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Whiplash injuries and neurotomy : a pain in the neck for patients, researchers, clinical providers, and… Bassett, Kenneth, 1952-; Sibley, Lyn M.; Anton, Hugh; Harrison, Philip; Kazanjian, Arminée, 1947- Jun 30, 2001

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Centre for Health Servicesand Policy ResearchWHIPLASH INJURIES AND NEUROTOMY:A PAIN IN THE NECK FOR PATIENTS,RESEARCHERS, CLINICAL PROVIDERS,AND THE AUTOMOBILE INSURANCE INDUSTRYBCOHTA 01:7C          JUNE 2001British Columbia Office of Health Technology AssessmentPresented atISTAHC 17 th Annual MeetingPhiladelphia  PA3 – 6 June 2001U N I V E R S I T Y  O F  B R I T I S H  C O L U M B I AWHIPLASH INJURIES AND NEUROTOMY:A PAIN IN THE NECK FOR PATIENTS, RESEARCHERS,CLINICAL PROVIDERS, AND THE AUTOMOBILEINSURANCE INDUSTRYKen Bassett  MD PhDSenior Medical ConsultantBC Office of Health Technology AssessmentUniversity of British ColumbiaLyn M Sibley  BSc MHAResearcherBC Office of Health Technology AssessmentCentre for Health Services & Policy ResearchUniversity of British ColumbiaHugh Anton  MDClinical Associate Professor, Physical Medicine and RehabilitationHead, Division of Physical Medicine and RehabilitationG F Strong CentreUniversity of British ColumbiaPhilip Harrison  MDAssociate Professor, RadiologySt. Paul's HospitalVancouver BCArminée Kazanjian  Dr SocPrincipal InvestigatorBC Office of Health Technology AssessmentUniversity of British ColumbiaPresented at theInternational Society of Technology Assessment in Health Care17th Annual MeetingPhiladelphia  PA    3 - 6 June 2001BC Office of Health Technology AssessmentCentre for Health Services and Policy ResearchUniversity of British Columbia429 - 2194 Health Services MallVancouver, British ColumbiaCanada  V6T 1Z3tel (604) 822-4810fax: (604) 822-5690bcohta@chspr.ubc.cawww.chspr.ubc.caWhiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology Assessment1BACKGROUNDThe Insurance Corporation of British Columbia (ICBC), the major motor vehicleinsurance provider in the province commissioned the BC Office of Health TechnologyAssessment to conduct an independent assessment of the effectiveness and safetyevidence regarding percutaneous radio-frequency n urotomy (PRFN).The focal condition of the present study is chronic cervical pain due to whiplash injury.  Itis commonly believed that whiplash injury is due to muscle or ligament strain.  There ishowever evidence that in chronic cases, the injury is at times a lesion on the superior facetof the zygapophyseal joint (z-joint).  The z-joints are paired synov al joints which bridgethe vertebrae of the cervical spine. (Figur s 1 & 2)These lesions cannot be detected with either physical or radiological examination.Determining the presence of z-joint pain and the identity of the z-joint involved is madeby injecting local anaesthetic either into individual z-joints or to the nerves that supplythose joints.1PRFN is a palliative nerve-moderating heat-treatment that transiently interrupts peripheralnerve function.  PRFN does not treat an underlying cause of pain.  At best, it providessymptom relief while, ideally, healing takes place.PRFN generates multiple localized heat-lesions that temporarily denature the nerveleading to the z-joint, and thereby reduces the neck pain associated with chronicwhiplash.1  To perform the procedure, a medical specialist locates a cannula with anexposed needle tip on the correct anatomical structure by using an image-intensifyingx-ray machine.  A radio-frequency current passes into surrounding tissues along thelength of the un-insulated portion of the needle, and creates a lesion which encompassesthe nerve.2Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology Assessment2Figure 1: Vertebra and Related Nerves 3Figure 2: Vertebra and Related Nerves 3RESEARCH QUESTIONDoes scientifically valid effectiveness and safety evidence support PRFN treatment ofchronic cervical pain arising from zygapophyseal joint injury following motor vehicleaccidents?PURPOSE(1) Systematically to gather and critically appraise the scientific evidenceregarding PRFN versus: no treatment; placeboor other interventions.(2) To estimate the British Columbia population health impact of PRFN.Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology Assessment3METHODSA systematic review was conducted aimed at identifying and assessing the availablescientific evidence on effectiveness of PRFN.· Relevant studies were identified by searching computerized bibliographicdatabases and fugitive information sources.· All randomized controlled trials and controlled trials were critically appraised ifthey: compared any form of PRFN, used any type of control intervention; reportedat least one health outcome; and had a minimum observational period of 4 weeks.A review of the literature on the epid miology of whiplash was conducted.  Studies werereviewed if they examined incidence or prevalence of whiplash or the time-to-recovery ofsubjects with whiplash; and study subjects suffered a neck injury in a motor vehicleaccident (other causes excluded).An expanded evaluative framework was used to assess the scientific evidence put forwardin support of neurotomy testing and treatment strategies along seven dimensions:1) the population at risk; 2) test performance; 3) clinical management; 4) health outcomemeasures; 5) population health impact; 6) economic impact; and 7) social impact.A model was developed based on this framework.Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology AssessmentI4Figure 3:  Diagram of findings[Numbers in brackets indicate result headings](2)(1)(3)(4)(5)(6) 75% have repeat procedures= 2025% no repeat procedure= 670% > 90 days free of pain= 26 - 30830% limited relief= 11 - 13237% test (+) for C3-C5 z-joint pain= 37 - 44063% test (-)= 63 - 75010% referred for block= 100 - 1,19090% not referred= 900 - 10,7103-35% have chronic neck pain= 1,000 - 11,90065-97% recover in < 6 months= 22,100 - 33,000850/100,000 have whiplash= 34,000Population without whiplash= 3,966,000Population of BC4,000,000Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology Assessment5RESULTSThe findings are shown diagrammatically in Figure 3 (in which the following resultheadings are indicated).(1) INCIDENCE OR WHIPLASH INJURY Published ICBC data provides a population-based annual estimate of 850/100,000.4Applying this estimate to the BC population of approximately 4 million people resultsin a total of 34,000 whiplash injuries per year.(2) INCIDENCE OF CHRONIC NECK PAIN The subset of the population eligible for PRFN can be estimated from time-to-recoverydata.  The subset of interest are whiplash injury patients with cervical pain symptomspersisting beyond twelve months from the time of injury.  The potential PRFN referralpopulation is estimated at 3% of the total whiplash-injury population.5-6  This wouldpotentially result in approximately 1,000 patients per year in BC referred to a cervicalspine pain-treatment centre for evaluation following automobile accidents.(3) REFERRAL TO PAIN CLINIC Only a portion of patients eligible for referral will actually be referred to a chronic-painclinic.  Referral will depend on several factors including patient and physician interestin and awareness of PRFN, cost to the patient, as well as availability and location of theservices.  Current services in BC would allow as few as 10% (100) of the estimated 1,000people eligible for PRFN referral, are actually referred.(4) POSITIVE BLOCK The total positive diagnostic tests is estimated at 36% - 38%.  If 100 patients arereferred, 50 will have predominant neck pain and 50 will have predominant headache.Of the 50 with predominant neck pain, approximately 25 will have ‘positive diagnostictests’.  Of the 50 with predominant headache, approximately 12 will have a ‘positivediagnostic test’.7Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology AssessmentI6(5) INITIAL PAIN RELIEF Approximately 70% of these patients that elected to have n urotomy would have > 90days free of pain.  In the BC model of 100 patients referred, 37 would be median nerveanaesthetic diagnosis-positive for z-joint levels below C2/C3 and about 70% (26 patients)would achieve this level of benefit.  It should be recalled that the 70% efficacy estimateapplies only to patients with z-joint levels below C2/C3.  In a non-randomized trial, theefficacy of therapy at the C2/C3 level was not considered adequate to justify treatment atthis level.8(6) ONGOING RELIEFProlonged pain relief, through repeat procedures, can be anticipated in about 75% ofpatients achieving initial benefit.  A study by McDonald 9 shows that repeat proceduresare possible and also that they are likely to be effective if the initial response lastedgreater than 30 days.  Considering the BC model, approximately 20 will achieveprolonged pain relief through repeat procedures.Limitations of health impact estimateThe health impact estimate provides, at best, a crude estimate of the number of patientswho may be referred for PRFN assessment.  The estimate is rudimentary because itrequires as yet unconnected insurance and clinical data.The randomized control trial estimates of benefit are based on the technical capability ofone ‘senior’ individual working under extremely strict research conditions.  “In principle,technical problems may affect the efficacy of the procedure.  An inaccuracy of 1mm inelectrode placement is sufficient for the target nerve to escape adequate coagulation.” 9Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology Assessment7CONCLUSIONS· PRFN has been shown effective versus placebo in one RCT involving 24 verycarefully-selected patients with chronic neck pain following whiplash injury.  Thisresearch establishes a higher standard for outcome research in the area of chroniccervical pain management.  The burden of proof now rests with alternate treatmentprograms to show benefits verses PRFN.· PRFN is at a critical stage in public policy formulation.  Promising clinical findingsare counter-balanced by investigational concerns over lack of effectiveness (asopposed to efficacy) evidence.  Given the concerns, rapid diffusion of this technologywould be inappropriate.  On the other hand to limit the technology unnecessarilywould restrict proven pain relief efficacy for certain individuals.  A balance is needed,in which training and resource allocation may properly proceed, but withdissemination made conditional on further outcome research.· Further outcome research requires a treatment and a control group to determinebenefit versus harm in a particular setting, such as BC.· In addition, the work of Lord et al and Bogduk may have set a higher standard foroutcome research than the level otherwise available in the field of whiplash injury.More generally, efficacy evidence from a randomized control trial is likely to helplegitimate whiplash injury as a clinical entity, rather than what has been cynicallyreferred to as the clinical manifestation of a litigious insurance opportunity. [REF]Whiplash Injuries & Neurotomy:  A pain in the neck …BC Office Of Health Technology AssessmentI8REFERENCES                                                1 Lord SM, Barnsley L, Bogduk N. Cervical zygapophyseal joint pain in whiplash injuries.Spine: State of the Art Reviews 1998;12(2):301-22.2 Bogduk N, Macintosh J, Marsland A. Technical limitations to the efficacy of r diofrequencyneurotomy for spinal pain. Neurosurgery 1987;20(4):529-35.3 Bogduk N. Neck pain. Aust Fam Med 1984;13(1):26-30. 4 Physical Medicine Research Foundation. The BC whiplash initiative. Vancouver (BC):Physical Medicine Research Foundation, [cited Nov 7, 2000] Available from:URL:http://www.health-sciences.ubc.ca/whiplash.bc/. 5 Spitzer WO, Skovron ML, Salmi LR, Duranceau J, Suissa S, Zeiss E. Scientific monograph ofthe Quebec task force on whiplash-associated disorders: redefining "whiplash" and itsmanagement. Spine 1995;20:1S-76S. 6 Cassidy JD, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. Effect of eliminatingcompensation for pain and suffering on the outcome of insurance claims for whiplash injury.New Engl J Med 2000;342(16):1179-86. 7 Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequencyneurotomy for chronic cervical zyg pophyseal-joint pain. N Engl J Med 1996;335(23):1721-6. 8 Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment ofcervical zygapophysial joint pain: a caution. Neurosurgery 1995 Apr;36(4):732-9.9 McDonald GJ, Lord SM, Bogduk N, Sindou MP, Long DM, Burchiel KJ, Kanpolat Y. Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neckpain. Neurosurgery 1999;45(1):61-8.

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