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

Neurosurgeon

Welcome Back MRI and Pain Management Centre

Kamloops,BC

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

Cervical

Thoracic

Lumbar

superior articular process

inferior articular process

Vertebrae at front of spine

Facet joints at back

Cervical spine -zygophaseal joint

Cartilage

Meniscoid

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

Osteoarthritis

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

muscles

ligaments

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

Alternatives

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

Fusion