Relevance
Back pain is not only suffering for people, but also great socio-economic losses.
According to epidemiological studies conducted in countries with developed economies and medicine, more than 70% of patients at the initial appointment complain of malaise associated with spinal disease. This is caused by the widespread prevalence of pathological conditions of the spine, referred to by doctors as osteochondrosis, spondyloarthrosis, spondylosis, etc. In recent decades, doctors of various specialties have significantly increased interest in the problems of vertebrogenic pain, methods of studying it, methods of prevention and treatment. On the one hand, the development of new instruments, implants, and methods for surgical correction of a pathologically altered spine allows surgery to be at the pinnacle of technological progress, and on the other hand, a vertebrologist today is faced with the problem of choosing the optimal method of surgical treatment for the patient [2,3]. Surgical intervention for vertebrogenic pain is currently almost exclusively limited to spinal fusion. However, in December 2001, the Swedish Lumbar Spin study Group published the results of a prospective randomized study. 294 patients with chronic pain of degenerative etiology were examined, excluding cases of specific radiological diagnoses, such as spondylolisthesis. This study found that patients treated with spinal fusion had lower functional scores and higher pain scores 2 years after surgery than nonoperative patients. In light of this, the question arises about the advisability of performing extensive surgical interventions in patients with vertebrogenic pain [2].
Over the past years, a number of minimally invasive methods for treating spondylogenic pain syndrome by destroying nervous tissue have been proposed, including the method of radiofrequency denervation (RFD). This method is currently an alternative to traumatic medical interventions on the cervical, thoracic and lumbar spine when patients experience vertebrogenic pain and conservative therapy is ineffective.
FACETOPLASTY
A minimally invasive innovative technology for introducing ViscoPlus synovial fluid prosthesis into the joint cavity is called facetoplasty. The main component of the complex liquid is hyaluronic acid.
The procedure helps restore the normal structure of the affected joint, “attracts” (sorbs) additional water molecules and retains them in the joint cavity. As a result of the operation, the normal volume of the joint is restored, pain and limitation of movement are reduced. There is evidence of stimulation of regeneration of cartilage surfaces.
Unfortunately, the administration of ViscoPlus and other similar drugs is possible only in cases where there are no signs of abnormal joint shape or bone growths. In practice, facetoplasty in the treatment of the spine is used for patients in the middle age group up to 60 years.
Materials and methods
We observed 245 patients (150 women and 95 men) aged from 21 to 69 years (average age - 54.3 years). The reason for contacting a doctor was complaints of pain in the cervical (18 patients), thoracic (19 patients) and lumbar (208 patients) spine.
All patients underwent a radiation examination, including radiography of the spine in two projections (for neck pain and lumbar pain, functional tests were additionally performed); in doubtful cases, MRI or CT of the affected area was prescribed to exclude disco-radicular conflict. Radiographs in the case of degenerative changes in the intervertebral discs and joints revealed subchondral sclerosis of the vertebral endplates, a decrease in the height of the intervertebral space, sclerosis and deformation of the articular surfaces, a violation of their congruence, and the possible development of uncovertebral arthrosis [4], (Fig. 1).
The intensity of pain was assessed using a pain audit card, the maximum pain level of which corresponds to 100 points. Patients also underwent a study of the biomechanics of the cervical and lumbar spine using a three-dimensional motion analyzer Zebris 3-D Motion Analyzer (Zebris medizintechnik, Germany) (Fig. 2). The patients were found to have impaired biomechanics of the cervical and lumbar spine, which was expressed in limited extension and asymmetry in the amplitude of oblique and rotational movements.
Based on clinical and radiological examination in these groups of patients, it was found that the cause of the pain syndrome was degenerative changes in the facet (facet) joints, i.e. the diagnosis was formulated as spondyloarthrosis of certain segments (in the cervical region, segments from C3 to C6 (97%) were most often affected, in the thoracic region - from Th5 to Th12 (96%), in the lumbar region - segments L3-4, L4-5, L5 -S1 (97%). Reduction or complete relief of pain after para-articular diagnostic blockade with 2% lidocaine solution at the level of the lesion allowed us to finally establish that the pain comes from a compromised joint. Considering the fact that not all clinicians recognize the role of pathology of the intervertebral joints in the genesis back pain, we should dwell in more detail on the clinical picture of “facet syndrome". Often the onset of pain is associated with extension and rotation of the spine and other torsional overloads. All patients in the group with cervical spine disease experience pain (sometimes very pronounced) and limitation of movements .Pain often radiates to the shoulder girdle, shoulder joint, shoulder.Unlike radicular pain caused by compression of the corresponding nerve by a herniated disc, pain should not be localized in the forearm and fingers. When examining the patient, attention is drawn to the forced position of the head, asymmetry of the shoulder girdle, tension of the paravertebral and collar muscles on one or both sides. As a rule, movements in the cervical spine are limited, especially extension and rotation of the head. With isolated damage to the intervertebral joints, the doctor will not find pathological changes in the reflex and sensitive areas of the upper extremities. Outgoing referred pain from the facet joints of the thoracic and lumbar spine is lateralized, diffuse, difficult to localize, sclerotomous in distribution and, as a rule, does not descend below the knee. It is limited to the thoracic or lumbosacral region above the corresponding facet joint, radiating to the gluteal region and upper thigh (with lumbar localization). Facet pain can be more or less cramping, intensify with prolonged standing, extension, especially if it is combined with bending or rotation to the painful side, when changing body position from lying to sitting and vice versa. Characteristic is the appearance of short-term morning stiffness and an increase in pain towards the end of the day. Unloading the spine - bending it slightly, taking a sitting position, using support (stand, railing) - reduces pain. Physical examination can reveal smoothness of the lumbar lordosis, rotation or curvature of the spine in the thoracic, thoracolumbar or lumbosacral regions, tension in the paravertebral muscles and/or quadratus dorsi on the affected side, muscles of the popliteal fossa, and hip rotators. Local pain on palpation of the facet joint is typical. As a rule, there are no neurological sensory, motor or reflex disorders. Symptoms of “tension” of the nerve roots and limitation of movements as such are also not typical. Sometimes, in chronic cases, some weakness of the erector spinae and popliteal muscles is detected. Pain from the L5-S1 joint is reflected in the coccyx, hip joint, back of the thigh, and sometimes in the groin area. L4-5 joint irritation is characterized by pain radiating from the site of irritation to the buttock, hamstrings, and hip joints, and only occasionally to the tailbone. From the L3-4 joint, pain spreads to the chest area, the lateral surface of the abdomen, the groin, reaches the front surface of the thigh and very rarely to the tailbone and perineum. Irritation of higher level facet joints (Th12–L1, L1-2, L2-3) is limited to the appearance of pain in the upper back and abdomen, thoracic and even cervical regions. Pain from the Th3-4-5 joints often radiates to the interscapular and subscapular region [1,4].
All patients received conservative treatment on an outpatient basis. The therapeutic complex included drug treatment (non-steroidal anti-inflammatory drugs, vitamin therapy, biostimulants, etc.), periarticular blockades - for diagnostic and therapeutic purposes (with the obligatory administration of steroid drugs - diprospan 1.0 ml), physiotherapy, massage, corset therapy, psychotherapy . If conservative therapy was insufficiently effective or the effect was short-lived, patients underwent radiofrequency destruction of the facet nerves. Taking into account the specific clinical manifestations of intervertebral joint degeneration, we have identified the following indications for isolated radiofrequency destruction of the facet nerves: long-term pain in the cervical/thoracic/lumbar spine (more than 6 months); exacerbation of pain in the spine after extension and rotation of the head/torso, prolonged fixed position of the head/torso (for example, working on a computer); increased pain in the spine with deep palpation of the joints; absence of signs of root compression (neurological deficit); no improvement after physiotherapy; significant reduction in neck/low back pain after periarticular blockade at one or more levels; compliance of the clinic with radiological findings (spondyloarthrosis); pain intensity on the pain audit scale is more than 15 points.
We also identified general contraindications for performing RFD: dependence on narcotic and sedative drugs, alcohol, the presence of social and psychological factors that determine the perception of pain, age younger than 18 and older than 80 years, previous spinal surgeries, and a history of spinal circulatory disorders [2]. ].
The manipulation was performed in an operating room. With the patient in the prone position for RFD at the thoracic and lumbar levels and on the back when performing RFD at the cervical level, under local anesthesia with a solution of novocaine 0.5% - 10.0 ml, under the control of an electron-optical converter, a puncture of the para-articular region in the area of the nerves was performed , going to the joint capsule. As a rule, puncture was performed simultaneously at three to four levels (Fig. 3). The needle position was controlled in two projections (Fig. 4).
Then, to identify the correct needle position, electrical stimulation of the facet nerves with a frequency of 50 Hz was performed using a Stryker Interventional spine MultiGen RF Console radiofrequency generator (Fig. 5) or an RFG-3C PLUS generator from RADIONICS. The patient should experience a tingling sensation in the area of the corresponding facet joint in the range between 0.4 and 0.6 V. Next, the frequency was reduced to 2 Hz and muscle contractions in the limbs were observed, the absence of which indicated the correct position of the electrode. For the purpose of anesthesia, a 0.5% novocaine solution (no more than 2.0 ml) was injected into the area of expected destruction and radiofrequency destruction itself was carried out.
The patients tolerated the manipulation well. They were kept in bed for thirty minutes after denervation, during which time anti-inflammatory therapy was administered (Xefocam 8 mg IM). Then the patients were allowed to get up. Patients were discharged under outpatient supervision by a neurologist on the same day. At the outpatient stage, rehabilitation treatment (therapeutic gymnastics of the upper and lower extremities) and anti-inflammatory therapy were carried out. For 4-6 weeks, it was recommended to avoid heavy physical and sports activities. Patients were recommended to start work 7–14 days after the procedure.
The results of treatment of patients using radiofrequency denervation were compared with the results of conservative treatment of patients with spinal spondyloarthrosis. This group included 106 patients (64 women and 42 men) aged from 24 to 65 years. 8 patients were treated for pain in the cervical spine, 9 – in the thoracic spine, 89 – in the lumbar spine. The complex of conservative treatment included the use of medications: NSAIDs (diclofenac, meloxicam, lornoxicam), muscle relaxants (Mydocalm), antidepressants, vitamins . All patients received physiotherapeutic treatment, exercise therapy, and massage.
How does the radiofrequency denervation procedure work?
The procedure does not require hospitalization and is performed in the operating room under local anesthesia. Under fluoroscope control, isolated cannula needles are installed in the area of projection of the pain nerves. Once the needles are correctly inserted, an active electrode is inserted into them and radiofrequency ablation is actually carried out. This electrical stimulation may cause a tingling or burning sensation or trigger habitual pain. The tip of the needle is heated to 80°C. The denervation time is ~90 s for each needle inserted. After the operation is completed, the needles are removed.
results
We did not note any complications either during the operation or in the early or late postoperative periods. After radiofrequency destruction for 1-2 weeks, in 79% of cases, patients, despite a significant decrease in the intensity of the pain syndrome, continued to complain of a feeling of heaviness in the manipulation area. After 3-6 weeks this feeling disappeared. We assessed the effect of denervation before the patient was discharged to work, after 1 month, 6 months, 1 year and 1.5 years from the moment of RFD.
The results of the manipulation were divided into three groups: good - no pain, satisfactory - no pain at rest, a significant decrease in its intensity during movements, no need to take analgesics, and unsatisfactory - maintaining the intensity of the pain syndrome at the same level.
When assessing the results early after the manipulation, in all cases a decrease in pain was noted, on average, by 36 points on the pain audit scale both in the corresponding part of the spine and in the extremities. After a month, a good outcome of the disease was noted in 101 (41%), satisfactory – in 137 (56%), unsatisfactory – in 7 (3%) patients. Thus, a month after the manipulation, improvement occurred in 97% of patients. After 6 months, the distribution of disease outcomes remained approximately the same. A year later, an analysis of the results of treatment in 195 patients was carried out: a good outcome was noted in 62 (32%), satisfactory - in 117 (60%), unsatisfactory - in 16 (8%) patients. Positive results remained in 92% of patients, although the proportion of good assessments decreased and the proportion of satisfactory assessments increased. After 1.5 years, we observed 180 patients, in 143 of them the pain resumed with almost the same intensity.
According to the pain rating scale, it was found that before surgery the intensity of pain was 47.1 ± 6.9 points, after 3 days – 11.4 ± 3.5 points, after 1 month – 6.9 ± 4.1 points, after 6 months – 7.7 ± 3.8 points, after 1 year – 8.5 ± 4.3 points, after 1.5 years – 37.7 ± 3.3 points. Apparently, reinnervation of the spinal segments has occurred and during this period a repetition of radiofrequency destruction is possible. The manipulation was repeated in 47 patients with a pronounced positive effect.
In turn, in the control group, before conservative therapy, the pain intensity was 46.3 ± 5.3 points, at the end of treatment – 21.7 ± 4.2 points, after 6 months – 39.5 ± 3.2 points, after 1 year – 45.4 ± 5.6 points (Fig. 6).
Thus, it is obvious that not only the higher effectiveness of RFD compared to conservative therapy, but also a longer period of remission after the procedure.
A study of the biomechanics of the cervical and lumbar spine before and one month after surgery showed that the amplitude and speed of movements in the spinal segments increases significantly.
The maximum level of flexion in the lumbar spine increased by an average of 33 degrees (from 25 ± 3.4 degrees to 58 ± 5.1 degrees (p < 0.05)), the maximum level of extension increased by an average of 18 degrees (from 7 ± 2.6 degrees to 25 ± 4.2 degrees (p < 0.05)), the speed of flexion-extension movements increased by an average of 62 degrees per second (from 33 ± 1.8 degrees per second to 95 ± 4.7 degrees per second (p<0.05)), the amplitude of lateral bending of the body increased by an average of 41 degrees (from 32 ± 1.6 degrees to 73 ± 3.2 degrees (p<0.05)). The maximum level of flexion in the cervical spine increased by an average of 34 degrees (from 31 ± 2.5 degrees to 65 ± 3.3 degrees (p < 0.05)), the maximum level of extension increased by an average of 37 degrees (from 22 ± 4.2 degrees to 59 ± 1.8 degrees (p<0.05)), the speed of flexion-extension movements increased by an average of 70 degrees per second (from 59 ± 3.7 degrees per second to 129 ± 1.7 degrees per second (p<0.05)), the amplitude of lateral head tilts increased by an average of 46 degrees (from 41 ± 2.2 degrees to 87 ± 3.5 degrees (p<0.05)). Improving the kinematics of the spine due to the elimination of pain in the absence of surgical action directly on the joints slows down the process of degeneration of the joint capsule, ligamentous apparatus and intervertebral discs [4].
Facet joint block
Effectively relieves pain by administering local anesthetic drugs in combination with a glucocorticoid hormonal agent directly into the cavity of the facet joint, or into the area where the sensory nerve passes. The anesthetic temporarily blocks the transmission of impulses along the nerve, instantly relieving pain, while the glucocorticoid hormone, having a pronounced anti-inflammatory effect, quickly eliminates the inflammatory process, swelling and compression of tissue (the main causes of pain), thereby prolonging the effect of the blockade.
Radiofrequency ablation of the spine: treatment benefits
This approach to combating spinal problems is highly effective with minimal time investment. Other advantages of the procedure include:
- Rapid recovery in the first days after treatment;
- No need for full anesthesia;
- Careful monitoring by the doctor of the area affected by the device;
- No trauma;
- High degree of tolerance;
- Minimal risk of complications and adverse reactions.
Radiofrequency ablation of the spine costs significantly less than invasive surgery. In addition, the procedure can be performed several times on the same area of the body.
Who should undergo penile denervation in Moscow?
This operation is perfect for men with premature ejaculation caused by hypersensitivity of the head, especially with the primary form (for more information about the various forms of premature ejaculation, see here ).
One of the conditions for high efficiency of denervation of the head is the presence of a permanent sexual partner and regular sex life. For men with infrequent and irregular sexual intercourse, other ways to increase the duration of sexual intercourse are recommended ( see here )
In order to assess in advance the effectiveness of denervation of the glans penis, it is recommended to undergo a Lidocaine test. 20-30 minutes before sexual intercourse, apply 10% Lidocaine spray (or better Emla cream) to the frenulum area, leave for 10 minutes and rinse with water. Then evaluate the result.
A positive result of the Lidocaine test - an increase in the duration of sexual intercourse by 2-3 times - indicates good prospects for surgical treatment of premature ejaculation - denervation of the head.
A negative result (that is, no effect) indicates the neurogenic nature of premature ejaculation ( read here )