Radiofrequency-treatments

Oro-facial pain

Koen Lauwers, MD, FIPP

Koen Lauwers, MD, FIPP BPS 2014

Smoking and physical inactivity

Pain 153 (2012) : 56-61, Risk factors for medication –overuse headache ; 11 year follow up , 27000 patients

P(medication-abusus induced headache= MOH) X2

90% of cluster headache patients = smokers !

Koen Lauwers, MD, FIPP BPS 2014

Stop the pain !

Stop smoking ! Start moving !

Google : > 20 miljon references The Cleveland Clinic-website of well- being in Ohio : 1.The Journal of Head and Face Pain, 48: 545–552. doi: 10.1111/j.1526-4610.2007.01037.x. Accessed 6/17/2013. 2.JAMA. 2012;308(18):1889-1896. doi:10.1001/jama.2012.14276. Accessed 6/17/2013.

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Koen Lauwers, MD, FIPP BPS 2014

1. RF treatment : what does it do ?

2. Where do we place our needle(s) ?

3. How do we work ?

4. What are de main complications ?

5. Do we have good results ?

6. Future ?

7. What did you learn ?

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1. Radiofrequency ( RF ) treatment ?

Koen Lauwers, MD, FIPP BPS 2014

= >100 years old = high frequency alternating current distal T /Voltage/Amperage controlled treatment

change of structure - different = safe RF = neurodestructive (high T) PRF =pulsed radiofrequency treatment = neuromodulative

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Koen Lauwers, MD, FIPP BPS 2014

2. Where do we place our needles ?

1. Trigeminal ganglion 2. Sphenopalatine ganglion 3. Cervical facetinnervation 4. Cervical dorsal root ganglion 5. Stellate Ganglion 6. Superficial-peripheral ( nervus occipitalis maior, n.supra-orbitalis, n.mandibularis, …) 7. Intra-articular ( TMJ )

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Neuro-anatomical relation facies / neck

Koen Lauwers, MD, FIPP BPS 2014 16

Koen Lauwers, MD, FIPP BPS 2014

RF: 3x 60’ 60-65-70°C under wake-up anesthesia

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1.RF treatment of Trigeminal ganglion :

2. Clusterheadache

Koen Lauwers, MD, FIPP BPS 2014

Algie vasculaire de la face

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2. RF of Sphenopalatine ganglion

Koen Lauwers, MD, FIPP BPS 2014

RF treatment : 60 s 80°C

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NOM

AP

3. Cervical facetinnervation :

RF treatment : 60s 80°C

4. PRF of cervical dorsal root ganglion :

Koen Lauwers, MD, FIPP BPS 2014

PRF cervical DRG : 2 Hz, 45 V, < 42°C, 2 minutes

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C6

C6

5. Diagnostic and RF treatment of Stellate Ganglion :

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Needle in tunnelvision RF 1 minute 80°C at C7

Diagnostic at C6 Black = contrast

Koen Lauwers, MD, FIPP BPS 2014

V1 V2 V3

Cervical 2-3

Cervical 3-4-5

Cervical 5-6

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Sensoric innervation of head/face skin

6. Sensoric innervation of head/face skin

Koen Lauwers, MD, FIPP BPS 2014

Greater occip. n. (C2)

Third occip. n. (C3)

Greater auric n. (C 2,3)

Lesser occip. n. (C 2)

V1

V2

V3

V0

Vc C2

C3

Transv. cut n. of neck (C 2,3)

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Pulsed RF treatment of peripheral nerves 2 Hz, 45 V, max.42°C- > 2 minutes

Koen Lauwers, MD, FIPP BPS 2014

3. How do we work ?

- Most important : interdisciplinary- good selection of patients

- Sterile conditions- disposable needles/sets-informed consent - Operating theatre ( lead protection)

- X-ray (conventional and/or CT guided) - echography

- Daycare or one night in hospital ( depending on schedule)

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Koen Lauwers, MD, FIPP BPS 2014

4. Main (possible) complications of interventional (RF) treatment :

- General : - Bleeding :

- superficial - Deep : IC bleeding – choakmuscle bleeding- nosebleeding

- Infection - Specific :

- Gasser :

facial hypesthesie ( 50%)-masseter muscle weakness ( 10%), dry eyes ( 10%?)

- Sphenopalatine ganglion : bradycardia, palatine or dental numbness, max.nerve lesion

- Stellate ganglion : IA vertebralartery injection/death – pneumothorax - Horner

- Facetdenervation : burning pain ( temporary )

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5. Results :

Koen Lauwers, MD, FIPP BPS 2014

- Trigeminal nerve RF treatment : very high initial succes for TN - less duration than Janetta Solitary V3 > solitary V2 or multi V pain - RF sphenopalatine ganglion : episodic > chronic cluster headache - RF of cervical facet innervation for cervicogenic headache :

high succes rate if good patient selection and if major Occipital nerve

Lopez et al Neurosurg 2004; Tatli et al. Acta Neur (Wien) 2008

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Koen Lauwers, MD, FIPP BPS 2014

diagnose behandeling Evidentie ratio

Trigeminusneuralgie RF van het ganglion 2B+

Clusterhoofdpijn RF pterygopalatinum

2C+

Persisterende idiopath.aangezichtspijn

RF pterygopalatinum

2C+

Cervicogene hoofdpijn Injectie NOM cortico

1B+

RF facetten mediale takken

2B+-

Injectie AA-gewricht

2C- : negatieve aanbeveling

PRF van het C2-3 DRG

Studie verband

WAD-whiplash RF facetten mediale takken

2B+

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6. (near) Future ?

Koen Lauwers, MD, FIPP BPS 2014

- More interdisciplinary work and prevention of pain = communication + explanation = better selection for RF treatment ! - Technical : less invasive

less radiationdoses – more echography(?) better needles, (more perifepheral?) optimalization electrical current parameters ( rTMS = repititve transcranial magnetic stimulation) - Medical

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7. Conclusion : what did you learn ?

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1. Prevention of pain = key stone of our job ( communication on life-style) 2. There is rather good evidence for treating patients wiht oro- facial pain by RF interventional paintreatment 3. Key-point = patient selection by interdisciplinary work 4. Rf treatment is safe in experienced hands

Thank you for being here today !

www.klina.be

Koen Lauwers, MD, FIPP BPS 2014