Correspondence

Treatment of Chronic Cervical Zygapophyseal-Joint Pain

N Engl J Med 1997; 336:1530-1531May 22, 1997

Article

To the Editor:

With regard to the article by Lord et al. on percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain (Dec. 5 issue),1 one of the principles of treatment after musculoskeletal injury is to protect the injured area and prevent the patient from assuming postures and performing movements that continue to aggravate the injury. This may be especially difficult with a neck injury. Much of the pain experienced by the subjects in this study before the surgery probably served no useful purpose and caused unnecessary suffering. Yet some of the pain may have warned or prompted them to avoid certain postures and activities: to turn the torso rather than the neck or to extend the thoracic spine and flex the neck at the occiput to avoid impingement of facet joints. The neurotomy procedure creates the substrate for Charcot's joint in patients with a mean age of 43 years and a life expectancy of more than 30 years. Comparison of patients treated with neurotomy with controls 5 to 10 years after the procedure would be important. Will neurotomy eventually lead to an anesthetic, unprotected, degenerative joint?

Paul J. Drinka, M.D.
Ken Jaschob, P.T.
Wisconsin Veterans Home, King, WI 54946-0620

1 References

1. 1

   Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med 1996;335:1721-1726
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Charcot's arthropathy is not a feature of denervated joints; it occurs in denervated limbs in which the muscles and other deep tissues are also anesthetic. Consequently, the damage characteristic of Charcot's joints results from lack of protection by the surrounding muscles, because the muscles that act on a joint, not the joint itself, are the cardinal source of the awareness of a body part and its movement through space.1 Indeed, selective denervation of the wrist does not cause Charcot's arthropathy.2

Radio-frequency neurotomy does not render a cervical zygapophyseal joint liable to Charcot's arthropathy. The zygapophyseal joint is one of three joints in a cervical segment in which the contralateral zygapophyseal joint, the ipsisegmental disk, and the orientation of the articular facets maintain mechanical stability. Furthermore, medial-branch neurotomy denervates no more than 20 percent of the muscles acting across a segment.3 Provided that neurotomy is restricted to one or two segments, the integrity of the cervical musculature is essentially maintained. Moreover, radio-frequency neurotomy is not permanent; nerves regenerate in due course. Therefore, any unwanted impairment, should it arise, would not be permanent.

Chronic cervical zygapophyseal-joint pain causes physical, psychological, and social disability, yet it affords no particular protection to a segment that is otherwise mechanically stable. For these reasons we are disposed to relieve chronic cervical zygapophyseal-joint pain rather than fear a condition that, on the basis of the available evidence, is very unlikely to occur.

Susan M. Lord, B.Med., Ph.D.
Nikolai Bogduk, M.D., Ph.D.
University of Newcastle, Callaghan, NSW 2308, Australia

3 References

1. 1

   McCloskey DI. Kinesthetic sensibility. Physiol Rev 1978;58:763-820
   Web of Science | Medline

2. 2

   Buck-Gramcko D. Denervation of the wrist joint. J Hand Surg Am 1977;2:54-61
   Medline

3. 3

   Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982;7:319-330
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Greg J. McDonald, Susan M. Lord, Nikolai Bogduk. (1999) Long-term Follow-up of Patients Treated with Cervical Radiofrequency Neurotomy for Chronic Neck Pain. Neurosurgery 45:1, 61
   CrossRef