Monday, February 13, 2012

Published papers by Dr Stuckey

I expect to pass through life but once. If therefore there be any kindness I can show or any good thing I can do to any fellow being, let me do it now as I shall not pass this way again.
                        William Penn

Percutaneous *Rhyzolysis: Active Treatment of Chronic Back Pain
Richard H Stuckey, MB
Abstract. When percutaneous rhizolysis was first presented, its efficacy in the treatment of back and neck pain was claimed to be due to denervation of zygapophyseal joints. This claim was quickly refuted, and thus the procedure did not gain general medical acceptance. By focusing attention on posterior vertebral structures as a cause of back pain, it was the forerunner of the more sophisticated zygapophyseal joint blocks and denervation techniques. In the series presented, 73% of a group of 202 patients with hitherto intractable back or neck pain were significantly improved 12 months after percutaneous rhizolysis. As this treatment is targeted at myofascial trigger points, consideration will be given to the link between these peripheral points and underlying osseous pathology. It will be postulated that this treatment interrupts afferent pain transmission from these trigger points, thus effecting longer lasting pain relief than other methods of treating trigger point pain.

Percutaneous rhizolysis was first presented by Rees in 1971. His original paper (1) generated a great deal of world-wide interest both because of the claimed success rate and for focusing attention on the posterior vertebral structures as a cause of back pain.

The explanation given for the pain relief was that this procedure divides the medial branch of the posterior ramus of the segmental nerves, thus denervating the zygapophyseal joints and thereby alleviating any pain coming from these joints. This theory was widely criticized; it was claimed that the blade is not long enough and the incision usually too lateral to reliably access these nerves. Many also stated that even if the joint was denervated, then it would surely degenerate with the passage of time.

Over the years attention has focused on the zygapophyseal joints as a source of back pain. Despite the last criticism mentioned above, more accurate and sophisticated (and expensive) methods of denervating zygapophyseal joints have been developed, including local anaesthetic blocks and destruction of the medial branch of the posterior ramus of the segmental nerves by freezing, radiofrequency diathermy, or sclerosant injection (“facet rhizotomy”). The original procedure seems to have been forgotten.
For more than 2 years I have been using Rees’s modified procedure and will present a series of 202 consecutive cases treated by percutaneous rhizolysis and followed up 12 months later. The results compare favourably with any method of zygapophyseal denervation. An alternative theory will be postulated to explain this pain relief and the advantages of this technique.

The Series:

Patients

The series comprised 254 consecutive patients who pain had been present for more than 6 months, was getting worse at the time of consultation, and had not responded to other forms of treatment. In 202 patients (79.5%) 12-month follow-up was achieved.
The 202 cases comprised 51 cervical, 24 thoracic, and 127 lumbar problems. There were 97 men and 105 women. The average patient age was 59.5 years, and the average pain duration was 13.6 years.

Diagnosis

The diagnoses made prior to presentation were many and varied (Table 1). Osteoarthritis was by far the most common. In a significant percentage of cases no diagnosis had been offered to explain the pain. Where a diagnosis of degeneration or osteoarthritis was made, there was virtually no correlation between the severity of radiological signs and the severity of clinical symptoms.

Prior Treatment


Every patient in this series had, in the past, been unsuccessfully treated with some or all of the following modalities: NSAIDS, physiotherapy, chiropractic treatment, acupuncture, massage, injections, epidural corticosteroid injection, and operation.
The majority had been told that all treatment options had been tried and that there was nothing that could be done.

Physical Examination


In the majority of patients, specific neurological deficits could not be elicited. When limb pain was present, it usually did not correspond to a recognised dermatome. The only consistent physical finding was the presence of well-localised tender spots (“trigger points”, points of Travell (2), distal points of Russel (3) and various other synonyms). These points were usually near the level of maximum pain and often, but not always, they lay over the zygapophyseal joints. If the pain was unilateral, the trigger points were always on the same side as the pain.
The surface anatomy of these points was remarkably constant. While they could be found in any muscle of the body, the vast majority occurred at one of seven sites (Fig 1). Pressure on these points (particularly 3 and 7 in Fig.1) often reproduced the patient’s limb pain.

Table 1:     Most common pre-treatment diagnosis
1.    Osteoarthritis
2.    No diagnosis
3.    Disc degeneration
4.    Spondylitis
5.    Osteoporosis
6.    Pinched nerve

Procedure
This was similar to that originally published by Rees (1)
•    The appropriate trigger points were identified and marked
•    The area was cleansed with topical antiseptic
•    3ml of 0.5% xylocaine plain was injected
•    The rhizolysis blade (ENT microblade 52L or M) was introduced 15°cephalad to the vertical, moved caudally 30° and removed. By moving the blade through a much shorter arc, hematoma formation was virtually abolished.
•    A pressure dressing was applied (sutures were not used in any patient)
•    Subsequent treatments, if required, were usually done at monthly intervals; the average number of treatments was two per patient.
•    Patients were deliberately given no post-procedure instructions regarding weight loss, exercises, or lifestyle change; they were instructed to contact me if the pain recurred.
•    Follow-up was done 12 months after treatment

Results
At the follow-up examination, patients were asked to allocate their current pain and disability status into one of six groups:
  1. Worse
  2. No change
  3. Mild improvement
  4. Moderate improvement
  5. Marked improvement
  6. Total resolution as compared with pre-treatment pain levels.

A good result was considered as moderate improvement, marked improvement, or total resolution. By this definition 72.8% of cases achieved a good result (Table 2). Almost all who showed improvement commented on a markedly increased mobility of the area treated, and previously tender trigger points were no longer present. None of those who were worse attributed this decline to the rhizolysis procedure. Of the 202 cases, 13 had had previous vertebral surgery – four of these achieved total resolution of their pain and nine were unchanged. Thus, this procedure does not work as well when there has been prior surgery.
This is the first follow-up series of percutaneous rhizolysis to be reported and reaffirms previous publications (non-follow-up) as to the efficacy of this procedure (1,4-7).

Table 2:  comparative pain status 12 months after rhizolysis
 

No of patients
%
Worse
7
3.5
No change
37
18.3
Mild improvement
11
5.4
Moderate improvement
33
16.3
Marked improvement
81
40.2
Total resolution
33
16.3
TOTAL
202
100

Discussion
Uncontrolled trials such as this are, of course, subject to many variables and thus one cannot make dogmatic conclusions. By leaving the follow-up for 12 months, variables such as patient expectations, practitioner’s suggestions, and effect of local anaesthetic would clearly not be operating. It would be reasonable to conclude from the figures that percutaneous rhizolysis provides a variable degree of relief in a high percentage of selected patients with intractable back and neck pain. The main point of discussion must surely be:  Why does it work?
The initial assertion by Rees (1) was that this procedure divides the medial branch of the posterior ramus of the intersegmental nerves. This was thought to denervate the zygapophyseal joints and thus relieve any pain arising from these joints. This theory was, for sound reasons, disputed and the procedure was not generally accepted by most of the medical profession.  Some of the reasons for this disputation were the following:
•    An incision 2-3 cm from the midline would cut the lateral, not medial, branch of the posterior ramus and thus denervation of zygapophyseal joints would not be effect5ed
•    In obese people, the blade used is not long enough to reach the intertransverse membrane (8) and thus neither medial nor lateral branches would be cut.
•    In many people, points of Travell do not over-lay zygapophyseal joints. While ‘peripheral rhzolysis’ done at these points often produces spectacular results, the improvement obviously has nothing to do with zygapophyseal denervation
•    Even if these joints were denervated, what would happen to them in years to come?

Those who levelled this criticism relied (and still rely) mainly on the Mixter-Barr theory (9) as the cause of back pain. This theory suggests that the majority of back pain is due to pressure by either bone, disc material, or ligament hypertrophy on exiting segmental nerves. No significance is attributed to the presence of trigger points. Strict adherence to this theory leaves the majority of back pain sufferers undiagnosed, inadequately and unsympathetically treated, and often unnecessarily operated on.
In the series presented, the only constant factor was the presence of trigger points in the vicinity of the pain. The following theory endeavours to link together underlying osseous pathology, myofascial trigger points, and pain production. It would lead to a more rational explanation as to why percutaneous rhizolysis works:
1.    A variety of stimuli (trauma, ‘whiplash’, injury, overuse, arthritis of vertebral body or apophyseal joint, disc degeneration, disc prolapsed) sets up a ‘trigger point’ in adjacent ligamentous or muscular supports.
2.    From this trigger point noxious stimuli are transmitted centrally by either the Aᵹ (myelinated) or C (nonmyelinated) slow conducting nerve fibres. These fibres relay in the dorsolateral tracts for central transmission (10). Thus, a sensory (or pain) arc is established and it is not necessarily the initiating cause which propagates the pain (Fig 2)
3.    ‘Rhyzolysis’ divides these afferent nerves, thus interrupting the sensory arc and effecting pain relief (Fig 3). The zygapophyseal joints are thus not denervated and continue to function normally.
4.    The procedure thus relieves that percentage of the overall pain caused by the trigger points and leaves the patient with the percentage of overall pain which was, in fact, coming from the underlying osseous pathology.

This theory would fit in with most of the objections to the previously published theory on the success of this procedure. It would also explain why most people do not get 100% relief, why some (very few) recur, and why the procedure does not work for clinically obvious and significant vertebral canal stenosis. It should thus be viewed as an adjunct to, and not in competition with, vertebral surgery.


Another observation is that percutaneous rhizolysis effects much longer pain relief than other methods used to treat myofascial pain (injections, freezing, sclerosants, massage, acupuncture, thermal change, etc.).

While the follow-up in this series varies from a minimum of 12 months to a maximum of 24 months, I have seen a number of patients who have had this treatment more than 10 years previously. These patients are still enjoying significant pain relief and their vertebral columns (in particular the zygapophyseal joints) are functioning normally. Other authors (11, 12) have published more formal analyses of the long-term results of a similar procedure. Shealy adapted Rees’s original procedure by producing chemical denervation of the zygapophyseal joints (“facet rhizotomy”). This is done by injecting 0.5cc of 4.5% phenol in glycerine under radiological control near zygapophyseal joints where it had already been shown that marcaine produced temporary pain relief. At an 8 year follow-up 72% of people not previously operated upon were still enjoying good to excellent pain relief. There was no suggestion of long-term damage to the apophyseal joints.
Thus, whether percutaneous rhizolysis denervates zygapophyseal joints or not, it has a similar success profile to other procedures, is cheaper, simpler and quicker, and obviously is not detrimental to the long-term health of the zygapophyseal joints. It is equally applicable at any level of the vertebral column and can also be used on peripheral trigger points which commonly occur in the trapezius, gluteus, and scapula muscle groups. Percutaneous rhizolysis thus has greater clinical scope than facet denervation by whatever means.

Conclusion
The purpose of this article is twofold: first, to reaffirm, by way of a follow-up series, that percutaneous rhizolysis gives lasting relief to a large percentage of selected patients with intractable back or neck pain; second, to put forward an alternative theory as to why it works. This theory is not viewed as an endpoint, but as a stepping stone to more detailed research and discussion on this, and similar, methods of relieving back pain.
Percutaneous rhizolysis should be viewed as part of the overall treatment protocol in selected patients with intractable back and neck pain before expensive and invasive investigations and operations are embarked upon.

References
1.    Rees S. Multiple bilateral sub-cutaneous rhizolysis in the treatment of the slipped disc syndrome. Ann Gen Pract 1971; 16:126-127
2.    Travell J, Travell W. Therapy of low back pain by manipulation and of referred pain in the lower extremities by infiltration. Arch Phys Med 1946; 27:537
3.    Russel WR. Treatment of intractable pain. Proc Roy Soc Med 1959; 52:983
4.    Toakley JG. Subcutaneous lumbar rhyzolysis – an assessment of 200 cases. Med J Aust 1973; 2:490-492
5.    Francis JG. Subcutaneous lumbar rhizolysis – an assessment of 200 cases. Med J Aust 1973; Oct 13:102
6.    Stuckey RH. Percutaneous rhizolysis: Why does it work? Med J Aust 1990; 152:500
7.    Cyriax J. Treatment of intractable back-ache. In: Textbook of orthopaedic medicine, Vol 1 Balliere-Tindall, London, 1982, 348
8.    King JS. Randomised computerised trials of the Rees and Shealy methods of the treatment of low back pain. In: Morley TP (ed) Current controversies in neurosurgery. WB Saunders, Toronto, 1976, 89-93
9.    Mixter W, Barr, JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 1934; 211:210-215
10.    Travell J, Simons D. Myofascial pain and dysfunction. The trigger point manual. Williams and Wilkins, Baltimore, 1983; 13-17
11.    Shealy CN. Facet rhizotomy/denervation. A fifteen year experience. J Neurol Orthop Med Surg 1988; 9:107-109
12.    Silvers HR. Lumbar percutaneous facet rhizotomy. Spine 1990; 15:36-40

When Rees first presented this technique in 1971, he claimed that pain relief was achieved by cutting the nerve supply to zygapophyseal joints (1). I have been using the identical technique but believe the procedure produces pain relief by interrupting pain transmission from myofascial trigger points (2, 3).
The following six cases demonstrate the variety of patients suitable for this treatment, and the selectivity of response. A brief comment will follow each case and the commonality of all cases will be considered in the discussion.

Case 1
A 59 year old man developed severe back, neck, and head pains following a motor car accident in 1968. In 1972 the patient had a cervical (C45) fusion which produced mild (but not sustained) improvement; in 1974 he had a laminectomy (L45) which produced no change; and in 1975 a lumbar fusion which he described as ‘moderately successful’.

Over the next 13 years he had crippling neck and head pain (much worse on the left side), in addition to severe lumbar pain and right buttock pain which radiated down to his right knee. Assorted ‘conservative treatments’ along with enormous quantities of analgesics and relaxants produced no pain relief, and he was forced to leave his senior position in his state’s police force.
Physical examination was unremarkable except for obvious restriction of movement and for the prominence of myofascial trigger points in the vicinity of his pain. In the neck, both the symptoms and tenderness were much worse on the left side, and in his low back both the symptoms and tenderness were predominantly right sided.

‘Rhyzolysis’ was performed at three levels at the base of the patient’s neck (C67, C7T1, T1T2) with rapid resolution of all his head and neck pains. Minor recurrence of pain 4 months later necessitated two levels being retreated. A single procedure at the L45 level produced rapid resolution of all his back and leg symptoms. Each procedure took 5 minutes, was performed by the author, with the patient fully ambulant immediately thereafter.
The patient has been virtually pain free for 2 years without any analgesic medication.

Comment

This patient had chronic pain and major underlying vertebral abnormalities in that he had had both cervical and lumbar fusion. His symptoms were attributed to the underlying osseous pathology and no relevance was attached to the presence of trigger points. Rapid pain relief followed appropriate treatment.

Case 2
An exceptionally fit 37 year old man was involved in a serious motor accident in 1986. Back pain began 3 days later and he also rapidly developed head, neck, and leg pain. When he saw the author in 1989 he complained of the following:
1.    Constant lumbar pain, worse on the left side
2.    Severe burning sensation in his left hip, worse after exercise
3.    Constant pain in both legs
4.    Constant ache in both groins and testicles
5.    Intermittent acute shooting pains in both groins
6.    Marked urinary frequency, occasional incontinence, and nocturia, between five and seven times per night
7.    Constant neck and right arm pains
8.    Frequent occipital headaches radiating to his forehead.
During the previous 2 years the patient had seen a multitude of doctors, orthopaedic surgeons, neurologists, and urologists. Extensive investigations had been performed (including X-rays, CT scans, and renal function studies), all of which were normal. No operative intervention had been suggested and regular physiotherapy had made no difference.

The patient was unable to do any form of work, required one or two walking sticks most of the time, was unable to stand for more than 2 hours, was incontinent and slept poorly due to pain and nocturia.
Physical examination was again unremarkable except for prominent myofascial trigger points. The following levels were treated with the following results.
•    L45 – immediate resolution of burning hip pain and reduction in back pain
•    L5S1 – leg pain improved, suprapubic pain gone
•    L34 – back pain virtually gone, groin pain resolved, nocturia improved dramatically
•    C56 – headaches gone, arm pain unchanged
•    T12 – less arm pain, scapula pain persists
•    T23 – all arm, neck, and head pain gone
•    Left thigh and left calf – left leg pain resolved
•    Right thigh and right calf – right leg pain resolved

The first six procedures were done over an 8 week period. The last two procedures were performed 5 months later due to the persistence of his leg pains.
The patient is now back in full time work, almost pain free, exercising at least 1 hour per day, training for a triathlon, sleeping well, not having nocturia, and enjoying his life for the first time since the accident.

Comment

No cause could be found for this patient’s severe pain and disability; it was implied that he was malingering. No significance was attached to the presence of trigger points and he obtained relief following percutaneous rhizolysis.

Case 3

Following a motor accident in 1958, a 59 year old man, a former rugby player, developed severe neck pain and headaches, which were exacerbated by a second accident in 1979. Since that time he had had severe, crippling neck pain, and headaches, in addition to bilateral arm weakness and parasthesia. Conservative treatment (physiotherapy and chiropractic) had made no difference. In 1981 he was advised to have a cervical fusion but declined.

I first saw him in 1988. Physical examination revealed a mild restriction in most movements and prominent trigger points on both sides of his cervical spine. X-ray (1988) revealed advanced cervical spondylosis with encroachment on some of the lower intervertebral exit foraminae (Fig. 1A,B).

The first procedure, at C45 level, led to almost immediate relief of the patient’s headaches. Following treatments at C56 and C67 levels his neck pain disappeared. Arm pain and tingling resolved and considerable strength return to both arms. A subsequent heavy fall led to recurrence of some of the pain but this responded to further treatment.

He has now been virtually pain free for 18 months with minimal use of analgesics.


Comments

This patient’s symptoms had, for 20 years, been attributed to cervical degeneration. The tender points in his neck had been noted but not considered significant. Rapid resolution of his pain followed percutaneous rhizolysis treatment, although his advanced cervical spondylosis is possibly worse.

Case 4
A 38 year old woman had experienced constant but fluctuating neck and head pains for 25 years. She described the pains as originating in the base of the neck, radiating to the occiput, and then all over her head; both sides were equally affected. Multiple ‘conservative’ treatments had been tried with no improvement (including medication, physiotherapy, and chiropractic). A diagnosis of arthritis had been put to the patient (despite her age and the fact that no X-ray had been taken). She was never pain free and relied heavily on analgesics.
Physical examination was remarkable except for the presence of trigger points at the C45 level. A single procedure was done at this level. Over the ensuing 14 months she has not had any head or neck pain, used any analgesics, worn a collar, or needed any other therapy.

Comment
In this case a diagnosis of arthritis has been made without an X-ray being taken. Extremely rapid relief of pain, which has been present for more than half her life, followed a single rhizolysis treatment. Again, no significance has been attached to the easily palpable trigger points. Her neck is now nontender.

Case 5
A 70 year old man presented with 20 years of vague, fluctuating back pains which had become markedly worse over the previous 2 years. His pain was mainly right sided and radiated to his right thigh, calf, and foot. The leg and foot pain bothered him more than his back.
Physical examination was unremarkable except for the presence of trigger points in both buttocks and sacrum. Pressure on the buttock trigger points reproduced his leg and foot pain. X-ray showed gross osteoarthritis with a marked spondylolisthesis of L5 on S1 (Fig. 2A, B). His pain had been attributed to the radiologically apparent osteoarthritis.

Following rhizolysis to his two right5 sacral trigger points his foot pain resolved rapidly and his thigh pain improved slowly. The left side was treated likewise 2 months later. For the 12 months following these procedures he has had no back or leg pain.

Comment

In this case gross radiological changes had been presumed to be causing the patient’s symptoms, and the trigger points were ignored as a possible cause of pain. In retrospect, the original diagnosis was incorrect.


Case 6
A 57 year old woman presented with 10 years of increasing lumbar pain. The right side was worse than the left and she also had right calf and foot pain.
Physical examination demonstrated right-sided trigger points but nothing else. Conservative treatments had not helped. X-ray showed ‘advanced degenerative disease’ at both L34 and L45 levels.
Rhyzolysis at the lowest three lumbar levels led to the rapid abolition of all symptoms. Two years later her calf pain recurred. This was associated parasthesia and was more severe than 2 years before. There was no recurrence of her back pain. CAT scan revealed vertebral canal stenosis at the L45 and L5S1 levels and following laminectomy her leg symptoms abated instantly. She has since been free of both back and leg pain.

Comment

As with the other patients, radiological abnormalities had been used to explain her pain for 10 years. Rapid and near total relief followed rhizolysis treatment. Two years later she presented again with typical unilateral pseudo-claudication of vertebral canal stenosis and underwent a very successful laminectomy. The point of debate here is what gave her the initial 2 years of relief.

Discussion
In all these cases, the presence of trigger points had been ignored as a source of pain.
The patients with underlying radiological abnormalities had been told that this was the cause of their pain and that there was nothing that could be done for them. Retrospective assessment has proven this to be wrong in that all have had lasting relief (over 14 months) following percultaneous ‘rhzolysis”.
The patients with normal underlying vertebral columns had been told such things as to ‘pull themselves together’ and ‘forget about the pain’. Both these patients had rapid resolution of their problems and are now leading normal lives.
The last case described demonstrated that this procedure does not work for clinically obvious vertebral canal stenosis (as it does not for acute intervertebral disc protrusion). Both these conditions should be easily recognised clinically and appropriate treatment instituted.
The common thread in each of these patients, and indeed all the patients that I treat, is the presence of trigger points. It is my belief that trigger points are the central issue in most people’s chronic back pain and that this procedure divides afferent, pain-conducting nerve fibres, thus effecting longer pain relief than other methods of treating trigger point pain. Whether ‘rhzolysis’ works by this means or Rees’ theory, or as a myotomy or a fasciotomy, matters little to the patient. In properly selected cases it is highly, and rapidly effective and should be offered to more pain sufferers.
‘Rhyzolysis’ should therefore not be viewed as being ‘in competition’ with surgery or any of the non-invasive methods of treating back pain. Rather it should be viewed as part of the overall treatment protocol of patients with intractable back pain where the passage of time and ‘conservative’ treatments have not helped. Its use should be considered before surgery.

Reference
1.    Rees WS. Multiple bilateral sub-cutaneous rhizolysis in the treatment of the slipped-disc syndrome. Ann Gen Practice 1971; 16:126-127
2.    Stuckey RH. Percutaneous rhyzolysis: Why does it work? Med J Aust 1990; 152:500
3.    Stuckey RH. Percutaneous rhyzolysis: active treatment of chronic back pain. J Neurol Orthop Med Surg 1991; 12:116

1 comment:


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