Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Radio-frequency neurotomy provided lasting relief for chronic cervical joint pain

ACP J Club. 1997 May-Jun;126:71. doi:10.7326/ACPJC-1997-126-3-071


Source Citation

Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996 Dec 5;335:1721-6.


Abstract

Objective

To evaluate the effectiveness of percutaneous radio-frequency neurotomy in relieving pain in patients with chronic cervical zygapophyseal-joint pain.

Design

Randomized, double-blind, controlled trial with at least 52 weeks of follow-up.

Setting

Cervical Spine Research Unit, a tertiary referral center in Newcastle, Australia.

Patients

24 patients (mean age 44 y, 63% women) who had pain in ≥ 1 cervical zygapophyseal joint lasting > 3 months after a motor vehicle accident, had tried conventional therapy without success, had been referred by a medical practitioner, and had their perception of pain confirmed by placebo-controlled diagnostic blocks. Patients with C2-3 zygapophyseal-joint pain were excluded. All patients completed the study.

Intervention

12 patients were allocated to percutaneous radio-frequency neurotomy in which multiple lesions were made and the temperature of the electrode making the lesions was raised to 80°C for 90 seconds. 12 patients were allocated to a control treatment using an identical procedure except that the radio-frequency current was not turned on.

Main outcome measures

The number of patients free of pain, and the time to the return of ≥ 50% of the preoperative level of pain.

Main results

The median time to the return of ≥ 50% of the preoperative level of pain was 263 days in the active-treatment group and 8 days in the control group (P = 0.04). By 27 weeks, 7 patients (58%) in the active-treatment group remained free of pain compared with 1 patient (8%) in the control group { P = 0.009. This absolute risk improvement of 50% means that 2 patients would need to be treated with percutaneous radio-frequency neurotomy (compared with the control treatment) to have 1 additional patient remain free of pain at 27 weeks, 95% CI 1 to 7; the relative risk improvement was 600%, CI 44% to 3978%.}* 5 patients in the active-treatment group had numbness or dysesthesias in the cutaneous territory of the coagulated nerves, but none rated these sensory changes as troublesome.

Conclusion

Percutaneous radio-frequency neurotomy provided lasting pain relief in patients with chronic cervical zygapophyseal-joint pain.

Source of funding: Motor Accidents Authority of New South Wales.

For article reprint: Dr. S.M. Lord, Cervical Spine Research Unit, Faculty of Medicine, University of Newcastle, Callaghan, New South Wales, 2308, Australia. FAX 61-49-689422.

*Numbers calculated from data in article.


Commentary

Review: Manual therapy in combination with other treatments may provide short-term relief in mechanical neck pain

Neck pain is one of the most common symptoms for which patients seek treatment from primary care physicians. The socioeconomic burden of this disorder is enormous, and many conservative treatments have been proposed and used for it. As discussed in the review by Aker and colleagues, all of the better studies on conservative measures for the treatment of mechanical neck pain contained insufficient numbers of patients to scientifically show a benefit to those who were treated. To date, studies have failed to show that these conservative treatments do more good than harm.

It is important to note that the review by Aker and colleagues applies to patients with neck disorders that are not associated with neurologic deficit, headache, fractures, inflammatory disease, or neoplasm. The type of pain that is studied in this review is often referred to as muscle strain or muscle spasm. The results of this review do not pertain to patients who have radicular pain (i.e., radiating down the upper arm) and is often associated with cervical disc protrusion.

Such conservative measures as drugs, traction, ultrasonography, transcutaneous stimulation, and electromagnetic therapy have been used by clinicians for several years. Thus, the clinician is faced with a dilemma when dealing with a patient with mechanical neck pain because of the lack of clear evidence to indicate which treatment should be used. Until studies with larger patient populations are completed, the clinician should use treatments that are not likely to cause harm, such as rest and physical therapy, rather than treat patients with drugs that may have side effects or cause addiction.

The treatment for chronic neck pain after whiplash injury has also been disappointing. Such treatments as pain medications, physical therapy, intra-articular injections, or corticosteroids have not been found to have dramatic clinical benefit. The study by Lord and colleagues evaluates the effectiveness of radio-frequency neurotomy for patients with chronic neck pain lasting > 3 months after whiplash injury. This study showed a clear clinical and statistical benefit for radio-frequency neurotomy. Complications from the procedure were minimal and included dysesthesias that were not troublesome to patients.

It is important for the clinician to realize which patients are likely to benefit from radio-frequency neurotomy. The pain should be nonradicular, and patients should have been treated with conservative therapy (including analgesics, nonsteroidal anti-inflammatory drugs, opioids, physical therapy, traction, acupuncture, chiropracty, transcutaneous electrical nerve stimulation, heat, and exercise) for ≥ 3 months before considering this invasive treatment. Radio-frequency neurotomy should not be used in patients with C2-3 zygapophyseal-joint pain. Patients who are being considered for radio-frequency neurotomy should first have the cervical zygapophyseal joints blocked with local anesthetic to confirm that the pain is localized to these joints.

When faced with a patient who has chronic neck pain after whiplash injury and who has not responded to ≥ 3 months of conservative therapy, the clinician should strongly consider referring the patient to a specialist skilled in diagnostic cervical zygapophyseal-joint blocks and radio-frequency neurotomy.

Barbara Scherokman, MD
Kaiser PermanenteSpringfield, Virginia, USA


Author's Response

No clear evidence exists that directs clinicians to recommend rest and physical therapy care in general or not to recommend the use of medication for adults with acute or chronic mechanical neck disorders. Some early evidence based on randomized controlled trials (within methodologic limits) can assist with the clinical decision-making when attempting to manage pain for adults with acute or chronic mechanical neck disorders. The following treatments provide benefit: manual therapy combined with other therapies (commonly analgesics, patient education, heat or cold application, and exercise), electromagnetic field therapy, muscle relaxants, acupuncture, and topical anti-inflammatory agents. No benefit was shown from laser therapy, spray-and-stretch procedures, individualized or group educational strategies alone, traction, and transcutaneous electrical nerve stimulation; exercise alone was of unclear benefit.

Anita R. Gross, MSc