Percutaneous radiofrequency lumbar facet rhizotomy guided by computed tomography fluoroscopy

X-ray fluoroscopy-guided percutaneous radiofrequency facet rhizotomy is used to treat chronic low back pain. The traditional fluoroscopic approach to the medial branch of the posterior rami, however, is associated with a small incidence of complications. We describe a new method for radiofrequency lumbar facet rhizotomy in which computed tomography (CT) fluoroscopy is used to guide needle placement. Three patients with chronic intractable low back pain underwent CT fluoroscopy-guided percutaneous facet rhizotomy. After the safest and shortest route to the target site was determined on the CT image, the needle was advanced along the predetermined route under real-time CT fluoroscopy. When the needle tip was located at the target site, electrical stimulation was applied to verify proper electrode placement. After confirming the clinical effect and lack of complications under test block with a local anesthetic, denervation was performed using radiofrequency current. Pain scores of all patients were reduced after the procedure without any complications such as paralysis or neuritic pain. None of the patients complained of severe discomfort during the procedure. CT fluoroscopy-guided percutaneous lumbar facet rhizotomy appears to be safe, fast, and effective for patients with lumbar facet pain.     

内窥镜下脊神经背内侧支切断术治疗腰椎小关节综合征的临床疗效分析

目的探讨内窥镜下脊神经背内侧支切断术治疗腰椎小关节综合征的临床疗效。方法选择2012-08-2015-03我院诊治的腰椎小关节综合征患者78例,根据随机抽签原则分为观察组与对照组各39例,对照组给予局部封闭保守治疗,观察组给予内窥镜下脊神经背内侧支切断术治疗。结果所有患者均完成治疗,观察组术中见脊神经背内侧支存在多种变异;经过评定,两组治疗后1 d和3个月的疼痛评分均明显低于治疗前(P0.05),同时观察组治疗后3个月的疼痛评分也明显低于对照组(P0.05)。观察组治疗3个月内的神经根损伤、皮肤感觉功能缺失、疼痛性感觉迟钝、肺部感染等并发症发生情况明显少于对照组(P0.05)。治疗3个月后,观察组的优良率为94.9%,对照组为76.9%,观察组的优良率明显高于对照组(P0.05)。结论内窥镜下脊神经背内侧支切断术治疗腰椎小关节综合征,有明显的镇痛效果,术后并发症少。     

Percutaneous radiofrequency rhizotomy of lumbar spinal facets: The results of 46 cases

The results of percutaneous radiofrequency rhizotomy of lumbar spinal facets in 46 patients followed at least three months (mean 15 months) are reported and compared with those reported previously. Satisfactory pain relief three months after the procedure was achieved in 36.4 percent of patients without operations and in 41.7 percent of patients with operations other than fusion.No patient had previously undergone fusion.Treatment of low-back pain by using radio-frequency thermocoagulation of spinal facets is a simple, safe, and well-tolerated procedure. It can be used to relief of pain in spite of decreasing rates of success within the follow-up period.     

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain

Purpose

Chemical denervation is not recommended as part of the routine care of chronic non-cancer pain. Physicians face a dilemma when it comes to repeated interventions in cases of recurrent thoracolumbar facet joint pain after successful thermal radiofrequency ablation (RFA) in medial branch neurotomy. This study was performed to compare the effects of alcohol ablation (AA) with thermal RFA in patients with recurrent thoracolumbar facet joint pain after thermal RFA treatment.

Methods

Forty patients with recurrent thoracolumbar facet joint pain after successful thermal RFA defined as a numeric rating scale (NRS) score of ≥7 or a revised Oswestry disability index (ODI) of ≥22 % were randomly allocated to two groups receiving either the same repeated RFA (n = 20) or AA (n = 20). The recurrence rate was assessed with NRS and ODI during the next 24 months, and adverse events in each group were recorded.

Results

During the 24-month follow-up after RFA and AA, one and 17 patients, respectively, were without recurring thoracolumbar facet joint pain. The median effective periods in the RFA and AA groups were 10.7 (range 5.4–24) and 24 (range 16.8–24) months, respectively (p < 0.000). No significant complications were observed with the exception of injection site pain, which occurred in both groups.

Conclusion

In our patient cohort, alcohol ablation in medial branch neurotomy provided a longer period of pain relief and better quality of life than repeated radiofrequency medial branch neurotomy in the treatment of recurrent thoracolumbar facet joint pain syndrome after successful thermal RFA without significant complications during the 24-month follow-up.     

经皮内镜下胃造口术（附6例报告）

目的 探索用微创法行胃造口术。方法 在胃镜引导下，穿刺点选择在胃体的大、小弯之间。局麻下，给6位需长期行肠内营养的患，行经皮穿刺胃造口术。结果 从置入胃镜到胃造口术完成中需10-15分钟，术中和术后均无出血、消化液漏入腹腔等并发症。结论 经皮内镜下胃造口术是一种创伤小、安全性大、手术时间短的胃造口方法。     

经皮脊神经背内侧支毁损术治疗腰椎术后慢性腰痛

[目的]观察经皮脊神经背内侧支毁损术治疗腰椎术后慢性腰痛的临床疗效。[方法] 2015年8月～2017年5月,收治腰椎术后慢性腰痛患者43例,所有患者均经对照性诊断封闭确诊。根据患者选择及知情同意,20例行经皮脊神经背内侧支毁损术治疗(射频消融组),23例采用神经阻滞术治疗(神经阻滞组)。所有患者治疗前后随访时应用视觉模拟评分(VAS评分)、腰椎Oswestry功能障碍指数(ODI指数)及患者满意度(PSI)评价治疗效果,并行腰椎动力位X线片检查,测量腰椎活动度(ROM)。[结果]所有患者获得6～32个月的随访。治疗后1周,两组VAS评分、ODI指数及腰椎整体ROM明显优于治疗前(P0.05),但两组间在2个时间点的差异均无统计学意义(P0.05)。此后,射频消融组各指标随时间延长持续改善,而神经阻滞组各指标显著恶化,治疗后1、3个月及末次随访时射频消融组上述指标显著优于神经阻滞组,差异均有统计学意义(P0.05)。末次随访时,射频消融组的患者满意度[(1.75±0.77) vs(2.70±0.86),P0.05]和治疗有效率(90.00%vs 39.13%,P0.05)显著优于神经阻滞组。[结论]经皮脊神经背内侧支毁损术是治疗腰椎术后慢性腰痛安全、有效的方法,疗效优于传统局部神经阻滞方法。     

Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis.

BACKGROUND CONTEXT: The publication of several recent studies showing minimal benefit for radiofrequency (RF) lumbar zygapophysial (l-z) joint denervation have led many investigators to reevaluate selection criteria. One controversial explanation for these findings is that the most commonly used cutoff value for selecting patients for l-z (facet) joint RF denervation, greater than 50% pain relief after diagnostic blocks, is too low and hence responsible for the high failure rate. PURPOSE: To compare l-z joint RF denervation success rates between the conventional greater than or equal to 50% pain relief threshold and the more stringently proposed greater than or equal to 80% cutoff for diagnostic medial branch blocks (MBB). STUDY DESIGN/SETTING: Multicenter, retrospective clinical data analysis. PATIENT SAMPLE: Two hundred and sixty-two patients with chronic low back pain who underwent l-z RF denervation at three pain clinics. OUTCOME MEASURES: Outcome measures were greater than 50% pain relief based on visual analog scale or numerical pain rating score after RF denervation persisting at least 6 months postprocedure, and global perceived effect (GPE), which considered pain relief, satisfaction and functional improvement. METHODS: Data were garnered at three centers on 262 patients who underwent l-z RF denervation after obtaining greater than or equal to 50% pain relief after diagnostic MBB. Subjects were separated into those who received partial (greater than or equal to 50% but less than 80%) and near-complete (greater than or equal to 80%) pain relief from the MBB. Outcomes between groups were compared with multivariate analysis after controlling for 14 demographic and clinical variables. RESULTS: One hundred and forty-five patients obtained greater than or equal to 50% but less than 80% pain relief after diagnostic MBB, and 117 patients obtained greater than or equal to 80% relief. In the greater than or equal to 50% group, success rates were 52% and 67% based on pain relief and GPE, respectively. Among patients who experienced greater than 80% relief from diagnostic blocks, 56% obtained greater than or equal to 50% relief from RF denervation and 66% had a positive GPE. CONCLUSIONS: Using more stringent pain relief criteria when selecting patients for l-z joint RF denervation is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment from good candidates.     

脊柱内窥镜下腰脊神经背内侧支射频消融术治疗慢性腰椎小关节源性腰痛

目的探讨脊柱内窥镜下腰脊神经背内侧支射频消融术治疗中老年慢性腰椎小关节源性腰痛的近期疗效。方法采用回顾性队列研究的方法,选取2015年9月—2017年9月杭州市中医院收治的28例慢性腰椎小关节源性腰痛患者,其中14例采用脊柱内窥镜下腰脊神经背内侧支射频消融术治疗(手术组),14例采用经皮腰椎关节突关节封闭治疗(非手术组)。分别对2组患者进行电话、门诊随访,记录治疗前及治疗后1周、1个月、3个月、6个月、1年的腰痛视觉模拟量表(VAS)评分、日本骨科学会(JOA)评分和Oswestry功能障碍指数(ODI)并进行比较,评估2种治疗方案近期疗效的差异。结果治疗前2组患者VAS评分、JOA评分和ODI差异均无统计学意义(P 0.05)。治疗后2组患者各时间点VAS评分、JOA评分和ODI均较治疗前改善,其中手术组与治疗前相比差异有统计学意义(P 0.05);手术组患者VAS评分、JOA评分和ODI的改善情况均优于非手术组,差异有统计学意义(P 0.05)。结论脊柱内窥镜下腰脊神经背内侧支射频消融术治疗慢性腰椎小关节源性腰痛能够显著缓解患者症状、改善预后,近期疗效较好,相比经皮腰椎关节突关节封闭具有一定优势。     

Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain

STUDY DESIGN: A prospective audit. OBJECTIVE: To establish the efficacy of lumbar medial branch neurotomy under optimum conditions. SUMMARY OF BACKGROUND DATA: Previous reports of the efficacy of lumbar medial branch neurotomy have been confounded by poor patient selection, inaccurate surgical technique, and inadequate assessment of outcome. METHODS: Fifteen patients with chronic low back pain whose pain was relieved by controlled, diagnostic medial branch blocks of the lumbar zygapophysial joints, underwent lumbar medial branch neurotomy. Before surgery, all were evaluated by visual analog scale and a variety of validated measures of pain, disability, and treatment satisfaction. Electromyography of the multifidus muscle was performed before and after surgery to ensure accuracy of the neurotomy. All outcome measures were repeated at 6 weeks, and 3, 6, and 12 months after surgery. RESULTS: Some 60% of the patients obtained at least 90% relief of pain at 12 months, and 87% obtained at least 60% relief. Relief was associated with denervation of the multifidus in those segments in which the medial branches had been coagulated. Prelesion electrical stimulation of the medial branch nerve with measurement of impedance was not associated with outcome. CONCLUSIONS: Lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. Adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. Electrical stimulation before lesioning is superfluous in assuring correct placement of the electrode.     

Percutaneous cryodenervation of lumbar facet joints: a prospective clinical trial

Facet joint pain is an important aspect of degenerative lumbar spine disease, and radiofrequency medial branch neurotomy remains an established therapy, while cryodenervation has still been poorly examined. This study was undertaken to examine the effects of medial branch cryodenervation in the treatment of lumbar facet joint pain. This was a prospective clinical case series. Patient selection was based on the history, physical examination and positive medial branch blocks. Percutaneous medial branch cryodenervation was performed using a Lloyd Neurostat 2000. Target parameters were low back pain (VAS), limitation of activity (McNab) and overall satisfaction. Fifty patients were recruited, and 46 completed the study. The follow-up time was 1 year. At 6 weeks, 33 patients (72%) were pain free or had major improvement of low back pain; 13 (28%) had no or little improvement. Including failures, mean low back pain decreased significantly from 7.7 preoperatively to 3.2 at 6 weeks, 3.3 at 3 months, 3.0 at 6 months and 4.2 at 12 months (P<0.0001). Limitation of the activities of daily living improved parallel to reduced pain. Our results suggest that medial branch cryodenervation is a safe and effective treatment for lumbar facet joint pain.     

肾上腺髓脂瘤(附六例报告)

目的：探讨肾上腺髓脂瘤的临床与病理特点。方法：对6例肾上腺髓脂瘤患者的临床表现、实验室检查、影像学和病理检查等资料进行分析。结果：6例患者临床表现腰部或胁肋部不适、隐痛或胀痛；伴肥胖2例，伴高血压4例。影像学检查特征为有脂肪组织，伴软组织影、出血灶、钙化及残留肾上腺组织等。6例均行肾上腺和肿瘤切除术，病理检查显示肿瘤由成熟脂肪细胞和骨髓造血细胞组成。随访6个月-7年，临床症状消失，无肿瘤复发。结论：CT、MRI检查有助于肾上腺髓脂瘤的术前诊断，病理检查见成熟脂肪细胞与骨髓造血细胞相互交错为其特点。