Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule

Abstract

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught using an oblique approach to the anterior lateral capsule of the cervical facet joint. The goal is to position the electrode at the proximal location of the recurrent branch after it leaves the exiting nerve root and loops back to the cervical facet joint. The standard oblique approach to the recurrent nerve requires the testing of both motor and sensory components to verify the correct position and ensure safety so as to not damage the slightly more anterior nerve root. Bilateral lesions require the repositioning of the patient's neck. Poorly positioned electrodes can also pass anteriorly and contact the nerve root or vertebral artery. The direct posterior approach presented allows electrode positioning over a broader expanse of the facet joint without risk to the nerve root or vertebral artery. Over a four-year period, direct posterior radiofrequency ablation was performed under fluoroscopic guidance at multiple levels without neuro-stimulation testing with zero procedural neurologic events even as high as the C2 spinal segment. The direct posterior approach allows either unipolar or bipolar lesioning at multiple levels. Making a radiofrequency lesion along the larger posterior area of the facet capsule is as effective as the traditional target point closer to the nerve root but technically easier, allowing bilateral access and safety. The article will review the anatomy and innervation of the cervical facet joint and capsule, showing the diffuse nerve supply extending into the capsule of the facet joint that is more extensive than the recurrent medial sensory branches that have been the focus of radiofrequency lesioning.

Development and Description of a New Multifidus‐Sparing Radiofrequency Neurotomy Technique for Facet Joint Pain

“…As this is performed in the vertical midpoint of the joint, it does not take into account the entry points of the superior and inferior medial branch nerves, which enter from the superior and inferior aspect of the joint, respectively, and may be less than optimally denervated with a horizontally focused approach. This technique was developed as an add‐on to conventional RFN and has been applied to lumbar 59 and cervical 60 facet joints.…”

Clinical Efficacy of Pulsed Radiofrequency Treatment Targeting the Mid-cervical Medial Branches for Intractable Cervicogenic Headache

“…The previous technique to treat CHA that involved PRF targeting the upper level of the cervical spine rarely resulted in injury, although it carried an inherent risk of complications because of the proximity of anatomic structures such as the nerve roots and vertebral artery. 9 – 11 And vertebral artery injury could be fatal for patients. In contrast, there are no such anatomic structures around the mid-cervical medial branches, and the cervical lamina prevents damage to important structures.…”

“… 5 – 8 However, this results in only short-term pain relief in the posterior head, and it can lead to some complications, such as vascular and nerve injuries. 9 – 11 Because of these limitations, we have attempted PRF targeting the mid-cervical medial branches, and we evaluated the clinical efficacy and safety of this modality as an alternative treatment option for CHA.…”

Infiltrationen und Radiofrequenztherapie der lumbalen und zervikalen Facettengelenke und der Iliosakralgelenke: Überblick, Evidenz und Ergebnisse

“…Palea et al (2018) beschreiben ein sicheres Vorgehen bei der Denervierung der nervalen Strukturen in der dorsalen Kapsel des zervikalen Facettengelenks. In einer kleinen prospektiven Studie (n = 18) konnten die Autoren über einen Zeitraum von 4 Jahren bei 83 % eine deutliche Schmerzreduktion entsprechend der visuellen Analogskala von 1 -3 ohne jegliche weitere Therapie feststellen [46].…”

“…Langfristige kontrolliert randomisierte Studien stehen hier ebenfalls aus. Der Evidenzgrad der lumbalen und zervikalen Facettendenervierung ist stark abhängig von strikten Einschlußkriterien und standardisierter Durchführung der Technik und ist mittel bis gering [31,46,47].…”