What is the lumbar and cervical rhizolysis?

Rhizolysis is a minimally invasive technique for treatment of symptoms of chronic cervical and lumbar spine pain originating in the facet joints. The term facet-type pain refers to a clinical problem, which does not always have a clear correlation with imaging tests, CT radiography, or MRI. However, up to a quarter of the cases of low back or axial cervical pain may originate in these joints, whose anatomical name is lumbar and cervical zygopophyseal intervertebral joint (Z-joint).

What cases is it used for?

Rhizolysis is used for patients with chronic low back or cervical pain, generally not irradiated (starting in one place and spreading to another). The main objective is to help reduce the impact this disabling pain has on daily activity and to give more patients a chance to resolve their pain without recurring to spinal surgery.

The characteristics of facet pain are common to other causes of chronic lumbar and cervical pain. However, the clinical parameters most often found during the examination are as follows:

Lumbar region

  • Low back pain radiating down to the buttocks or hips, or to the lower limbs (usually not radiating below the knee).
  • Overload on the lumbar region that increases during prolonged standing or sitting.
  • Sharp pain when the joint is palpated.
  • Stiffness or loss of range of motion, especially flexion-extension and lumbar rotation.
  • There are no sensory-motor neurological deficits or osteoarticular reflex deficits in the lower extremities.
  • The pain does not usually increase with Valsalva maneuvers (exhaling air with the mouth and nose closed).

Cervical region

  • Cervical irradiated pain that increases with extension or lateral flexion of the head.
  • Cervical overload that increases during prolonged sitting, holding the neck in a static position or with repeated movement of the arms (common in professional activities that require staying in the same position for prolonged periods of time or require making repetitive movements with the arms).
  • Sharp pain when the cervical region or the posterolateral area of the neck is palpated.
  • Stiffness in the cervical region that radiates to the neck or interscapular region.
  • There are no sensory-motor neurological deficits or osteoarticular reflex deficits in the upper extremities.
  • The pain does not usually increase with Valsalva maneuvers.

What is involved in the procedure?

The technique consists of using heat to make controlled damage to the nerve fibers that are the source of the pain. The procedure is performed in the Outpatient Minor Surgery Unit. It is minimally invasive and causes very little pain.

The procedure is performed with the patient lying face down, with their head to one side and lying on pillows to be as comfortable as possible. It is carried out with local anesthetic and light sedation of the patient. Electrodes are placed according to the locations indicated by radiological projections to systematically check their situation.

Types

1. LUMBAR RHIZOLYSIS

The lesion is made using radiofrequency on the medial branch of the nerve, which supplies the zygopophyseal intervertebral joint, the deep back musculature and the interspinous, supraspinatus, intertransverse ligaments, the yellow ligament and the skin.

Before beginning to make the lesion, we perform a double sensory and motor stimulation to verify the correct location of the electrode tip. Sensory stimulation (50Hz, less than 0.7V) often reproduces the patient's pain, including irradiated pain. When this happens, it is considered a sign of good prognosis.

The motor stimulation (2Hz, up to 2.5V) should not cause muscle contraction in the territory corresponding to the nerve being stimulated, although there may be a weak pulsing contraction of the paravertebral musculature. This is enough to guarantee that we are not injuring the anterior branch, the spinal nerve.

Once the previous verification step has been performed, we can proceed to the facet rhizolysis by means of thermocoagulation with an electrode at 80ºC for 90 seconds. Medical tests on cadavers have shown that amount of damage caused by this thermocoagulation is limited to the approximate volume of a 0.5 to 1 cm diameter sphere. Placing the needle in tangential position to the nerve is recommended as it improves results. Several levels can be performed at the same time and the lesion can also be bilateral. Based on our experience, we prefer to use deep sedation on the patient during thermocoagulation, to avoid the painful and burning sensation that it causes. One or more levels can be treated, unilaterally or bilaterally

2. CERVICAL RHIZOLYSIS

The lesion is made with radiofrequency on the medial branch of the cervical nerve, which supplies the zigoapofisary intervertebral joint, the supraspinatus and interspinous ligaments and deep muscles (multifidus, interspinal).

This procedure can be done using one of several approaches. Based on our experience, we use the lateral approach because it offers technical advantages and greater comfort for the patient on the operating table. For this approach, the patient is placed on his back with slight hyperextension of the chin.

As in the procedure in the lumbar region, cervical rhizolysis is performed using local anesthesia and light sedation. In lateral projection, we locate the levels to be treated and then we mark the center of the cervical zygopophyseal joint, which in this projection has the shape of a “rhombus”. The needle is carefully inserted in the direction of the target point (located in the center of the rhombus shape) using a radiological view of the tunnel, until it touches the bone. In the anteroposterior view of the fluoroscope, the correct position of the needle at the tip of the joint is checked.

Before making the lesion, each needle is used to perform a sensitive stimulation (50Hz to 0.5V), during which the patient notices paresthesias (“pins and needles”) or a sensation of pressure in the stimulated neck area. The stimulation may also cause the patient to feel the pain they were suffering, but it does not irradiate.

Next, we perform motor stimulation (2Hz to 2V), with may cause fasciculations of the paraspinal musculature to appear, which must also not show rhysoroot distribution. At Instituto Clavel we perform this rhizolysis using pulsed radiofrequency following a 45V protocol for 120 seconds. One or more levels from C2 to C7 can be treated unilaterally or bilaterally.

Recovery and rehabilitation

Since rhizolysis is a treatment of symptoms, by itself it is not a long term solution, and must be accompanied by reeducation of neck and back posture, together with recovery of the body’s equilibrium. For this, we recommend isometric exercises to strengthen the cervical, scapulo-dorsal and abdominal muscles (your “core”).

On the average, the pain relief provided by rhizolysis in the mid-lumbar branch is 10.5 months (range between 4-19 months). It can be repeated with similar results, as long as a clinical examination confirms it is appropriate and no new symptoms have appeared due to another cause or other medical conditions.

Risks

Complications that may occur are post operative localized or neuropathic pain for several days in 0.5% of cases; allergic reaction to the superficial anesthetic, superficial infections; small skin burns from poorly positioned electrodes or broken electrodes. Transient motor or sensory deficits are exceptional, however, due to the fact that the electrode is guided under fluoroscope control in the operating room and with the supervision and intervention of an anesthesiologist.

Who are the doctors at Instituto Clavel who perform rhizolysis?

Sources

  • Cohen SP, et al. Multicenter, ramdomized, comparive cost-effectiveness stuty comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology 2010: 113:395-405.
  • Dreyfuss P, Halbrook B, Pauza K. Efficacy and validity of radiofrecuency neurotomy for chronic lumbar zygapofiseal joint pain. Spine. 2000; 25: 1270-1277.
  • Kornick C, Kramarich SS, Lamer TJ, Todd Sitzman B. Complications of lumbar facet radiofrequency denervation. Spine 2004;29:1352-4.
  • National Institutes of Health. Research on low back pain and common spinal disorders. NIH Guide, Vol. 26. PA97-058. Betheseda (MD): National Institutes of Health; 1997.
  • Pérez-Cajaraville J. et al. Radiofrecuencia de facetas lumbares y cervicales. Rev. Soc. Esp. Del Dolor, Vol. 18,Nº 4, Julio-Agosto 2011. 
  • Pevsner Y, Shabat S, Catz A. The role of radiofrecuency in the treatment of mechanical pain of spinal origin. Eur Spine J. 2003; 3: 357-62.
  • Rees Wes. Multiple bilateral percutaneous rhizolisis of segmental nerves in the treatment of the intervertebral disc syndrome. Ann Gen Prac. 1971; 26: 126-127.
  • Tomé Bermejo F. et al. Dolor Lumbar crónico de origen facetario. Eficacia del tratamiento mediante rizólisis percutánea. Patologia del Aparato Locomotor, 2006 Vol. 4, nº2: 139-146.
  • Schofferman J, Kine G. Effectiveness of repeated radiofrecuency neurotomy for lumbar facet pain. Spine. 2004; 29: 2471-3.
  • Van Eerd M, Patijn J, et al. Cervical facet pain practice. 2010;10(2): 113-23.
     

Want to know more?
Tell us about your case!

Contact us so that we can give you a personalized assessment.

Share on: