Ramus Cummunicans Block for discogenic pain?

[mmglobal]

Last month I went to see a new neurologist with a client of mine. I spent several hours with Dr. Sheldon Jordan in Westwood. There was a lengthy meeting with the client about his upcoming procedure, and also more than an hour in the OR for an RF ablation. (This was not a rhizotomy or a typical nerve ablation.. but that is another subject. If the patient chooses to come and post, you'll learn more about it, but for now, I'll focus on other topics.)

One of the things we discussed was the potential for treating discogenic pain with a nerve block. Diagnostic injections are possible, followed by RF ablation of the nerve, similar to rhizotomy. If this works for some people, it may be perfect for people who are like I was... still had good disc height... no leg pain... but suffereing from disabling low back pain. In my case, I would have gotten to surgery anyways, as my discs continued to break down an rupture, but there were 5 years before my ADR surgery that were mostly 0% leg pain, 100% LBP, still with good disc height. If this treatment worked, I may have had many months of relief.

Google produced many results. Here are a few:

This will be an interesting discussion. I'll be spending more time with Dr. Jordan next month. I'll post more as I learn more.

All the best,

Mark
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The use of radiofrequency lesions for pain relief in failed back patients. Sluijter ME. International disability studies 1988;10(1):37-43.

If conservative measures fail in the treatment of the failed back patient and if there is no indication for further surgery, interruption of nerve pathways conducting noxious stimuli may be attempted. The indication for such treatment is made on the result of a series of prognostic blocks analysing the conduction pattern of noxious stimuli. A new technique is described to interrupt the grey communicating ramus, conducting afferent fibres from the anterolateral and anterior parts of the annulus fibrosus. Results indicate a discrepancy between the result of radiofrequency lesions and the outcome of prognostic blocks. The discrepancy is more pronounced in failed back patients. Treatment with radiofrequency lesions is well tolerated and it has few adverse effects. It has a measure of success in a group of patients who are very difficult to manage otherwise.

A randomized controlled trial of radiofrequency denervation of the ramus communicans nerve for chronic discogenic low back pain. Oh WS, Shim JC. Clin J Pain. 2004 Jan-Feb;20(1):55-60.

OBJECTIVE: The objective of this study was to determine the efficacy of percutaneous radiofrequency (RF) thermocoagulation of the ramus communicans nerve in patients suffering from chronic discogenic low back pain.

METHODS: Forty-nine patients who suffered chronic discogenic low back pain at only 1 painful vertebral level, and whose pain continued after undergoing intradiscal electrothermal annuloplasty (IDET), were randomly assigned to 1 of 2 treatment groups. The lesion group (n = 26) received RF thermocoagulation of the ramus communicans nerve. Patients in the control group (n = 23) received an injection of lidocaine without radiofrequency. Visual analog scale (VAS) pain scores, analgesic requirements, SF-36 subscales, and the overall patient satisfaction with the procedure were tabulated.

RESULTS: The average follow-up period was 4 months. The patient-reported VAS pain scores were significantly lower (P < 0.05) in the lesion group. The scores of the RF lesion group improved by a mean increase of 11.3 points (P < 0.05) on the SF-36 bodily pain subscale, and by a mean increase of 12.4 points on the physical function subscale (P < 0.05). In a follow-up analysis within the RF lesion group, VAS pain scores improved by a mean reduction of 3.32 (P = 0.001). The scores improved by a mean increase of 14.5 points (P = 0.005) on the SF-36 bodily pain subscale and 15.2 points(P = 0.002) on the physical function subscale within the RF lesion group. One patient in the lesion group complained of mild lower limb weakness, but he completely recovered at postoperative 15 days without any serious problems.

DISCUSSION: In patients with chronic discogenic low back pain, percutaneous RF denervation of the ramus communicans nerve should be considered as a treatment option.

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Gray ramus communicans nerve block: novel treatment approach for painful osteoporotic vertebral compression fracture Chandler G, Dalley G, Hemmer J Jr, Seely T. South Med J. 2001 Apr;94(4):387-93.

BACKGROUND: Osteoporotic vertebral compression fracture (OVCF) is a common complication of osteoporosis in the aging population. Refractory chronic pain may develop, and few effective treatment options exist.

METHODS: We retrospectively analyzed 52 cases in which gray ramus communicans nerve block was used for painful OVCF after failure of conservative analgesic therapy. All were office-based, fluoroscopically guided procedures; a combination of 2% lidocaine and 2% sterile triamcinolone diacetate (Aristocort) was injected on the gray ramus tract of the somatic nerve root corresponding with radiographically documented OVCF. Patient-reported and physician-reported pain scores, analgesic medication use, and overall patient satisfaction were measured. The average follow-up period was 9 months.

RESULTS: A 1-point improvement in pain scores was reported by 92% of patients and 88% of physicians; a 4-point improvement was reported by 63% and 58%, respectively. No patients reported increased pain scores; physicians reported increases in two cases. Decreased analgesic requirement was documented in 42%. Patient satisfaction was "high" in 50% and "medium" in 25%. No procedural complications occurred.

CONCLUSION: Prompt and sustained improvements in all parameters, especially pain scores, support widespread clinical application of this safe effective and cost-effective therapy.