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Clinical Predictors of Success and Failure for Lumbar Facet Radiofrequency Denervation Steven P

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Clinical Predictors of Success and Failure for Lumbar Facet Radiofrequency Denervation Steven P ORIGINAL ARTICLE Clinical Predictors of Success and Failure for Lumbar Facet Radiofrequency Denervation Steven P. Cohen, MD,*w Robert W. Hurley, MD, PhD,* Paul J. Christo, MD,* James Winkley, MD,w Meraj M. Mohiuddin, MD,z and Milan P. Stojanovic, MDz with chronic low back complaints.1,2 Whereas previous Objective: To determine the clinical factors associated with the small, uncontrolled studies proposed a ‘‘lumbar facet success and failure of radiofrequency denervation of the lumbar syndrome’’ based on a scoring system composed of facet joints. historical and physical exam findings,3 larger, better designed studies failed to identify a set of clinical features Methods: Clinical data were garnered from 3 academic medical 4,5 centers on 192 patients with low back pain who underwent predictive of response to controlled blocks. It is now radiofrequency denervation after a positive response to diag- widely accepted that the only valid method to diagnose nostic blocks. Success was defined as Z50% pain relief lasting the lumbar facet joints as definitive pain generators is at least 6 months. Factors evaluated for their association with through the use of either diagnostic intra-articular z-joint injections or blockade of the medial branches and L5 outcome included duration of pain, opioid use, symptom 6 location, paraspinal tenderness, pain exacerbated by extension/ primary dorsal rami (MBB) that innervate the joints. rotation (ie, facet loading), MRI abnormalities, diabetes, Whereas these 2 techniques are widely believed to provide smoking, scoliosis, obesity, prior surgery and levels treated. comparable diagnostic utility, the evidence supporting this notion is based on only 2 randomized studies, neither Results: The only factor associated with a successful outcome of which used a crossover design or prescreened patients was paraspinal tenderness. Variables that correlated with for lumbar z-joint pain.7,8 Because the medial branches treatment failure were ‘facet loading,’ long duration of pain, innervate not only the lumbar z-joints but also the and previous back surgery. multifidus muscle, the interspinous ligament and muscle, 9 Conclusions: It is counterproductive to use ‘facet loading’ as the and the periosteum of the neural arch, one might infer sole basis for choosing patients for facet interventions. In that diagnostic MBB are inherently less specific than low- patients at high risk for treatment failure, taking additional volume intra-articular injections. However, in the absence steps to reduce the rate of false-positive screening blocks may of any definitive treatment or gold standard for diagnosis, improve outcomes. this supposition is impossible to prove. Two reasons many practitioners cite as the rationale for performing Key Words: facet joint, low back pain, medial branch block, MBB in lieu of intra-articular injections are that they are predictive value, radiofrequency, zygapophysial joint easier to perform and serve as a trial run before medial (Clin J Pain 2007;23:45–52) branch radiofrequency (RF) denervation. In any case, the utility of both types of blocks is limited by the high rate of false-positive results, estimated to be between 25% and 1,10 umbar zygapophysial joint (z-joint) pain is a common 38%. Lcause of axial low back pain (LBP), with an estimated Until recently, the assertion that RF denervation of prevalence ranging between 15% and 40% in patients the medial branches and L5 dorsal rami provided intermediate to long-term pain relief for lumbar facet pain went largely unchallenged, as 2 controlled and Received for publication January 7, 2006; accepted August 8, 2006. numerous uncontrolled studies supported its efficacy.11–13 From the *Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Yet in the past 6 years, 2 double-blind, placebo-controlled Baltimore, MD; wDepartment of Surgery, Walter Reed Army studies have been published showing no or minimal Medical Center, Washington, DC; and zPain Management Division, benefit for RF denervation compared to sham lesion- Department of Anesthesiology and Critical Care, Massachusetts ing.14,15 There are several possible explanations for this General Hospital, Harvard Medical School, Boston, MA discrepancy, with the 2 most likely ones being methodo- This study was supported by a Congressional grant from the John P. Murtha Neuroscience and Pain Institute, Johnstown, PA, and the logical flaws in the earlier studies leading to invalid U.S. Army. conclusions, and the failure of later studies to properly The opinions or assertions contained herein are the private views of the identify the best candidates for RF denervation. In the authors and are not to be construed as official or as reflecting the United States, facet joint interventions are the second views of the Dept of the Army or the Dept of Defense. most commonly performed pain management procedures, Reprints: Steven P. Cohen, MD, 550 North Broadway, Suite 301, 16 Baltimore, MD 21029 (e-mail: [email protected]). ranking just behind epidural steroid injections. It is thus Copyright r 2006 by Lippincott Williams & Wilkins surprising that among the plethora of research conducted Clin J Pain Volume 23, Number 1, January 2007 45 Cohen et al Clin J Pain Volume 23, Number 1, January 2007 on facet arthropathy, no studies have sought to identify RF Denervation what factors predict a successful outcome for facet joint RF denervation was performed as an ambulatory RF denervation, and which characteristics predispose procedure using superficial local anesthesia and if patients to failure. The purpose of this study is to identify necessary, intravenous sedation. With the C-arm which demographic and clinical variables are associated intensifier positioned to confer a slightly oblique or with a positive outcome after lumbar medial branch and antero-posterior view, 22-gauge SMK-C10 (Radionics, L5 dorsal ramus RF lesioning. Burlington, MA) cannulas with 5-mm active tips were inserted parallel to the course of the nerve until the bone was contacted at the junction between the superior border of the transverse process and the superior articular PATIENTS AND METHODS process for all medial branch lesions, and at the junction After obtaining permission to conduct this study of the ala and articular process of the sacrum for all L5 from the Internal Review Boards at 3 different institu- dorsal ramus lesions. For each lesion, correct placement tions, Walter Reed Army Medical Center (WRAMC), was confirmed using electrostimulation at 50 Hz, with The Johns Hopkins Medical Institutions (JHMI), and concordant sensation achieved at r0.5 V. Before lesion- Massachusetts General Hospital (MGH), the medical ing, multifidus stimulation and the absence of leg records of 216 consecutive patients who underwent contractions was verified with electrostimulation at medial branch and L5 dorsal rami RF denervation 2 Hz. After satisfactory electrode placement, 0.5 mL of between January 2004 and May 2005 for suspected lidocaine 1% was injected through each cannulae to lumbar facet joint pain were reviewed. Twenty-four reduce thermal pain. The RF probe was then reinserted patients with ambiguous or missing medical records were and a 90-second, 801C lesion was made using an RF excluded, leaving 192 patients eligible for inclusion. generator (Electrothermal 20S Spine System, Smith Z Inclusion criteria for RF denervation were age 18 and Nephew, Andover, MA or Radionics RF Lesion Z years, chronic LBP 3 months duration, absence of Generator System, Model RFG-3C, Radionics, Valleylab, Z focal neurologic signs or symptoms, and 50% pain Boulder, CO). relief after diagnostic MBB. Excluded from the study were patients with a known, specific cause of LBP (eg, spondylolisthesis or significant spinal stenosis), untreated Outcome Measures and Statistical Analysis coagulopathy, or concomitant medical (eg, poorly con- All pain scores were measured using 0-10 visual trolled cardiac condition) or psychiatric illness (as analog scale (VAS) pain scores. A successful treatment determined historical findings, and prescreening Beck was defined as a Z50% average (proportioning rest and Depression Inventory) likely to compromise evaluation or activity scores) reduction in preprocedure VAS pain score treatment. that persisted at least 6 months after the procedure. In addition to treatment outcome, the other demographic and clinical variables recorded for analysis were age, sex, Lumbar Medial Branch and L5 Dorsal duration of pain, opioid usage, location of symptoms, Ramus Blocks presence of paraspinal tenderness (pain overlying the Diagnostic MBB were performed using our pre- facet joints with an estimated 4 kg of applied force), viously described single17,18 and multiple needle19 techni- presence of pain exacerbation with extension and/or axial ques. Before needle placement, the skin at each entry rotation (facet loading), MRI evidence of lumbar facet point was anesthetized using r1 mL of lidocaine 1%. joint hypertrophy or degeneration, history of diabetes, Patient with unilateral pain underwent unilateral blocks; smoking history, scoliosis, obesity (body mass index those with bilateral or central pain received bilateral Z30), prior back surgery, number of levels denervated, blocks. The number of levels blocked varied according to and for procedures done at WRAMC, active duty the patient’s symptoms. Correct needle placement was status. confirmed in both antero-posterior and oblique fluoro- For the WRAMC patient subset, a secondary scopic
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