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Targeted Radiofrequency Ablation as an Adjunct in Treatment of Lumbar Facet Cysts.

ABSTRACT: Lumbar facet cysts are frequently found in patients with facet degeneration and segmental instability. When the facet cyst is localized in the neural foramina and lateral recess or becomes large, it can cause radiculopathy or neurogenic claudication. These symptomatic cysts are typically treated interventionally with drainage and a corticosteroid injection or attempts via overinflation to rupture the cyst; however, these procedures have a significant recurrence rate (up to 50%) and often need to be repeated or lead to lumbar surgery if unsuccessful. This is the first report of using targeted radiofrequency (RF) current as an adjunct to cyst drainage. Although RF has been used for years to treat facet pain indirectly by targeting the medial facet nerve branches, with this technique, under image guidance, the actual cyst is percutaneously drained and then cauterized along with the associated facet capsule, where the original cyst developed. This has improved overall results with less cyst recurrence than previous percutaneous methods and was documented with both intermediate and long-term followup clinically and with magnetic resonance imaging (MRI) scans. This report reviews the underlying anatomy and pathology of the facet joint relating to the development of facet cysts and how current percutaneous treatments for lumbar facet cysts can be supplemented and improved by adding targeted RF ablation to the percutaneous options available to treat a lumbar facet cyst.

SUBMITTER: Hatgis J

PROVIDER: S-EPMC5499940 | biostudies-other | 2017 Jun

REPOSITORIES: biostudies-other

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Project description:What we already know about this topicWHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: With facet interventions under scrutiny, the authors' objectives were to determine the effectiveness of different lumbar facet blocks and their ability to predict radiofrequency ablation outcomes.MethodsA total of 229 participants were randomized in a 2:2:1 ratio to receive intraarticular facet injections with bupivacaine and steroid, medial branch blocks, or saline. Those with a positive 1-month outcome (a 2-point or more reduction in average pain score) and score higher than 3 (positive satisfaction) on a 5-point satisfaction scale were followed up to 6 months. Participants in the intraarticular and medial branch block groups with a positive diagnostic block (50% or more relief) who experienced a negative outcome proceeded to the second phase and underwent radiofrequency ablation, while all saline group individuals underwent ablation. Coprimary outcome measures were average reduction in numerical rating scale pain score 1 month after the facet or saline blocks, and average numerical rating scale pain score 3 months after ablation.ResultsMean reduction in average numerical rating scale pain score at 1 month was 0.7 ± 1.6 in the intraarticular group, 0.7 ± 1.8 in the medial branch block group, and 0.7 ± 1.5 in the placebo group; P = 0.993. The proportions of positive blocks were higher in the intraarticular (54%) and medial branch (55%) groups than in the placebo group (30%; P = 0.01). Radiofrequency ablation was performed on 135 patients (45, 48, and 42 patients from the intraarticular, medial branch, and saline groups, respectively). The average numerical rating scale pain score at 3 months was 3.0 ± 2.0 in the intraarticular, 3.2 ± 2.5 in the medial branch, and 3.5 ± 1.9 in the control group (P = 0.493). At 3 months, the proportions of positive responders in the intraarticular, medial branch block, and placebo groups were 51%, 56%, and 24% for the intraarticular, medial branch, and placebo groups, respectively (P = 0.005).ConclusionsThis study establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation.

Project description:Background contextLumbar radiofrequency ablation (RFA) is an intervention used to treat facet-mediated chronic low back pain. In some studies with methods consistent with clinical practice guidelines, RFA results in improvements in pain and functional limitations. However, in other studies, RFA demonstrates limited benefit. Despite unanswered questions regarding efficacy of RFA, its use is widespread.PurposeTo describe trends in the utilization and cost of lumbar RFA and lumbar facet injections.Study design/settingRetrospective cohort study.Patient sampleThe sample was derived from the IBM/Watson MarketScan Commercial Claims and Encounters Databases from 2007 to 2016.Outcome measuresLongitudinal trends in the distribution and quantity of lumbar facet injections before lumbar RFA, corticosteroid administration during lumbar facet injections, progression to lumbar RFA after lumbar facet injections, lumbar RFA utilization, and costs of these interventions.MethodsTwo primary cohorts were identified from patients who received lumbar RFA or lumbar facet injection procedures. Utilization rates per 100,000 enrollees were determined for both cohorts. The mean, median, and interquartile ranges of the number of facets targeted and costs per procedure were calculated by year and laterality, as well as overall. Costs in 2018 dollars were estimated by summing gross payment totals from patients and insurance plans. This study was supported by funds from the NIH, and has no conflict of interest associated biases.ResultsFrom 2007 to 2016, lumbar RFA sessions performed per 100,000 enrollees per year increased from 49 to 113, a 130.6% overall increase (9.7% annually). Lumbar facet injection use increased from 201 to 251 sessions per 100,000 enrollees, a 24.9% overall increase (2.5% annually). In the year after a lumbar facet injection, 26.7% of patients received lumbar RFA; 28.6% received another injection but not RFA; and 44.7% received neither. The number of patients receiving two lumbar facet injection procedures prior to lumbar RFA grew from 51.1% in 2010 to 58.8% in 2016. For lumbar RFA, the cost per 100,000 enrollees went from $94,570 in 2007 to $266,680 in 2016, a 12.2% annual increase. For lumbar facet injections, the cost per 100,000 enrollees went from $257,280 in 2007 to $396,580 in 2016, a 4.9% annual increase.ConclusionsThis analysis showed consistent growth in both the frequency and procedure cost of lumbar RFA and facet injections among a large, national, commercially insured population from 2007 to 2016.

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Targeted Radiofrequency Ablation as an Adjunct in Treatment of Lumbar Facet Cysts.

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