Saturday, March 31, 2012

Facet Joint Rhizotomy and Chronic Pain

Neurosurgeons and rocket scientists are right up at the top for me.  Rhizotomy is a procedure in which the nerves around the facet joints are treated to relieve pain. The facet joints are the lumps you feel along either side of the spine from the head to the butt. Neurosurgeon. Dr. Richard Brownlee gave a superb presentation at the Trial Lawyers Association of British Columbia Essential Soft Tissue Injury Conference. I was using my light weight Macair and didn't have an external cd drive with me. The woman lawyer beside me was hauling a heavy weight lap top but had the CD presentation made for this presentation displaying on her screen. The slides were terrific. I watched them on the big screen but was thankful I had the CD to look at later.   Dr. Brownlee was as succinct as I've known neurosurgeons to be. No waste of words, excellent almost military clear  communication, what needs to be said, is said without the frills and whistles. Answering questions he was brilliant.  Very informative. Obviously a highly accomplished clinician and a surgeon and no doubt a source of profound relief for so many patients.   My notes give a glimpse of the subject and the nature of the conference material.  I would suggest people who are interested attend the conference and get the CD's next year. In lieu of that, see the presenters.

Facet Joint Rhizotomy
-Dr. Richard D. Brownlee
Welcome Back MRI and Pain Management Centre
March 31 2012
Trial Lawyers of BC Essential Soft Tissue Conference
MRI’s early - shows the disc tear or ligament injury in first 3 months
Won’t necessarily change the treatment but might have significance for legal matters
Unless you treat the psychological part as well as you treat the physical some people aren’t going to get better -some people are just so angry at the insurance companies
Facets - little joints of spine
superior articular process
inferior articular process
Vertebrae at front of spine
Facet joints at back
Cervical spine -zygophaseal joint
Facet Capsule
Synovium and fluid
these joints are prone to arthritis and wear and tear getting older and change of fluid with aging
Degeneration of the cartilage in the facet joint can be pain generators
Synovial cyst
Capsule tear
Synovial impingement
5-40% of back pain is facet pain
50% of whiplash pain is facet joint pain
MRI images show degeneration
White is water on mri
Back pain - or neck pain - soft tissue or facet joint
Leg pain - more likely pinched nerve
Facet Joint Syndrome
Ghormley 1933
Back pain resulted from nerve root compression - today it’s not so much the pinching of nerve but the osteoarthritis and inflamation and transmission of pain to the mind
Nothing pathognomonic -extension or twising, or activities requiring flexed posture
No neurological abnormalities
Lumbar facet Joint pain
Local tenderness over facet joint, stabbing, burning, aching, back hips,thigh or calf
Referred pain - studies have shown where it can be referred
Low back Pain
40% in older population
15% in younger population
Cervical facet pain
neck pain, shoulder pain, upper back, cervicogenic
Bogduck - done alot of research
Apri and Bogduck 1992 -
Chronic Neck Pain - commonly facet joint
C2-3 and C5-6 most common levels
Post mortem facet studies, people killed in car accicent
intr articular hemorrhage
capsular tears
miniscular tars
bone and cartilage fractures
Diagnositic Imaging
alot of people have degenerative change and don’t have pain
Some of people most disabled by pain have healthiest looking back on MRI in contrast those who don’t have complaints might have worst images
When it comes to ordering MRI’s - tends to be that doctors don’t like to order unless surgery is to be considered
sources of back or neck pain
discs - annular tear, herniation
facet joints
Diagnosing Facet Joint Pain
Hirsch 1963 - produced back pain by injecting joints with hypertonic sailine, relieved pain with local anesthetic
Facet joint Injection
25% false positive by this method
Bogduck, 1980 anatomic dissections showed each joint innervated by 2 nerves
Medial Branch Blocks
  • 2 local anesthetics
  • anesthetic block
  • Comparative anesthetic block - person comes different times
  • short and long acting anesthesia - send home and have patient record pain relief hourly
Facet Rhizotomy
percutaneous thermocoagulation of the facet joint
Van Cleef -1999 - comparison
Drefuss t al 200 - at 12 month 60% and 80% improvements
Needles are xray guided
Can’t see nerve but based on anatomic studies of Bogduck
thermal coagulation of medial branch to facet joint
alternating current, 80 degrees celsius, 90 seconds
have to be careful not to damage the vertebral artery
complications are extremely low - less than .1 %
good pain relief for months to years (1-3 years)
can be repeated with equal efficacy
medications - narcotics, nsaid, seizure,etc
dynamic stabiization - major procedure , I do lots but takes 3-4 hours and 3 months to recovery so rhizotomy often better as it can work as well, but still good  in right people

No comments: