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| CASE REPORT |
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| Year : 2022 | Volume
: 36
| Issue : 1 | Page : 49-52 |
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Cooled radiofrequency ablation of cervical medial branches for treatment of facetogenic pain
Nithya Dinesh, Rajat Gupta, Deep Divanshu Lall, Ashu Kumar Jain
Department of Pain Medicine and Palliative Care, Artemis Hospital, Gurugram, Haryana, India
| Date of Submission | 29-Oct-2021 |
| Date of Decision | 30-Nov-2021 |
| Date of Acceptance | 03-Jan-2022 |
| Date of Web Publication | 25-Apr-2022 |
Correspondence Address:
Dr. Nithya Dinesh
Room Number 1023, Ground Floor OPD, Department of Pain Medicine and Palliative Care, Artemis Hospital, Gurugram, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijpn.ijpn_87_21
In cervical spine, the anatomical course of medial branch in significantly different and thermal radiofrequency ablation (RFA) of the cervical median branch though proven effective is technically challenging. Cooled RFA (CRFA) is a newer revolutionary technique that creates a larger spherical lesion and thus compensates for the anatomical variability of the medial branches in the cervical spine. Our case report is aimed to discuss the technique of CRFA for the treatment of cervical facetogenic pain. Right C2–C5 medial branch CRFA was done under fluoroscopic guidance under monitored anesthesia care using 17G with 75 mm length and 2 mm active tip cooled radiofrequency cannula. After 8 weeks of follow-up, the patient reported 80% pain relief.
Keywords: cervical facetogenic pain, cooled radiofrequency ablation, radiofrequency ablation, thermal radiofrequency ablation
How to cite this article:
Dinesh N, Gupta R, Lall DD, Jain AK. Cooled radiofrequency ablation of cervical medial branches for treatment of facetogenic pain. Indian J Pain 2022;36:49-52 |
How to cite this URL:
Dinesh N, Gupta R, Lall DD, Jain AK. Cooled radiofrequency ablation of cervical medial branches for treatment of facetogenic pain. Indian J Pain [serial online] 2022 [cited 2023 Mar 31];36:49-52. Available from: https://www.indianjpain.org/text.asp?2022/36/1/49/343832 |
| Introduction | |  |
Evidence supports radiofrequency ablation (RFA) of trhe medial branches for providing symptomatic relief of chronic neck pain.[1],[2],[3]
In thermal RFA (TRFA), the electrodes are to be placed parallel to the medial branches for effective lesioning.[2]
Successful denervation of all the medial branches may not be completely possible by TRFA, and doing multiple lesioning in the cervical region increases the risk of procedure.[4],[5]
Cooled RFA (CRFA) is a new technique which is based on heat neurotomy (60°C vs. 70°C–80°C in TRFA) with the resulting ablative area twice as long and extending distally from the tip of the electrode.[5]
| Case Report | | |
A 50-year-old female patient presented with right-sided neck and referred pain to shoulder and headache for the past 1 year.
It was intermittent, moderate in intensity (Numerical rating score (NRS) 7/10), increased with neck movements while relieved with lying down.
There was no associated numbness or tingling in the area of pain.
On examination, bilateral C2–C5 paraspinal tenderness (right >>left) was present and bilateral trapezius trigger points were present, with negative provocative tests (spurling, shoulder abduction relief test, neck distraction test, Jackson's compression test, Lhermitte's sign).
There were no associated sensory or motor deficits.
History was unremarkable for known comorbidities.
Laboratory investigations were within normal limits.
Radiologically, X-ray of the cervical spine revealed straightening of the cervical spine with degenerative changes and multiple level osteophytes (C2–C6) [Figure 1]. Magnetic resonance imaging was suggestive of mild prolapsed intervertebral disc at C3–C5 with no significant nerve root compression [Figure 2]. | Figure 1: X-ray of the cervical spine straightening of cervical spine, degenerative changes - multiple osteophytes
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 | Figure 2: Magnetic resonance imaging cervical spine prolapsed intervertebral disc C3–C6
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Hence, we diagnosed the case as cervical facetogenic pain syndrome.
The patient was refractory to medical management (not responding to physiotherapy, chiropractors, anti-inflammatory, and muscle relaxants); hence, we planned a right C2–C5 medial branch diagnostic block followed by RFA under monitored anesthesia care and fluoroscopic guidance.
The patient was explained about the procedures and informed consent was taken.
Following the preprocedure checklist, the diagnostic block was performed under fluoroscopic guidance with 0.5 cc of lignocaine 1% at each level. Postprocedure, the patient reported more than 80% relief in pain for a duration of 6–8 h, and hence, a confirmed diagnosis of right-sided cervical facetogenic pain was made. The next day, the patient was taken up for RFA.
On the day of procedure, baseline vitals were recorded.
A 20G intravenous (IV) cannula was placed on the left hand and IV ceftriaxone 1 g was given after a test dose ½ h before the procedure. Antiemetic and IV pantoprazole 40 mg were also given before procedure.
In the Cath lab standard monitors were placed and the patient was positioned in Left- modified Swimmer's position. The target vertebrae were squared and articular pillars were superimposed with appropriate fluoroscopic orientation.
Under strict aseptic precautions, parts were prepared and draped.
Under local anesthesia, a 17G cooled radiofrequency (RF) cannula, with 75 mm length and 2 mm active tip, was inserted at the right C2–C5 articular pillars in the lateral view [Figure 3] and [Figure 4]. | Figure 3: Right C2–C3 electrodes being placed in modified swimmer's view under fluoroscopic guidance
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 | Figure 4: Right C4–C5 electrodes being placed in modified swimmer's view under fluoroscopic guidance
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The tips of the cannula were placed at the centroid of the articular pillar [Figure 5] and [Figure 6]. | Figure 6: Right C4–C5 electrodes being placed in modified swimmer's view under fluoroscopic guidance
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The final position was confirmed on the anteroposterior view [Figure 7].
Once the electrodes were appropriately positioned, the stylet was replaced by the RF probe. The final stimulation requirements were as follows:
- Sensory stimulation (50 Hz) threshold was less than 0.5 V that created paresthesia/pain which was concordant to the respective dermatomal distribution
- Motor stimulation was done at thrice the sensory stimulation to rule out the involvement of the selective nerve root at the level
- Impedance was checked to ensure a complete electrical circuit and they ranged from 200 to 400 Ohms [Figure 8].
Following that , 0.5ml of 1% Xylocaine was given before lesioning at each level. The cooled RF lesioning was done at 60° for 2.5 min.
Before drug delivery, cannula positions were again confirmed with 0.5 cc of omnipaque dye injected under live fluoroscopy.
Thereafter, 1.0 cc of drug containing 1 mg of dexamethasone with 0.25% bupivacaine was injected at each level after negative aspiration of blood/cerebrospinal fluid.
The patient was shifted to the recovery room in stable position.
Postprocedure, IV paracetamol 1 g was given and cold packs were placed at procedural site. Hemodynamic parameters were stable, and postprocedure, the patient was monitored in the recovery room for 2 h.
The patient is on regular follow-up for the past 2 weeks. She reports 80% pain relief postprocedure and her visual analog scale score is 2/10. She still reports 80% pain relief (at 8 weeks of follow-up) and is doing active physiotherapy.
| Discussion | | |
To our knowledge, this is the first clinical case to report the efficacy of CRFA for the treatment of cervical facetogenic pain.
There is evidence that TRFA of the medial branches provides symptomatic relief for chronic pain originating from the facet joint in the cervical, thoracic, and lumbar regions.[5]
However, there are only few studies comparing TRFA versus CRFA in the lumbar and thoracic, but none in the cervical region.[5]
Cervical medial branch RFA is a minimally invasive technique for the treatment of cervicogenic headache and chronic neck pain.[5]
The most important complication is injury to nerve root and vertebral artery.
In pulsed RFA, the electrodes are placed perpendicular to the nerve which is technically easier. However, the duration of pain relief in pulsed RFA for the cervical median branch is debatable.[6]
CRFA is a new technique which is based on heat neurotomy (60°C vs. 70°C–80°C in TRFA) with water circulation around the electrode tip causing a larger spherical ablative area with the resulting area twice as long and extending distally from the tip of the electrode.[5]
This compensates for the anatomic variability of the medial branches in the cervical spine.
CRFA has similar electrode (perpendicular needle) placement as pulsed RFA, thus making it technically easier compared to TRFA.[5]
CRFA produces comparable lesion as TRFA.[5]
The most important complication in CRFA is the skin burn which is avoided by using a smaller active tip of 2 mm and positioning the active tip in the middle third of rhomboid.
In view of paucity of literature in CRFA in the cervical region, further studies are warranted.
We propose CRFA as a potentially more effective treatment alternative for cervical facet-mediated pain, with potential advantages including the ability to create larger lesion, providing easier access to the nerves, and shortened fluoroscopic exposure.
There might be a possibility of this procedure be done elsewhere, but there are no trials or case reports available.
We report one such case done by us, perhaps the first and only case done till date in India!
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Zundert J, Patijn J, Hartrick C, Huygen F, Mekhail N, Kleef M. Evidence-Based Interventional Pain Medicine. Chichester: John Wiley & Sons; 2012.  |
| 2. | Engel A, Rappard G, King W, Kennedy DJ; Standards Division of the International Spine Intervention Society. The effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy: A systematic review with comprehensive analysis of the published data. Pain Med 2016;17:658-69. |
| 3. | Poetscher AW, Gentil AF, Lenza M, Ferretti M. Radiofrequency denervation for facet joint low back pain: A systematic review. Spine (Phila Pa 1976) 2014;39:E842-9. |
| 4. | Engel A, King W, Schneider BJ, Duszynski B, Bogduk N. The effectiveness of cervical medial branch thermal radiofrequency neurotomy stratified by selection criteria: A systematic review of the literature. Pain Med 2020;21:2726-37. |
| 5. | Gungor S, Candan B. The efficacy and safety of cooled-radiofrequency neurotomy in the treatment of chronic thoracic facet (zygapophyseal) joint pain: A retrospective study. Medicine (Baltimore) 2020;99:e19711. |
| 6. | Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep 2008;12:37-41. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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