Una publicación de la revista: Interdisciplinary Pain Therapy
Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule
Medicina del Dolor Uruguay
Publicado el
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.
Figure 1. Anatomic model showing the approach angles for direct posterior radiofrequency versus the standard approach A: Posterior view of anatomic model showing inferior to the superior angle for two different electrode positions (single and double electrodes) along the posterior edge of the C4-5 and C5-6 facet joints. The two electrodes (dashed black arrows) are angled to match the inferior to superior inclination of the facet joint and positioned lateral to the interlaminar space. The two electrodes spaced between 4 mm and 8 mm apart create a larger bipolar lesion. On the opposite side, the solid black arrow shows a unilateral posterior approach at C4-5 and C5-6, angled again inferior to the superior and slightly medial to the lateral to create a lesion in the posterior edge of the capsule. B: Posterior-lateral oblique view similar to the approach for standard radiofrequency lesioning that targets the more anterior edge of the facet joint. This puts the electrode closer to the exiting nerve root.
Figure 2. Axial magnetic resonance imaging (MRI) showing the relationship of the facet joint to other cervical structures A: Normal axial image of MRI cervical spine. The superior facet (SF) and inferior facet (IF) can be clearly seen. The uncovertebral joint (UC) can be seen lateral to the disc (solid black arrow). The uncovertebral joint emanates from the more lateral edge of the inferior vertebrae. The posteriorly located horizontal facet joint is seen (solid white arrow). B: Small midline annular tear (dotted white arrow). The facet joints are seen on both sides (solid white arrow). C: Herniated disc into the ventral floor of the cervical canal (solid black arrow). The facet joints are clearly seen (solid white arrow). D: Large posterior and lateral osteophyte from the back of the uncovertebral (UC) joint forming a spur into the intervertebral foramina (solid white arrow). The horizontal facet joint is clearly seen as in the other examples but there is minimal posterior enlargement of the facet capsule on the same side as the large osteophyte (dashed white arrow).
Figure 3. Intraoperative images of posterior electrode placement A: Patient having bipolar posterior medial facet radiofrequency lesions using two electrodes placed parallelly but vertically on the more oblique side of the C5-6 joint for bipolar lesioning. B: Lateral intraoperative film showing an angle (40 degrees) parallel to the direction of the joint from caudal to cranial to approach the posterior facet joint (dashed black arrow). The inferior facet (if) and superior facet (sf) are marked at C2-C3. The two bipolar electrodes are seen (wide black arrow) at C2-3 and the single unipolar electrode (dashed white arrow) can be seen at C3-C4, inclined at the same angle as the facet joint. C: Posterior bipolar C1-2 facet radiofrequency. Electrodes placed parallelly, about 4 mm apart, and horizontally, along the posterior facet capsule. The superior and more more anterior odontoid process (O) of C2 is clearly seen. D: Bipolar posterior facet radiofrequency electrodes at C2-3 for high cervical and occipital pain. The medial edge of the posterior facet capsule is seen (dashed black arrow).
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