Cryoneurolysis for cervicogenic headache – a double blinded randomized controlled study

Abstract

Background and aimsCervicogenic headache (CEH) is a debilitating condition and analgesics have limited effect. Percutaneous cryoneurolysis is thus still in use although the clinical evidence is lacking. We present a randomized, controlled study to assess the clinical efficacy of cryoneurolysis compared with a corticosteroid combined with a local anaesthetic.MethodsIn a university-based outpatient pain clinic we performed a randomized, double blinded, comparative study with an 18-week follow-up. After positive diagnostic test blocks 52 eligible patients were randomly allocated in a ratio of 3:2, 31 participants to occipital cryoneurolysis and 21 participants to injections of 1 mL methylprednisolone 40 mg/mL (Depo-Medrol®) combined with 1 mL bupivacaine 5 mg/mL.ResultsWe observed a significant pain reduction of more than 50% in both treatment groups, slightly improved neck function and reduced number of opioid consumers. After 6–7-weeks, however, pain intensity increased gradually, but did not reach baseline within 18 weeks. Although cryoneurolysis provided a more prolonged effect, the group differences did not reach statistical significance. Health related quality of life and psychological distress improved minimally. A large number reported minor and transient side effects, but we found no significant group differences. After 18 weeks, 29% rated the headache as much improved, and 12 (24%) somewhat improved, but a large proportion (78%) reported need for further intervention/treatment.ConclusionsCryoneurolysis provided substantial, but temporary pain relief, and the effect was not significantly different from injections of a corticosteroid combined with a local anaesthetic. Participants were selected by a single test block, and the neurolytic procedure was guided by anatomical landmarks and nerve stimulation. A stricter patient selection and an ultrasound-guided technique might have improved the results. Cryoneurolysis provides temporary pain relief not significantly superior to corticosteroid injection, and the results question the value of occipital cryoneurolysis for a chronic pain condition like CEH.ImplicationsOccipital cryoneurolysis may be considered when non-invasive treatments appear insufficient, but only for patients who have responded substantially to test blocks. A risk of local scar and neuroma formation by repeated cryoneurolysis, leading to neuropathic pain has been discussed by other researchers.

Efficacy of interventional treatment strategies for managing patients with cervicogenic headache: a systematic review

“…Cold temperature mediated ablation of sensory nerve fibers is relatively safe neuroablative technique. Cryoneurolysis of GON and LON was evaluated in refractory cases of CeH after positive diagnostic block in a randomized study by Kvarstein et al [ 36 ] and found significant pain reduction in both the treatment groups with no significant group difference.…”

“…To achieve a long-lasting analgesic effect, freezing destruction of nerve conduction has been attempted for refractory cases of CeH. Kvarstein et al [ 36 ] evaluated the clinical efficacy of occipital cryoneurolysis and compared it with local anesthetic and steroid injections. Despite a significant reduction in pain scores, pain intensity gradually increased after 6–7 weeks but had not returned to baseline by 18 weeks in both groups.…”

Krioanalgezija Gydant Lėtinį Skausmą

“…Po 18 savaičių vertinant pakartotinai, 78 proc. pacientų teigė, jog jiems reikalingas tolimesnis skausmo gydymas [20].…”

An open-label, single-arm trial of cryoneurolysis for improvements in pain, activities of daily living and quality of life in patients with symptomatic ankle osteoarthritis

“…Cryoneurolysis has demonstrated promise as a novel [ 20 ], effective therapeutic technique for providing long-term analgesia [ 21 ], including for cervicogenic headache [ 22 ], neuropathic pain [ 23 , 24 ] and phantom-limb pain [ 25 ]. The mechanism of action is well understood and has been described previously [ 26 ].…”