of median branches for facet arthropathy is a safe and efficacious modality with the potential for long-term benefit. Spine. 2001 Jun 15;26(12):E268-73. Radiofrequency medial branch neurotomy in litigant and nonlitigant patients with cervical whiplash: a prospective study. Sapir DA, METHODS: Sixty patients with cervical whiplash who remained symptomatic after 20 weeks of conservative management were referred for radiofrequency cervical medial neurotomy. The patients were classified as litigant or nonlitigant based on whether the potential for monetary gain via litigation existed. Each group underwent identical evaluation and treatment. Patients were observed for 1 year. Visual analogue scores and self-reported improvement were obtained before, immediately after, and 1 year after radiofrequency cervical medial neurotomy. RESULTS: Forty-six patients completed the study. The overall reduction in cervical whiplash symptoms and visual analogue pain scores were significant immediately after treatment (nonlitigants vs. litigants: 2.0 vs. 2.5, P = 0.36) and at 1 year (nonlitigants vs. litigants: 2.9 vs. 4.0, P = 0.05). One-year follow-up scores were higher than immediate post-treatment scores (nonlitigants vs. litigants: 2.5 vs. 3.6). The difference between litigants and nonlitigants in the degree of symptomatology or response to treatment did not reach significance. CONCLUSIONS: These results demonstrate that the potential for secondary gain in patients who have cervical facet arthropathy as a result of a whiplash injury does not influence response to treatment. These data contradict the common notion that litigation promotes malingering. This study also confirms the efficacy of radiofrequency medial branch neurotomy in the treatment of traumatic cervical facet arthropathy. Spine. 2000 May 15;25(10):1270-7. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Spine Specialists, East Texas Medical Center Neurological Institute, Tyler, TX 75701, USA. PaulDSpine@aol.com STUDY DESIGN: A prospective audit. OBJECTIVE: To establish the efficacy of lumbar medial branch neurotomy under optimum conditions. SUMMARY OF BACKGROUND DATA: Previous reports of the efficacy of lumbar medial branch neurotomy have been confounded by poor patient selection, inaccurate surgical technique, and inadequate assessment of outcome. METHODS: Fifteen patients with chronic low back pain whose pain was relieved by controlled, diagnostic medial branch blocks of the lumbar zygapophysial joints, underwent lumbar medial branch neurotomy. Before surgery, all were evaluated by visual analog scale and a variety of validated measures of pain, disability, and treatment satisfaction. Electromyography of the multifidus muscle was performed before and after surgery to ensure accuracy of the neurotomy. All outcome measures were repeated at 6 weeks, and 3, 6, and 12 months after surgery. RESULTS: Some 60% of the patients obtained at least 90% relief of pain at 12 months, and 87% obtained at least 60% relief. Relief was associated with denervation of the multifidus in those segments in which the medial branches had been coagulated. Prelesion electrical stimulation of the medial branch nerve with measurement of impedance was not associated with outcome. CONCLUSIONS: Lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. Adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. Electrical stimulation before lesioning is superfluous in assuring correct placement of the electrode. Neurosurgery. 1999 Jul;45(1):61-7; discussion 67-8. Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. McDonald GJ, Lord SM, Bogduk N. Newcastle Bone and Joint Institute, University of Newcastle, NSW, Australia. OBJECTIVE: To determine the long-term efficacy of percutaneous radiofrequency medial branch neurotomy in the treatment of chronic neck pain. METHODS: Between 1991 and 1996, radiofrequency neurotomy was performed in 28 patients diagnosed as having cervical zygapophysial joint pain on the basis of controlled diagnostic blocks. The procedure was repeated in patients whose pain recurred. Outcome measures were the proportion of patients who responded to the initial procedure and the duration of relief subsequently obtained. Outcome was correlated with the operator performing the procedure, the type of electrode used, litigation status, and the type of diagnostic blocks used to establish the diagnosis. RESULTS: Complete relief of pain was obtained in 71% of patients after an initial procedure. No patient who failed to respond to a first procedure responded to a repeat procedure, but if pain returned after a successful initial procedure, relief could be reinstated by a repeat procedure. The median duration of relief after a first procedure was 219 days when failures are included but 422 days when only successful cases are considered. The median duration of relief after repeat procedures was at least 219 days; several patients had ongoing relief at the time of follow-up. Outcome did not differ according to the operator, the type of electrode used, litigation status, or the type of diagnostic block used. CONCLUSION: Radiofrequency neurotomy provides clinically significant and satisfying periods of freedom from pain Acta Neurochir (Wien). 1993;122(1-2):82-90. Percutaneous facet denervation in chronic thoracic spinal pain. Stolker RJ, Vervest AC, Groen GJ. Pain Clinic University Hospital Utrecht, The Netherlands. In 40 patients with chronic thoracic spinal pain of more than 12 months duration which failed to respond to conservative treatment and with a previous evaluation by specialists, mainly neurologists and orthopaedic surgeons, the diagnosis of facet syndrome was made. This diagnosis was based on clinical criteria and a transient positive response to a prognostic blockade of the medial branch of the dorsal ramus of the thoracic spinal nerve. They were selected to undergo percutaneous radiofrequency denervation of the facet joints. The short and long-term results of 51 percutaneous thoracic facet denervations in 40 patients are described. After 2 months, 19 patients (47.5%) were pain-free, 14 patients (35%) had more than 50% pain-relief, and 7 patients (17.5%) had no relief. After a follow-up of 18-54 (average 31) months in 36 cases (3 patients had died because of malignancy, and 1 had undergone a spinal fusion), 16 patients (44%) were pain-free, 14 patients (39%) had more than 50% pain-relief and in 6 cases (17%) the result was poor. Adverse effects consisted of postoperative pain in 5 patients (12.5%). When conservative treatment fails, percutaneous thoracic facet denervation can be a safe and beneficial therapy in chronic thoracic spinal pain originating from the facet joints. PULSED RF Spine J. 2003 Sep-Oct;3(5):360-2. Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain. Mikeladze G, Espinal R, Finnegan R, Routon J, Martin D. Pain Medicine Program, Department of Anesthesiology, Medical College of Georgia, 1120 15th Street BIW 2144, Augusta, GA 30912, USA. BACKGROUND CONTEXT: Chronic zygapophyseal joint arthropathy is a cause of back and neck pain. One proposed method of treating facet joint pathology is ablation of medial branches and dorsal rami with pulsed radiofrequency (RF) waves. PURPOSE: Assessment of efficacy of pulsed RF application for treatment of chronic zygapophyseal joint pain. STUDY DESIGN/SETTING: Retrospective study of 114 patients at a pain management clinic. PATIENT SAMPLE: A total of 114 patients with clinical signs of facet joint involvement and a favorable response to a diagnostic medial branch block using local anesthetic, including 82 females and 32 males with a mean age of 52.8+/-12.6 years. Mean duration of pain was 7.52+/-5.26 years. Twenty-seven had previous back surgery, 83 patients had low back pain and 31 had cervical pain. Pain was on the left side in 47 patients, on the right side in 45 patients, bilateral in 22. OUTCOME MEASURES: Result was regarded as successful if pain reduction was more than 50% on visual analog scale and the duration of effect was more than 1.5 months. METHODS: After obtaining positive stimulation, pulsed RF was applied to medial branches of dorsal rami for 120 seconds with temperature at the tip of the electrode 42 C. RESULTS: Of 114 patients, who had positive response to diagnostic block, 46 patients did not respond favorably to pulsed RF application (pain reduction less than 50%). In 68 patients or 60%, the procedure was successful and lasted on average 3.93+/-1.86 months. Eighteen patients had the procedure repeated with the same duration of pain relief that was achieved initially. Previous surgery, duration of pain, sex, levels (cervical vs. lumbar) and stimulation levels did not influence outcomes. CONCLUSION: The results of our study showed that the application of pulsed RF to medial branches of the dorsal rami in patients with chronic facet joint arthropathy provided temporary pain relief in 68 of 118. Pain. 2003 Aug;104(3):449-52. Pulsed radiofrequency treatment of the Gasserian ganglion in patients with idiopathic trigeminal neuralgia. Van Zundert J, Brabant S, Van de Kelft E, Vercruyssen A, Van Buyten JP. Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Therapy, Ziekenhuis Oost-Limburg, Campus Andre Dumont, Stalenstraat 2, 3600 Genk, Belgium. janvanzundert@pandora.be Pulsed radiofrequency treatment has been described as a minimal invasive alternative to radiofrequency thermocoagulation for the management of chronic pain syndromes. We present here our first five high-risk patients with idiopathic trigeminal neuralgia who were treated with pulsed radiofrequency after multidisciplinary assessment; with a mean follow-up of 19.2 months (range 10-26). These patients were at high risk due to age, co-morbidities or previous interventional and surgical treatments. An excellent long-term effect was achieved in three of the five patients, a partial effect in one patient and a short-term effect in one patient. No neurological side effects or complications were reported. Urology. 2003 Mar;61(3):645. Pulsed radiofrequency as a treatment for groin pain and orchialgia. Cohen SP, Foster A. Department of Anesthesia, Pain Management Center, Walter Reed Army Medical Center, Washington, DC, USA Inguinal and testicular pain are challenging problems for which no reliable, standardized treatment exists. We report 3 patients with groin pain or orchialgia who were treated with pulsed radiofrequency of the nerves innervating these areas. All 3 patients reported complete pain relief at their 6-month follow-up visits. The techniques and settings used for the nerve blocks and radiofrequency procedures are explained in detail, along with a brief synopsis of the rationale for using it. Randomized, placebo-controlled studies are needed to better assess the efficacy of this procedure and identify eligible candidates.