Susan M. Lord

Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint-pain

BACKGROUND Chronic pain in the cervical zygapohyseal joints is a common problem after whiplash injury, but treatment is difficult. Percutaneous radiofrequency neurotomy can relieve the pain by denaturing the nerves innervating the painful joint, but the efficacy of this treatment has not been established. METHODS In a randomized, double-blind trial, we compared percutaneous radio-frequency neurotomy in which multiple lesions were made and the temperature of the electrode making the lesions was raised to 80 degrees C with a control treatment using an identical procedure except that the radio-frequency current was not turned on. We studied 24 patients (9 men and 15 women; mean age, 43 years) who had pain in one or more cervical zygapophyseal joints after an automobile accident (median duration of pain, 34 months). The source of their pain had been identified with the use of double-blind, placebo-controlled local anesthesia. Twelve patients received each treatment. The patients were followed by telephone interviews and clinic visits until they reported that their pain had returned to 50 percent of the preoperative level. RESULTS The median time that elapsed before the pain returned to at least 50 percent of the preoperative level was 263 days in the active-treatment group and 8 days in the control group (P=0.04). At 27 weeks, seven patients in the active-treatment group and one patient in the control group were free of pain. Five patients in the active-treatment group had numbness in the territory of the treated nerves, but none considered it troubling. CONCLUSIONS In patients with chronic cervical zygapophyseal-joint pain confirmed with double-blind, placebo-controlled local anesthesia, percutaneous radio-frequency neurotomy with multiple lesions of target nerves can provide lasting relief.

The prevalence of chronic cervical zygapophysial joint pain after whiplash.

Study Design. A survey of the prevalence of cervical zygapophysial jooint pain was conducted. Objectives. To determine the prevalence of cervical zygapophysial joint pain in patients with chronic neck pain after whiplash. Summary of Backgound Data. In a significant porportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggests many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic blocks. Methods. Fifty consecutive, referred patients with chronic neck pain after whiplash injury were studid using double-blind, controlled, diagnotic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. Results. A positive diagnosis was made only if both blocks relieved the patients pain and bupivacaine provided longer relief, Painful joints were identified in 54% of the patients (95% confidence interval, 40% to 68%). Conclusion. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.

Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain

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, and its effects can be reinstated if pain recurs.

Lack of Effect of Intraarticular Corticosteroids for Chronic Pain in the Cervical Zygapophyseal Joints

BACKGROUND Chronic pain in the cervical zygapophyseal joints is a common problem after a whiplash injury. Treatment with intraarticular injections of corticosteroid preparations has been advocated, but the value of this approach has not been established. We compared the efficacy of a depot injection of a corticosteroid preparation with the efficacy of an injection of a local anesthetic agent in patients with painful cervical zygapophyseal joints. METHODS Sixteen men and 25 women with pain in one or more cervical zygapophyseal joints after automobile accidents (mean age, 43 years; median duration of pain, 39 months) were randomly assigned to receive an intraarticular injection of either bupivacaine (0.5 percent) or betamethasone (5.7 mg) under double-blind conditions. The patients were followed by means of regular telephone contact and clinic visits until they reported a return to a level of pain equivalent to 50 percent of the preinjection level. The time from treatment to a 50 percent return of pain was compared in the two groups with the use of a survival analysis. RESULTS Less than half the patients reported relief of pain for more than one week, and less than one in five patients reported relief for more than one month, irrespective of the treatment received. The median time to a return of 50 percent of the preinjection level of pain was 3 days in the 21 patients in the corticosteroid group and 3.5 days in the 20 patients in the local-anesthetic group (P = 0.42). CONCLUSIONS Intraarticular injection of betamethasone is not effective therapy for pain in the cervical zygapophyseal joints after a whiplash injury.

False-positive Rates of Cervical Zygapophysial Joint Blocks

Objective:To determine the false-positive rate of anesthetic blocks of the medial branches of the cervical dorsal rami in the diagnosis of cervical zygapophysial joint pain. Design:Comparison between single diagnostic blocks, and a criterion standard of double-blind, controlled, differential anesthetic blocks. Setting:Tertiary referral center. Patients:The first 55 consecutive patients with neck pain for >3 months after and attributable to a motor vehicle accident, and who had completed a second diagnostic block after an initial positive response. A total of 60 joints was studied, with five patients providing two joints each. The mean age was 41 years: 61% were female. Methods:Each patient had been investigated with radiologically controlled blocks of the medial branches of the cervical dorsal rami to anesthetize the target cervical zygapophysial joint. The initial block was performed using either 0.5% bupivacaine or 2% lignocaine, randomly selected. The duration of pain relief was assessed in a double-blind fashion. The procedure was repeated with the complementary anesthetic. Only patients experiencing a longer period of pain relief from bupivacaine were considered to have true-positive responses. Results:The second block failed to relieve pain in two of the tested joints. In a further 14 joints, the control blocks relieved pain, but the patient failed to correctly discriminate the longer acting anesthetic. The remaining 44 joints met the criteria for true-positive responses. The false-positive rate of single blocks was 16 of 60 or 27% (95% confidence interval 15%, 38%). Conclusion:Uncontrolled diagnostic blocks are compromised by a significant false-positive rate that seriously detracts from the specificity of the test.

Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution.

Percutaneous radiofrequency neurotomy has been used in the treatment of pain from the cervical zygapophysial joints, but the results have been modest and not compelling. Several factors might account for its apparent poor success rate, including inadequate patient selection, inaccurate surgical anatomy, and technical errors. In an effort to overcome these confounders, we used comparative local anesthetic blocks to preoperatively, definitively diagnose cervical zygapophysial joint pain and developed an amended operative technique based on formal anatomical studies. An audit was conducted of our experience with 19 patients to determine whether there was sufficient merit in the amended procedure to justify a randomized, double-blind, controlled trial. The duration of complete pain relief was the principal outcome measure. Side effects and complications were also monitored. Of the 10 patients who underwent third occipital neurotomy for the treatment of C2-C3 zygapophysial joint pain, only 4 obtained long-lasting relief. The other six patients reported an early return of their pain and constituted technical failures; the third occipital nerve was inadequately coagulated and recovered in the immediate postoperative period. Of the 10 patients who underwent lower cervical medial branch neurotomy, 7 obtained complete pain relief for clinically useful periods and were able to resume their activities of daily living and employment. After procedures at all levels, a brief period of postoperative pain was experienced by the patients and ataxia was a side effect of third occipital neurotomy. There were no cases of postoperative infection or anesthesia dolorosa. Given the high technical failure rate of third occipital neurotomy, we recommend that this procedure be abandoned until the technical problems can be overcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical Zygapophysial Joint Pain

The role of the cervical zygapophysial joints as sources of chronic neck pain has attracted considerable attention and some controversy. Cervical zygapophysial joints are typical synovial joints and are innervated by the medial branches of the cervical dorsal rami. Stimulation of these joints in normal volunteers causes neck pain and pain referred to the head, shoulder girdle, and upper limb. Injuries to these joints, including tears of the joint capsule, intra-articular hemorrhage, bruising of the meniscoids, and fractures of the subchondral bone and articular pillars, have been found in postmortem studies. Diagnosis of such injuries in vivo has been a challenge because they defy resolution by conventional imaging. Local anesthetic blocks of the cervical medial branches are purported to be a reliable diagnostic test. In the past, their validity was disputed on the grounds that they could be nonspecific or confounded by placebo responses. Nevertheless, recent studies have shown that medial branch blocks are target-specific and that their reliability is increased by employing control blocks, either by using two local anesthetics with different durations of action (comparative blocks) or by adding an inactive placebo injection (placebo-controlled blocks). Based on controlled blocks, the prevalence of lower cervical zygapophysial joint pain is 49%, and among patients with chronic, dominant headache, the C2–3 zygapophysial joint is the single most common source of pain. Despite extensive study, no clinical features of cervical zygapophysial joint pain have been identified. Consequently, controlled local anesthetic blocks remain the only means of diagnosing the condition. There is no evidence to support the efficacy of any form of nonoperative treatment for cervical zygapophysial joint pain. Indeed, intra-articular steroids have been shown to be ineffective. Neurosurgery remains the only practical and validated treatment for this common condition.

Percutaneous Radiofrequency Neurotomy of the Cervical Medial Branches: A Validated Treatment for Cervical Zygapophysial Joint Pain

SummaryPercutaneous radiofrequency neurotomy is a minimally invasive, neuroablative procedure used to interrupt nociceptive pathways in patients with intractable pain. In the context of chronic cervical zygapophysial joint pain, the target nerves are the medial branches of the cervical dorsal rami t

Pain and psychologic symptoms of Australian patients with whiplash.

Study Design A survey of pain intensity and psychological symptoms in patients with chronic neck pain after whiplash injury. Objectives To describe the pain and psychological profiles of patients with chronic whiplash. Summary of Background Data Reports in the literature mention a constellation of symptoms associated with chronic whiplash injury but no systematic survey using objective patient report measures has been reported. Methods One hundred forty consecutive referred patients with chronic neck pain after a motor vehicle accident were studied using the SCL‐90‐R psychological profile and the McGill Pain Questionnaire. Results Psychological profiles and pain intensity ratings, similar to profiles obtained from patients suffering from rheumatoid arthritis and low back pain of organic origin, were obtained. Conclusions The SCL‐90‐R is a convenient instrument to administer to patients with whiplash. It yielded a characteristic profile of pain and appears to be more expedient than other psychometric tests for these patients.

CERVICAL SPINE DISORDERS

Recent research of disorders of the neck has concentrated on the efficacy of manual and other conservative therapies for neck pain and whiplash. Systematic reviews paint a poor picture of the quality of literature upon which many conventional, conservative therapies are based. Conclusive scientific data are lacking. Despite its unsavory reputation, whiplash has attracted considerable scientific inquiry. Multiple studies have brought data to bear that indicate that chronic neck pain after whiplash is not psychogenic, and that psychologic distress is secondary to the pain. Strong studies have shown that cervical zygapophysial joint pain is the most common basis for chronic neck pain after whiplash but that this condition cannot be diagnosed other than by using controlled diagnostic blocks. Surgical treatment of cervical zygapophysial joint pain has been proven to be effective in a double-blind controlled trial.