Radiofrequency Neurotomy – ablation of the medial branch of the dorsal ramus

In recent practice I have seen numerous patients seeking spine pain treatment in the form of radiofrequency neurotomy. This is otherwise known as radiofrequency ablation or rhizotomy. The procedure I am referring to is one in which the physician uses electrical energy to burn the tiny sensory nerve fibres that carry the pain signal from the facet joints of the spine.

My issue of greatest concern lies in the diagnosis. Patients need to be aware that unless they have had extremely accurate ‘diagnostic’ blocks to identify the pain facet as the pain source, they will not do well with neurotomy. Simply put, if the joints are falsely labelled as the pain source, burning the nerves for these joints will be useless.

Patients need to be aware that a minimum of 70% of their pain must disappear for the duration of the numbing medication (local anesthetic) at the time of the diagnostic block. As well, they need a confirmatory block on a second occasion. Typically, at the time of the confirmatory block, the diagnosing physician will either use a placebo (a fake, where the patient should NOT experience relief) or a different numbing medicine (a different local anesthetic, where the patient should again experience >70% relief for the expected duration of the new numbing medicine).

After the diagnosis of facet joint pain has been solidified, patient should enjoy high success rates following a well-performed neurotomy.

Spine Pain Treatment: Private vs. Public Medicine

I must be clear: the following is not a debate of the merits and imperfections of the Canada Health Act.  My goal is to answer the specific question “Why does Dr. Helper practice Interventional Spine Pain Medicine, primarily, in the private sector?”

 

My clearest response is to ask and answer a few more simple questions:

 

1.     What does it take to offer a high quality Interventional Spine practice?

a.     Quick access to a qualified spine physician

b.     A detailed assessment by that spine physician to accurately provide a diagnosis

c.      Quick access to MRI or CT scan

d.     Adequate operating/procedure room time

e.     Access to a fluoroscope (live x-ray machine for performing procedures)

f.      A qualified x-ray technologist

g.     A dedicated nurse who understands the procedures being performed

h.     A short wait list

 

2.     What is the current wait to access some of the necessary services in B.C.?

a.     Non-emergent (e.g. of emergent: spinal cord injury, infection, tumour) MRI of the lumbar spine: 7 months

b.     Basic Spine Injection: 1 to 4 months

c.      More advanced minimally invasive procedures: 3 to 12 months

 

3.     Why do some surgeons/physicians work in both the public and private sector? (E.g. 3 days public, 2 days private)

a.     Most surgeons are provided with inadequate O.R. time to keep up with the number of patients waiting to be treated. The only way for them to treat more patients is to find O.R. time somewhere else…private hospitals.

b.     Some surgeons who perform procedures X, Y and Z will provideX and Y in the public hospital and Z only in the private setting. This allows them to keep the wait list down on X and Y, while still being able to offer/perform Z.

 

4.     Why doesn’t Dr. Helper work in both the public and private sector?

a.     The short answer is, see question #1, #2, and #3.

b.     Access to resources is difficult in British Columbia (not that it is great anywhere in Canada!). 

c.      If a medical clinic were to provide optimal care for spine pain patients they would need to invest in an MRI scanner, a CT scanner, x-ray machine (or 2), an x-ray technician (or 2), a nurse (or 2), a secretary (or 2), an office building, and an O.R. suite (or 2). How will these resources be funded? You do the math.

Are All Spinal Injections the Same? Are They Practitioner Dependent?

You must remember that there are two types of injections: diagnostic injections and therapeutic injections:

1.     Diagnostic injections are performed because it is nearlyimpossible to be 100% sure about the exact diagnosis by history and physical examination alone. The goal is to precisely place local anesthetic (numbing medication) around or inside the suspected source of pain. If you obtain significant relief from this injection, it is likely that the true diagnosis has been found.

2.     Most therapeutic injections use a powerful anti-inflammatory medication (corticosteroids). The goal of the injection is to place a small amount of this potent anti-inflammatory medication exactly where the pain begins (e.g. joint, nerve). The goal is to precisely instill this medication where it will provide the greatest benefit to your spine problem.

The quality/efficacy of the spinal injections is practioner specific; base upon a combination of knowledge and skill. The treating physician must possess both to effectively treat spine pain patients.

For a diagnostic injection to be accurate it must block the target structure completely without blocking other spine structures that are only millimeters away. The specialist must place the needle safely within a millimeter of the target and deliver just enough medication (no less/no more) to bathe that structure without unpredictable spread to other structures. This requires not only manual skills, but also an understanding of spinal anatomy and the latest scientific literature to know exactly where to place that needle.

For a therapeutic injection, the goal is to place a small amount of medication at the exact source of pain. No matter how proficient the physician is at performing injection procedures, the skill is useless if the medication is injected at the wrong location. In choosing the correct location the spine specialist is required to utilize the information he/she acquired from the history, physical examination, radiological images, as well as the most up to date medical literature to identify the most likely anatomical source of your pain. If you are suffering from joint pain and the physician performs a nerve root block, you are not going to get results.

Evaluating and treating spine pain is a complex process that seems simple at first glance. The same can be said for the spinal injections themselves. If you are contemplating undergoing minimally invasive spine management make certain a qualified practitioner is treating you.

Degenerative Disc Disease

Degenerative Disc Disease is the most common cause of “mechanical back pain”. Unfortunately, it is also the most difficult back pain condition to treat. Typically, patients try simple conservative measures first; medication, physical therapy, chiropractic, massage, acupuncture, and spinal injections (epidural). When these treatments fail, they are evaluated for surgery. The classic surgery is a lumbar fusion. Long term outcomes from lumbar fusion surgery have been hit and miss. More recently, disc replacement surgery, otherwise known as disc arthroplasty, has created much excitement. However, this option has also been found to be less than perfect. So what is the solution?

Well, there is no simple solution. There is, however, another option. Some patients are candidates for a minimally invasive procedure to ablate (burn) the pain fibres in the intervertebral disc, itself. This involves placing a radiofrequency (electrical) probe into the posterior of the disc and using heat to shut down the pain fibres, thus reducing back pain.

These radio-frequency procedures gained a lot of attention in the past. The enthusiasm fizzled, slightly, as the results proved to be less than perfect. However, the concept of a minimally invasive procedure that may be performed to treat degenerative disc disease, thus avoiding the risks of open surgery, remains attractive. There is now a newer technology on the market called TransDiscal or Biacuplasty. It is the latest and greatest development in spine pain technology. Early studies are showing very positive results. It is likely that I will introduce this procedure to British Columbia before the end of 2008.

Neck Pain: Motor Vehicle Accidents

Neck pain following motor vehicle accidents is probably the most misunderstood condition I see in my spine clinic. Patients are often given a label of “soft tissue injury” or “mechanical neck pain” or “neck strain”. While these diagnoses are not completely incorrect, in my opinion, they are out-dated and imprecise. With a proper assessment and investigation the exact diagnosis may be isolated in 80% of cases. The final diagnosis if most often attributed to a single spine structure (facet joint, disc, nerve root, etc.). Once a proper diagnosis is made, there is a much greater understanding of the patient’s prognosis. Not only that, but the treatment may now be directed at a precise target. Essentially, the spine specialist may use a “sniper’s rifle” rather than a “shotgun blast” to treat the injured spine structure. This greatly improves the odds of successful treatment of the neck pain.