TABLE 8.

Summary of studies evaluating radiofrequency neurotomy (RFN) for chronic whiplash-associated disorder (WAD)

Reference, year, country, score	Population and methods	Outcome measures	Results
Lord et al (27), 1996, Australia, PEDro score = 8	Randomized controlled trial. 24 patients with ≥3 months pain in one or more cervical zygapophysial joints (excluding C2–C3) that was refractory to conventional therapy were randomly assigned to one of two treatment groups. 12 patients received percutaneous RFN, and 12 received a sham neurotomy. Patients received treatment only for their most painful joint	Pain intensity (VAS), the McGill Pain Questionnaire and yes/no questions regarding pain during activities were assessed at baseline and at a 3-month follow-up. Time to return of 50% preoperative pain level was also assessed via telephone contact	6 of 12 control group patients and 3 of 12 active treatment patients experienced return of pain immediately after the operation. Significantly different median times elapsed before pain returned to the 50% preoperative level: 263 days in the active treatment group compared with 8 days in the sham treatment group (P<0.05)
Husted et al (32), 2008, USA, ns	Case series. 22 patients with chronic WAD who had previous success with RFN but whose symptoms had returned were included in this study to receive another RFN treatment. One patient was lost to follow-up	Success of treatment was quantified as greater than 50% relief of pain following the operation	Repeat treatment was considered to be a success in 95% of patients and a failure in 1%. The mean duration of relief was 11.5 months, which is not significantly different from the duration of relief following initial treatment
Liliang et al (34), 2008, Taiwan, ns	Case series. 14 patients with chronic WAD underwent pulsed radiofrequency lesioning of the cervical medial branches. The procedures were performed in 2 cycles of 180 s after localization under fluoroscopy guide	Primary outcome measures included pain intensity (VAS) and medicine requirements. Outcomes were assessed at 1, 6 and 12 months after the procedure	12, 11 and 9 patients reported a greater than 60% reduction in pain at the 1-, 6- and 12-month follow-ups, respectively. Medicine requirements were also decreased in 13, 12 and 10 patients at the 1-, 6- and 12-month follow-ups, respectively
Prushansky et al (33), 2006, Israel, ns	Case series. 40 patients with chronic WAD (whose pain remained after receiving conservative treatments) underwent cervical RFN in various locations	Pain intensity (VAS), the Neck Disability Index, cervical range of motion, isometric cervical muscle strength, cervical pressure pain threshold, Symptom Checklist 90-R and subjective report of improvement were assessed at baseline and approximately 1 year after the intervention	Compared with baseline, patients showed significant improvement on each of the outcome measures, including pain intensity (32±30 versus 52±25), neck disability (17.2±9.7 versus 22.5±9) and cervical range of motion (251.3±68.2 versus 212±67.5), each significant at P<0.001. Collectively, improvement was noted in 70% of patients at the 1-year follow-up, with 80% satisfied with the procedure
Sapir and Gorup (31), 2001, USA, ns	Cohort study. 46 patients with ≥5 months of whiplash-induced headache, neck pain and shoulder pain were referred following a failed course of conservative treatment. 28 patients were litigant while 18 patients were nonlitigant. All patients had successful diagnostic medial branch nerve blocks before undergoing therapeutic RFN	Pain intensity (VAS), medication use and self-reported symptom improvement were obtained at baseline, 2 weeks and 1 year post-treatment	Compared with baseline, both litigants and nonlitigants experienced a significant reduction in pain intensity (from 8.2±1 to 3.6±1.8, P<0.05), and had reduced medication use by 50%; however, between-group differences were not significant
McDonald et al (29), 1999, Australia	Follow-up study. This study was a follow-up of 2 previous studies (Lord et al, 1995 [26] and 1996 [27]). Of the 28 patients who underwent RFN between C3–C4 and C6–C7, 11 were from Lord et al 1995 (26), 14 were from Lord et al 1996 (27) and 3 were new. Most patients received repeat procedures once their pain returned	The primary outcome measure was time to return of 50% preoperative pain level. Pain intensity (VAS) and the McGill Pain Questionnaire were assessed at baseline and at 3- and 12-month follow-ups or when pain returned	Pain refractory to the initial treatment (less than 30 days relief) did not respond to a second treatment. Recurrent pain that was relieved by the initial treatment for at least 90 days was relieved by repeat procedures for at least 90 days: median pain relief per procedure in this group (n=11) was 218.5 days; the range of cumulative duration of relief was 14 months to 5.4 years, as a result of 4 shorter-lasting procedures and 2 longer-lasting procedures
Wallis et al (28), 1997, Australia	Secondary analysis. This study used a subset of the patients included in Lord et al 1996 (27). Only the 17 patients with a single painful joint were retained for analysis. The authors reasoned that any untreated painful joints could negatively influence the patient’s psychological profile	Pain intensity (VAS), the McGill Pain Questionnaire, the Symptom Checklist 90-R and yes/no questions regarding pain during activities were assessed at baseline and at 3 months post-treatment	6 of 9 patients receiving the active treatment and 3 of 8 receiving the sham neurotomy experienced complete resolution of psychological distress, total pain relief and full restoration of function
Lord et al (26), 1995, Australia, ns	Case series. 19 patients with WAD for ≥3 months were diagnosed with cervical zygapophysial joint pain through comparative local anesthetic blocks. 10 patients underwent therapeutic third occipital neurotomy and 10 underwent lower cervical medial branch neurotomy. 28 procedures were performed for treatment of 21 joints	The primary outcome measure was duration of complete pain relief, defined as absolutely no pain in the targeted region. Progress was recorded at 3 and 12 months follow-ups, or when the pain returned	3 of 10 patients who underwent third occipital neurotomy and 7 of 10 patients who underwent lower cervical medial branch neurotomy obtained complete pain relief for clinically useful periods (6 months to 2 years). Ataxia was a regular side effect of third occipital neurotomy

ns No score; PEDro Physiotherapy Evidence Database; VAS Visual analogue scale