Management of Non Disco-genic low back pain: Our Experience of 40 Cases of RF Rhizotomy

Original Article

Management of non disco-genic low back pain: Ourexperience of 40 cases of RF rhizotomy

Prasad Rajendra*, Kapoor Amit

Department of Neurosurgery, Apollo Hospital, New Delhi, India

a r t i c l e i n f o

Article history:

Received 31 July 2013

Accepted 9 August 2013

Keywords:

Radiofrequency ablation (RF)

Facet joint pain

Non-disco-genic back pain

Lumbar facet block

Zygapophysial joint

a b s t r a c t

Aim: Patients with low back pain with no significant radicular pain and absent focal

neurological deficit, who have received conservative treatment over a long period of time

with no significant pain relief, need thorough assessment. Lumbar facet joint is an

important pain generator in this group of patients and treatment using radiofrequency

ablation is accessed, after patient selection by trial of facet joint block.

Settings: A tertiary referral hospital in India (Indraprastha Apollo Hospital, New Delhi).

Methods and material: 40 patients who had chronic low back pain with no radiculopathy. In

addition nature of the pain along with aggravating and relieving factors and clinical ex-

amination in particular tender facets were identified. Trial of lumbar facet joint block was

done for confirming source of pain. Subsequently radiofrequency rhizotomy of the median

branch of dorsal nerve root supplying the painful facet was done as a definitive procedure.

Results: The Modified Oswestry disability index showed significant improvement in all 40

patients immediate post procedure period. Recurrence of pain occurred within one month

of rhizotomy in three patients; others remained pain free for longer durations.

Conclusions: Facetal arthropathy is an important source of low back pain. Various treatment

options are available for management of chronic low back pain. Lumbar facet joint block if

leading to pain relief is diagnostic of facetal origin of back pain. Radiofrequency ablation of

median branchof the dorsal nerve root is an effective and less invasive option for treatment of

facet pain.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

(RF) rhizotomy or neurotomy is a therapeutic procedure

designed to decrease and/or eliminate pain symptoms arising

from degenerative facet joints within the spine. The procedure

involves denaturation of proteins in the nerves with highly

localized heat generated with radiofrequency thus functionally

destroying the nerves that innervate the facet joints. By

destroying these nerves, the communication link that signals

pain from the facet joint to the brain can be broken. The onset

of lumbar facet joint pain is usually insidious, with predispos-

ing factors including degenerative disc pathology and old age.

2. Subjects and methods

We discuss our experience with 40 patients who had chronic

low back pain with no radiculopathy.

* Corresponding author. Tel.: þ91 (0) 9810048369.E-mail address: neurosurgeryindia@gmail.com (P. Rajendra).

Available online at www.sciencedirect.com

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Those patients who had low backache with facetal

tenderness and no significant radiculopathy were included.

Patients who fulfilled these criteria were subjected to a trial

block with local anesthetic agent and steroids before sub-

jecting them to thermo ablation. Pre and post procedure pain

assessments was done using Modified Oswestry disability

index (MODI) score which were taken pre and post procedure

at one month and subsequently at periodic follow-ups upto 2

years.

MRI lumbar spine and X-rays of lumbar spine including

flexion and extension study were also done. Patients with

significant disc prolapse or instability were excluded.

Following pain relief with this test they underwent rhi-

zotomy under MAC (monitored anesthetic care) and IV fen-

tanyl, as a definitive procedure using motor and sensory

testing. Sensory testing was done at 50 Hz for 1 V, motor

testing was done at 2 Hz for 2 V and lesioning was done at 70�

centigrade for 60 s using continuous radiofrequency thermo

ablation Fig. 1 and Fig. 2.

3. Result

Total numbers of patients studied were 40 (15 male and 25 fe-

male) ages 26 yearse82 years (mean age 54.5). Most patients

were overweight with a BMI range from21.8 to 66.2 (mean 32.6).

OnMRI facetal degenerationwas seen inall patients (10patients

were grade I, 17 patients grade II and 13 were grade III) Fig. 3.

Trial of facet block using Sensorcaine and Depo-medrol

was done for confirming the pain generator. All patients

who had undergone the trial of facet block had good symp-

tomatic relief.

According to the pre procedure MODI score 30% (approx.)

patients were in the crippled condition and approximate 53%

were in severe disability & 7% patients were found to be

exaggerating their symptoms Fig. 4.

Similarly, post procedure MODI score of the same patients

showed 77% patients had minimal disability and 17% patients

had moderate disability.

At mean follow-up of 20 months 79% patients had no

recurrence and 13% had recurrence after 6 months of treat-

ment, while 8% had recurrence within 1 month.

One patient had post procedure dysesthesia, which settled

with medication.

2 levels facetal arthropathy was treated in 77% of patients,

1 level in 23% patients.

Most common involved level was L4eL5.

4. Discussion

The facet joint capsule and surrounding structures are richly

innervated with nociceptors that fire when the capsule is

stretched or subjected to local compressive forces.1,2 Pain

originating from the facet joints has long been recognized as a

potential source of low backache although secondary referral

of pain to facet joints has also been suggested. However, in the

past few decades, the scales of this controversy have reso-

lutely tipped toward the conviction that facet joints can be

and often are a primary source of low back pain.3

Anatomical studies suggest that with aging, the facet joints

become weaker and their orientation changes from coronal to

sagittal positioning, predisposing them to injury from rota-

tional stress. The threemost caudal facet joints, L3eL4, L4eL5,

and L5eS1, are exposed to the greatest strain during lateral

bending and forward flexion and are thus more prone to re-

petitive strain, inflammation, joint hypertrophy, and osteo-

phyte formation, same been the case in our study. Association

with obesity and female gender was noticed in our study.

Osteoarthritis of the facet joints is commonly found in asso-

ciation with degenerative disc disease. The prevalence rate of

facet joint pain varies widely in the literature, ranging from

less than 5% to upward of 90%.4e11 To a large extent, the wide

discrepancy in prevalence rates is a function of the diagnosticFig. 1 e Patient undergoing RF procedure.

Fig. 2 e Rf lesioning for right L4 medial branch.

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methodology used and the perspective and conviction of the

investigator.

In 1933, Ghormley coined the term “facet syndrome,” which

he defined as lumbosacral pain, with or without sciatica that

was likely to occur after a sudden rotatory strain. Shortly

thereafter, interest in the facet joints as potential sources of

back painwaned after the landmark article byMixter and Barr12

implicating lumbar disc rupture as themajor cause of low back

and leg pain. The 1940s saw a resurgence in the interest of facet

joints as pain generators when Badgley13 suggested that up to

80% of cases of low backache and sciatica are due to referred

pain from facet joint pathology, rather than direct nerve root

compression. In 1963, Hirsch et al14 published the first account

whereby the injection of facet joints reproduced patients back

pain. Rees, in 1971 described “facet rhizolysis”while Shealy15e16

pioneered the use of fluoroscopically guided radiofrequency

facet denervation to treat facet joint pain in the mid-1970s.

Discrepancies between pain provocation and pain patterns

have been found for facet joint stimulation.17e18 All of the

lumbar facet joints are capable of producing pain that can be

referred into the groin, although this is more common with

lower facet joint pathology. Pain emanating from upper facet

joints tends to extend into the flank, hip, and upper lateral

thigh, whereas pain from the lower facet joints is likely to

penetrate deeper into the thigh, usually laterally and/or pos-

teriorly. Infrequently, the L4eL5 and L5eS1 facet joints can

provoke pain extending into the lower lateral leg and, in rare

instances, even the foot. In 1988, Helbig and Lee designated a

“lumbar facet syndrome” were back pain was associated with

groin or thigh pain and paraspinal tenderness and reproduc-

tion of pain during extensionerotation maneuvers.

In studies conducted in patients with low backache, the

incidence of degenerative facet disease on computed tomo-

graphic (CT) scanning ranges from around 40% in some

studies,11 to upwards of 85% in others.5 MRI is considered to be

somewhat less sensitive than CT imaging for detecting

degenerative facet changes19e20 although several studies

conducted in chronic low backache patients found both the

sensitivity and specificity of MRI to be more than 90%

compared with CT.20 We do lumbar rhizotomy under C-arm

Fig. 3 e (a) MRI grades of facetal degeneration. (b) Facetal degeneration distribution in our 40 patients.

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guidance which has been shown to have equally good results

as of CT guided lumbar rhizotomy.21 Weishaupt et al22 have

described grades of facetal degeneration. Prevalence of facet

degeneration ranges from 8% to 14%22e24 in asymptomatic

individuals and was present in all subjects in our study with

no significant correlation with grade of facetal degeneration

and MODI scores. Pre procedure MODI scores showed 30%

(approx.) patients were in the crippled condition and

approximate 60% were in severe disabilities which post pro-

cedural improved to 77% showing minimal disability and 17%

patients were moderately disabled. Although successful trial

of facet block was taken as conformational for facetal pain

generator there can be false-positive facet blocks due to multi

factorial reasons including placebo response (18e32%) to

diagnostic facet interventions, use of sedation, the liberal use

of superficial LA, and the spread of injectate to pain generating

structures other than those targeted.25

Lau et al concluded the ideal electrode position is across the

lateral neck of the superior articular process rather than the

groove formed at the angle of the superior articular and trans-

verse processes, as was used in our study.26,27

Pre-selectionwith facet block, assessment of the efficacy of

radiofrequency denervation by performing electromyography

of the multifidus muscles were shown to be beneficial by

Dreyfuss et al.28 Although sensory stimulationwas used in our

study to corroborate proximity of the electrode to the targeted

medial branch, possibility of many patients perceiving

concordant sensory stimulation at 0.5 V or less, evenwhen the

electrode is far away from the target is well known. Attempt to

elicit multifidusmuscle contraction, because the samemedial

branch that innervates the facet joint also innervates this

paraspinal muscle reported improves positive outcomes28,29

and was used in this study. Investigators have found the

maximal lesion size reacheswithin 60 s of lesion time30e32 and

same time limit was adhered to in our study as longer dura-

tions are associated with increased incidence of numbness

and/or dysesthesias which usually tend to be transient and

self-limiting.33,34 The most common complication after facet

joint radiofrequency is neuritis, with a reported incidence of

less than 5%. In one study, the administration of corticoste-

roid or pentoxifylline was found to reduce the incidence of

post procedure pain after radiofrequency denervation,35 not

used in our study.

Serious complications and side effects are extremely un-

common after facet interventions. The metabolic and endo-

crine sequelae of intrafacetal depot steroids have not been

studied, but extrapolating from epidural steroid injections,

one would expect suppression of the hypothal-

amicepituitaryeadrenal axis lasting up to 4 weeks depending

on the depot steroid used, and impaired insulin sensitivity

manifesting as elevated glucose levels for less than a

week.36,37 Although rare, a host of infections have been re-

ported after intraarticular injections including septic arthritis,

epidural abscess, and meningitis.38e40 Case reports of spinal

anesthesia and post-dural puncture headache have also been

published.41,42 Burns are rare with radiofrequency procedures

and may result from electrical faults, insulation breaks in the

electrodes, and generator malfunction.15,43,44 There is also a

theoretical risk of thermal injury to the ventral rami if an

electrode slips ventrally over the transverse process. Recur-

rence of pain after radiofrequency occurs by regeneration of

nerve fibers, which has been typically reported to occur be-

tween 6months and 1 year and can bemanagedwith repeated

neurotomy with no diminution in efficacy.45

Conflicts of interest

All authors have none to declare.

Acknowledgment

We acknowledge the help of our researcher Ms. Meenakshi

Mohan who helped in the follow-up and compiling data of

these patients.

Fig. 4 e (A) Pre procedure score Modified Oswestry

disability index (MODI). (B) Post procedure MODI score. (C)

Pain recurrence rate.

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r e f e r e n c e s

1. Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI. Lumbarfacet pain: biomechanics, neuroanatomy andneurophysiology. J Biomech. 1996;29:1117e1129.

2. Stillwell DL. The nerve supply of the vertebral column and itsassociated structures in the monkey. Anat Rec.1956;125:136e169.

3. Borenstein D. Does osteoarthritis of the lumbar spine causechronic low back pain? Curr Pain Headache Rep.2004;8:512e517.

4. Long DM, BenDebba M, Torgerson TS, et al. Persistent backpain and sciatica in the United States: patient characteristics.J Spinal Disord. 1996;9:40e58.

5. Murtagh FR. Computed tomography and fluoroscopy guidedanesthesia and steroid injection in facet syndrome. Spine.1988;13:686e689.

6. Destouet JM, Gilula LA, Murphy WA, Monsees B. Lumbar facetjoint injection: indication, technique, clinical correlation andpreliminary results. Radiology. 1982;145:321e325.

7. Lau LS, Littlejohn GO, Miller MH. Clinical evaluation ofintra-articular injections for lumbar facet joint pain. Med JAust. 1985;143:563e565.

8. Moran R, O’Connell D, Walsh MG. The diagnostic value offacet joint injections. Spine. 1988;13:1407e1410.

9. Raymond J, Dumas JM. Intra-articular facet block: diagnostictest or therapeutic procedure? Radiology. 1984;151:333e336.

10. Lewinnek GE, Warfield CA. Clin Orthop Relat Res.1986;213:216e222.

11. Carrera GF. Lumbar facet joint injection in low back pain andsciatica: preliminary results. Radiology. 1980;137:665e667.

12. Mixter WJ, Barr JS. Rupture of the intervertebral disc withinvolvement of the spinal canal. N Engl J Med.1934;211:210e215.

13. Badgley CE. The articular facets in relation to low backpain and sciatic radiation. J Bone Joint Surg Am. 1941;23:481e496.

14. Hirsch C, Ingelmark BE, Miller M. The anatomical basis forlow back pain: studies on the presence of sensory nerveendings in ligamentous, capsular and intervertebral discstructures in the human lumbar spine. Acta Orthop Scand.1963;33:1e17.

15. Shealy CN. Percutaneous radiofrequency denervation ofspinal facets: treatment for chronic back pain and sciatica.J Neurosurg. 1975;43:448e451.

16. Shealy CN. Facet denervation in the management of back andsciatic pain. Clin Orthop. 1976;115:157e164.

17. Bough B, Thakore J, Davies M, Dowling F. Degeneration of thelumbar facet joints: arthrography and pathology. J Bone JointSurg Br. 1990;72:275e276.

18. Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N.The value of the provocation response in lumbarzygapophyseal joint injections. Clin J Pain. 1994;10:309e313.

19. Leone A, Aulisa L, Tamburrelli F, Lupparelli S,Tartaglione T. The role of computed tomography andmagnetic resonance in assessing degenerative arthropathyof the lumbar articular facets [in Italian]. Radiol Med.1994;88:547e5297.

20. Weishaupt D, Zanetti M, Boos N, Hodler J. MR imaging and CTin osteoarthritis of the lumbar facet joints. Skeletal Radiol.1999;28:215e219.

21. Park CH. Comparison of effectiveness of CT vs C-arm guidedpercutaneous radiofrequency lumbar facet rhizotomy. KoreanJ Pain. 2010 Jun;23(2):137e141.

22. Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of thelumbar spine: prevalence of intervertebral disk extrusion and

sequestration, nerve root compression, end plateabnormalities, and osteoarthritis of the facet joints inasymptomatic volunteers. Radiology. 1998;209:661e666.

23. Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N.A study of computer-assisted tomography: I. The incidence ofpositive CAT scans in an asymptomatic group of patients.Spine. 1984;9:549e555.

24. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT,Malkasian D, Ross JS. Magnetic resonance imaging of thelumbar spine in people without back pain. N Engl J Med.1994;331:69e73.

25. Hogan QH, Abram SE. Neural blockade for diagnosis andprognosis: a review. Anesthesiology. 1997;86:216e241.

26. Leclaire R, Fortin L, Lambert R, Bergeron YM, Rossignol M.Radiofrequency facet joint denervation in the treatment oflow back pain: a placebo controlled clinical trial to assessefficacy. Spine. 2001;26:1411e1417.

27. vanWijk RM, Geurts JW, Wynne HJ, et al. Radiofrequencydenervation of lumbar facet joints in the treatment of chroniclow back pain: a randomized, double-blind, sham lesioncontrolled trial. Clin J Pain. 2005;21:335e344.

28. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J,Bogduk N. Efficacy and validity of radiofrequency neurotomyfor chronic lumbar zygapophysial joint pain. Spine.2000;25:1270e1277.

29. van Kleef M, Barendse GA, Kessels A, Voets HM, WeberWE, deLange S. Randomized trial of radiofrequency lumbar facetdenervation for chronic low back pain. Spine.1999;24:1937e1942.

30. Bogduk N, Macintosh J, Marsland A. Technical limitations tothe efficacy of radiofrequency neurotomy for spinal pain.Neurosurgery. 1987;20:529e534.

31. Chua WH, Bogduk N. The surgical anatomy of thoracic facetdenervation. Acta Neurochir. 1995;136:140e144.

32. Vinas FC, Zamorano L, Dujovny M, et al. In vivo and in vitrostudy of the lesions produced with a computerizedradiofrequency system. Stereotact Funct Neurosurg.1992;58:121e133.

33. Yin W, Willard F, Carreiro J, Dreyfuss P. Sensory stimulation-guided sacroiliac joint radiofrequency neurotomy: techniquebased on neuroanatomy of the dorsal sacral plexus. Spine.2003;28:2419e2425.

34. Tzaan WC, Tasker RR. Percutaneous radiofrequency facetrhizotomy: experience with 118 procedures and reappraisalof its value. Can J Neurol Sci. 2000;27:125e130.

35. Dobrogowski J, Wrzosek A, Wordliczek J. Radiofrequencydenervation with or without addition of pentoxifylline ormethylprednisolone for chronic lumbar zygapophysial jointpain. Pharmacol Rep. 2005;57:475e480.

36. Kay J, Findling JW, Raff H. Epidural triamcinolone suppressesthe pituitaryeadrenal axis in human subjects. Anesth Analg.1994;79:501e505.

37. Ward A, Watson J, Wood P, Dunne C, Kerr D. Glucocorticoidepidural for sciatica: metabolic and endocrine sequelae.Rheumatology. 2002;41:68e71.

38. Alcock E, Regaard A, Browne J. Facet joint injection: a rareform of epidural abscess formation. Pain. 2003;103:209e210.

39. Orpen NM, Birch NC. Delayed presentation of septic arthritisof a lumbar facet joint after diagnostic facet joint injection.J Spinal Disord Tech. 2003;16:285e287, 255.

40. Gaul C, Neundorfer B, Winterholler M. Iatrogenic (para-)spinal abscesses and meningitis following injection therapyfor low back pain. Pain. 2005;116:407e410.

41. Goldstone JC, Pennant JH. Spinal anaesthesia following facetjoint injection: a report of two cases. Anaesthesia.1987;42:754e756.

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 0 5e2 1 0 209

42. Cohen SP. Postdural puncture headache and treatmentfollowing successful lumbar facet block. Pain Dig.1994;4:283e284.

43. Ogsbury JS, Simon RH, Lehman RA. Facet denervation in thetreatment of low back syndrome. Pain. 1977;3:257e263.

44. Katz SS, Savitz MH. Percutaneous radiofrequency rhizotomyof the lumbar facets. Mount Sinai J Med. 1986;53:523e525.

45. Schofferman J, Kine G. Effectiveness of repeatedradiofrequency neurotomy for lumbar facet pain. Spine.2004;29:2471e2473.

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