1. PERCUTANEOUS RF NEUROTOMY IS EFFECTIVE IN THE TREATMENT OF FACET JOINT SYNDROME Stefano Marcia, MD, A. Cauli, S. Marini, E. Piras, M. Marras Radiology University of Cagliari, Italy San Giovanni di Dio Hospital Chairman: Prof. Giorgio Mallarini

2. Consultant of Stryker Disclosure

3. Facet Joint Syndrome is a mechanical chronic low back pain characterised by stiffness and pain that increase with twisting and bending backwards It affects mainly adult subjects and its precise incidence is not defined Its main cause is osteoarthritis of the zygapophysial joints INTRODUCTION

4. FACET JOINT SYNDROME Mechanical back pain Low back stiffness Aggravated by rest, worse in the morning, and relived by repeated gentle motion Pain is centered in the hips, buttocks or thights, does not extend below knees, has no radicular pattern, and is aggravated by hyperextension Straight leg raise usually negative

5. FACET JOINT SYNDROME Poor correlation between duration and severity of pain and extent of facet degeneration Facet disease may be asymptomatic incidental finding on imaging Pain is related to irritation of joint innervation, because of capsular distension, inflammatory synovitis, entrapment of synovial villi between two articular processes, or actual nerve impingement by osteophytes

6. Anatomy: relevant nerves L4 DORSAL RAMUS OF SPINAL NERVE MEDIAL BRANCH INFERIOR ARTICOLAR BRANCH LATERAL BRANCH L5 L3 SUPERIOR ARTICOLAR BRANCH

7. Radiological signs

8. MRI Gd Enhancing inflammatory soft tissues changes surrounding facet joints Radiological signs

9. heat ablation of the lumbar medial branch responsible for the sensitivity of facet joints, in order to interrupt nerve conduction, using an electrode needle positioned under CT or fluoroscopic guide Percutaneous radiofrequency neurotomy

10. Leclaire R, Fortin L, Lambert R, Bergeron YM, Rossignol M: Radiofrequency facet joint denervation in the treatment of low back pain. Spine 2001; 26(13):1411-7 Schoffermann J, Kine G: Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine 2004; 29(21):2471-3 Nath S, Nath CA, Pettersson K: Percutaneous lumbar zygapophisial joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial. Spine 2008; 33(12):1291-7 Cohen SP, Raja SN: Pathogenesis, diagnosis, and treatment of lumbar zygapophysial(facet) joint pain. Anesthesiology 2007; 106:591-614 Chou R, Atlas SJ, Stanos SP, Rosenquist RW: Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical pratice guideline. Spine 2009

11. Radiofrequency denervation of the lumbar medial branch after accurate selection of patients and after precise positioning of the electrode-needle by means of neurophisiological testing long term pain relief PURPOSE

12. Patients selection Lumbar pain with typical signs of facet joint syndrome for at least 6 months Little response to pharmacological and physiotherapic treatment Degeneration of zygapophysial joints detected by Xray, CT and MRI Gd Absence of neurological signs EMG negative Anesthetic block

13. - Local or systemic infections - Coagulation disorders Controindications

14. CT suiteAngiographic suite Material and methods

16. Technique: - Prone position - Choice of the cutaneous site - Local anestesia - Introduction of the needle and insertion of the electrode - Verification of the correct position - Neurotomy Material and methods

17. Targets Material and methods Between the transverse and articular process!

18. Targets L5S1 (L5 dorsal ramus) Material and methods On the ala of the sacrum just lateral to the articular process!

19. Material and methods Needle positioning under fluoroscopic guide (length 100 mm exposed tip 5-10 mm)

20. Material and methods Needle positioning under fluoroscopic guide: operative position

21. Material and methods Needle positioning under fluoroscopic guide: operative position

22. Material and methods Needle positioning under fluoroscopic guide: operative position

23. Material and methods Needle positioning under fluoroscopic guide: operative position L5S1

24. Needle positioning under CT guide Material and methods

25. Insertion of the electrode Material and methods

26. Impedence values between 200 e 800 Ohms are significant for the correct target NEUROPHISIOLOGICAL CHECK Material and methods

27. SENSORIAL STIMULATION TEST Parameter settings: Frequency 50hz Intensity 0,2 – 0,7V NEUROPHISIOLOGICAL CHECK Material and methods - Confirms proximity of electrode to sensory fibers - Reproduces patient’s ‘typical pain’

28. Frequency 2hz Intensity 0,2 – 1V Material and methods NEUROPHISIOLOGICAL CHECK MOTORIAL STIMULATION TEST Parameter settings: - Confirms lesion will not damage motor nerves - No limb motion

29. Neurotomy Material and methods Parameter settings: 90° for 60”

30. Material and methods Patients : 45 Mean age: 70.3±13.0 Joints: 54 Fluoroscopic Guide: 44 CT Guide: 10

31. Follow up Material and methods Clinical evaluation VAS 0-10 analysis baseline and 1w, 1m, 6m, 12m after the procedure ODI 0-100% questionnaire baseline and 1m, 6m, 12m after the procedure

32. +1,1 -1,1 +2,1 -2,1 Results PAIN REDUCTION: VAS 0-10 (p<0.0001)

33. Results PAIN REDUCTION: use of analgesic drugs

34. Results Oswestry Disability Index(ODI) (p<0.0001)

35. No procedural complications No infections Results

36. Conclusions Lumbar medial branch neurotomy by means of RFD is an effective and safe procedure in reducing chronic back pain in patients with facet joint syndrome

37. stefanomarcia@aoucagliari.it Thank you