Lumbar Radiofrequency Ablation Research Articles

Multifidus atrophy and/or dysfunction following lumbar radiofrequency ablation: A systematic review.

Lumbar medial branch nerve radiofrequency ablation (LRFA) is an interventional procedure used to treat chronic lumbar facet joint pain. Because the medial branch nerves also innervate the multifidus muscle, it has been proposed that LRFA may pose a risk of multifidus atrophy and/or dysfunction. However, the quality and level of evidence to answer this clinical question have not been established. Therefore, this review aimed to systematically appraise the literature to discern whether the prevailing evidence substantiates the hypothesis in question. A systematic review compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed to evaluate the quality and level of evidence of studies reporting functional and/or structural changes in the multifidus muscle following LRFA. Only five cohort studies met inclusion criteria. Two studies assessed changes in multifidus function following LRFA with confirmed denervation at electromyography and significant reduction in multifidus shear modulus with ultrasound shear wave elastography. Of the four studies that evaluated changes in multifidus structure with magnetic resonance imaging following LRFA, two demonstrated a decrease in cross-sectional area or an increase in fat infiltration, one demonstrated no change, and one revealed an apparent increase. Given the destructive nature attributed to LRFA, some degree of multifidus atrophy and/or dysfunction may be plausible, albeit with a very low certainty that relies on a restricted body of literature of modest quality and with a presence of high bias. There is a paucity of studies discussing the potential association between LRFA and multifidus atrophy and/or dysfunction. In light of the shortage of high-quality studies and the absence of standardized protocols to assess both changes in the structure and function of the multifidus subsequent to LRFA, there is a pressing need for more prospective studies with a high methodological rigor to comprehensively address and answer this enduring debate in clinical practice.

Clinical manifestation and treatment strategy of intervertebral space infection after radiofrequency ablation of lumbar nucleus pulposus

To study the clinical manifestations and treatment of intervertebral space infection after percutaneous lumbar radiofrequency ablation of nucleus pulposus. A retrospective analysis was performed of 496 patients who underwent percutaneous lumbar disc decompression using low-temperature plasma radiofrequency ablation nucleus pulposus from June 2009 to June 2019. Six patients had lumbar infection, and the infection rate was 1.21%. All patients were male, ranging in age from 20 to 61 years old. Three patients underwent single segment radiofrequency ablation, two patients underwent dual segments ablation;and one patient underwent three segment ablation, totaling 10 intervertebral discs. One patient was complicated with type 2 diabetes before operation. The interval between infection occurrence ranged from 21 to 65 days. All 6 patients were followed up, and the duration ranged from 18 to 40 months, with an average of 24 months. Among them, 2 patients presented with symptoms of low back pain accompanied by fever, and imaging examination showed intervertebral space infection accompanied by abscess. In addition, 4 patients experienced low back pain but no fever, and MRI showed abnormal signals of the infected intervertebral endplate or vertebral body. One patient showed staphylococcus aureus in blood culture, while the remaining 5 patients showed negative bacterial culture. All the patients were treated with antibiotics after diagnosis. Four patients were treated with conservative management to control infection;1 patient was treated with debridement of posterior lumbar infection focus, and 1 patient was treated with debridement of posterior lumbar infection focus combined with interbody fusion and internal fixation. The occurrence of intervertebral space infection during lumbar radiofrequency ablation nucleoplasty should be given sufficient attention. Strict aseptic technique, avoiding repeated multi segment puncture, realizing early detection and treatment, and selecting appropriate treatment methods according to the severity of infection is the guarantee of achieving curative effect.

CRITICAL EVALUATIONS OF INTRA-ARTICULAR PLATELET RICH PLASMA ALONE OR COMBINATION WITH MEDIAL BRANCH RADIOFREQUENCY NEUROTOMY IN PATIENTS WITH LUMBAR FACET JOINT ARTHROPATHY: A PROSPECTIVE OUTCOME STUDY

Background: Common cause of chronic low back pain is lumbar facet joint arthropathy. Radiofrequency ablation (RFA) of medial branch currently preferred treatment in facet joint pain syndrome. Platelet-rich plasma (PRP) is known to initiate mesenchymal tissue healing by concentration of several fundamental protein growth factors. Our aim in this study is to evaluate the effect of co-administration of autologous PRP in lumbar facet and RFA of the medial branch of the dorsal ramus for lumbar facet arthropathy. Methodology: This was a prospective randomised study with a blind assessor. Eighty-one consecutive patients who complained of low back pain secondary to lumbar facet joint arthropathy were randomly allocated into three-groups: Group RF: only RFA done. Group PR: received both PRP plus RFA. Group PL: received only PRP. Primary outcome of the study was assessment of pain intensity using visual analogue scale (VAS). Result: The patients who had both RFA and PRP therapy had significant decrease in VAS score as compared to its baseline in the immediate and long term follow up period ([Formula: see text] < 0.001). However, for those who received only PRP, the decrease in VAS was more significant at 1 and 4 months. Similarly, there was a significant improvement in ODI score in patients who received both RFA and PRP ([Formula: see text] < 0.001). There was a gradual improvement in ODI in PRP group at 4-month interval. Rescue analgesics requirement was reduced and patients were better satisfied in those who received both RFA and PRP therapy. ([Formula: see text] < 0.05). Conclusion: The combined administration of RFA and PRP proved to provide better analgesia in both short-term follow up and long-term follow up than treatment with either method in patients with lumbar facet syndrome.

An International Survey on the Practice of Lumbar Radiofrequency Ablation for Management of Zygapophyseal (Facet)-Mediated Low Back Pain.

ObjectiveThe objective of this study was to survey current clinical practice related to lumbar radiofrequency (RFA) for the treatment of zygapophyseal (facet)-mediated low back pain.MethodsSurvey questions regarding the clinical practice of lumbar RFA were created and piloted by the American Society of Pain and Neuroscience (ASPN) leadership. After revision for clarity, health-care professionals worldwide who hold membership status within the ASPN Society and who offer lumbar RFA in their clinical practice were recruited to participate in this online survey. All responses were tabulated and summarized descriptively.ResultsA total of 329 participants responded in the survey. Most participants specialized in anesthesiology (68.4%) and physical medicine and rehabilitation (21.8%) and had been practicing pain management for more than five years (70.5%). Of physician respondents, 27.5% did not complete an Accreditation Council for Graduate Medical Education (ACGME)-accredited pain medicine fellowship and 16.5% were not board-certified in pain medicine. The majority of providers (69.7%) reported that they perform two diagnostic medial branch blocks prior to proceeding with lumbar RFA. Bupivacaine 0.5% was the most common medication utilized for both the first (37.4%) and second (37.1%) diagnostic blocks. There were 32.6% of total respondents who reported not utilizing contrast dye when performing diagnostic blocks. The vast majority of providers (91.4%) reported using conventional RFA for lumbar medial branch neurotomy.ConclusionThis survey study provides a summary of the application of lumbar RFA for the treatment of axial low back pain in the real-world setting. We highlight a significant portion of providers who perform lumbar RFA yet do not have pain fellowship training at an ACGME-accredited institution or do not maintain current pain medicine board certification. We also report deviations from standard practice, specifically the type of local anesthetic used for comparative diagnostic blocks and the omission of contrast injection during diagnostic blocks.

Chronic Pain Management

The management of various chronic pain conditions poses a significant challenge for providers of all specialties, particularly in the era of the opioid epidemic. Education on pain management, however, is often lacking in medical schools. This omission may prove disastrous in the current social climate. Recent literature concludes that trainees are not comfortable in managing chronic pain patients and demonstrates that even first-year medical students have formed negative attitudes toward patients with chronic pain in early clinical rotations.1 The task of reading a comprehensive textbook on pain management to supplement understanding of such a crucial topic may be daunting to a trainee or medical student with limited time. Pocket review books are invaluable to this group, and many highly rated pocket review books exist for a variety of subspecialties including anesthesiology and surgery.Chronic Pain Management, by Thanthullu Vasu, Shyam Balasubramanian, Mahesh Kodivalasa, and Pradeep Mukund Ingle, is an excellent choice for medical students or trainees on a pain management rotation, practitioners in primary care or internal medicine looking to further their knowledge of chronic pain management, or postmatch residents looking for prereading before starting a pain management fellowship. The book is 318 pages long and is split into 55 succinct chapters, none of which exceeds 10 pages in length. This makes for a particularly time-efficient read; a short 20-minute reading session may allow readers to cover a few chapters. The ability of the authors to condense pertinent material, even that which pertains to complex topics such as the physiology of pain in Chapter 3, is very impressive. The first half of the book is devoted to characterization of pain including that of the International Association for the Study of Pain, outlining pain assessment tools, and discussion of the presentation, pathophysiology, diagnosis, and management of various painful conditions. The second half details all of the pieces of a multimodal analgesic plan, including injection therapy, pharmacologic options, and noninterventional techniques such as physical therapy and complementary medicine. Unique to this book is a brief chapter on management of chronic pain in the current COVID-19 pandemic.This book will make an excellent companion for a medical student or resident on a chronic pain management rotation or as a primer before pain management fellowship. The authors recommend this book as a study resource for competitive examinations such as the American Board of Anesthesiology subspecialty examination in pain. I believe that this book is not a sufficient stand-alone resource in studying for such an examination, or as a sole resource in preparing for clinical practice. The chapter on radiofrequency ablation is limited to just over two pages and certainly is not comprehensive. It only pertains to lumbar medial branch radiofrequency ablation and does not cover water-cooled radiofrequency or cryoablation. A discussion of the evidence for lumbar radiofrequency ablation, a comparison between various types of ablation methods, the applicability of radiofrequency ablation to other painful conditions beyond lumbar facet arthropathy, and a more complete explanation of the physics involved in radiofrequency would be very helpful to a nascent pain management physician. Expansion of certain topics such as pain management in pregnant patients and in children (which is combined in Chapter 42, Pain Management in Special Populations) would be useful in board examination preparation as well as clinical practice.Overall, I am delighted to endorse this review book to anyone hoping to gain a better understanding of chronic pain management. It is well written, easy to follow, and promises to be an efficient read. My hope and belief is that those who read this book will gain a better overall view of pain management and what providers in this specialty have to offer, as well as some solid background on the management of chronic pain in the outpatient and inpatient settings. Hopefully, this book will allow practitioners to fill in knowledge gaps in education and feel more confident in managing patients with chronic pain.

Lumbar Radiofrequency Ablation Cannula and Probe Complications: Source for Potential Foreign Body

BACKGROUND: Radiofrequency ablation is a common approach for treating axial low back pain stemming from facet arthropathy. Many well-published complications have been addressed in the literature. This case demonstrates a hardware malfunction and underscores the importance of vigilance toward protocols to maintain radiofrequency probes during sterilization and reuse. CASE REPORT: In our case, the patient underwent a successful bilateral 2-level neurotomy. At the completion of the procedure, we removed all instruments and found that the probe was no longer attached to the connector. Multiple postprocedure x-rays were negative for a foreign body; the probe was later found in the cannula intact. This case report illustrates a rare potential complication for foreign body retention in an outpatient setting. CONCLUSION: Appropriate maintenance and handling of reusable probes during sterilization and use must be exercised. Alternatives include the use of disposable probes and connector cables. KEY WORDS: Radiofrequency ablation, foreign body, probe

Predicting Treatment Success with Facet Syndrome: An Algorithm to Predict Lumbar Radiofrequency Ablation Responders in a Military Population.

Radiofrequency ablation (RFA) of the medial branch nerve is a commonly performed procedure for patients with facet syndrome. RFA has previously been demonstrated to provide long-term functional improvement in approximately 50% of patients, including those who had significant pain relief after diagnostic medial branch block. We sought to identify factors associated with success of RFA for facet pain. Active-duty military patients who underwent lumbar RFA (L3, L4, and L5 levels) over a 3-year period were analyzed. Defense and Veterans Pain Rating Scale (DVPRS) and Oswestry Disability Index (ODI) scores were assessed the day of procedure and at the 2-month and 6-month follow-up. These data were analyzed to identify associations between patient demographics, pain, and functional status and patients' improvement after RFA, with a primary outcome of ODI improvement and a secondary outcome of pain reduction. Higher levels of starting functional impairment (starting ODI scores of 42.9 vs. 37.5; P = 0.0304) were associated with a greater likelihood of improvement in functional status 6 months after RFA, and higher starting pain scores (DVPRS pain scores of 6.1 vs. 5.1; P < 0.0001) were associated with a higher likelihood that pain scores would improve 6 months after RFA. A multivariate logistic regression was then used to develop a scoring system to predict improvement after RFA. The scoring system generated a C-statistic of 0.764, with starting ODI, pain scores, and both gender and smoking history as independent variables. This algorithm compares favorably to that of diagnostic medial branch block in terms of prediction accuracy (C-statistic of 0.764 vs. 0.57), suggesting that its use may improve patient selection in patients who undergo RFA for facet syndrome.

Effect of Patient Characteristics on Reported Outcomes Over 12 Months Following Lumbar Radiofrequency Ablation: A Retrospective Review of 500 Patients.

Low back pain is the leading cause of years lost to disability worldwide. Approximately 15% to 45% of chronic low back pain is due to facet joint arthropathy. Currently, no large-scale retrospective studies have investigated long-term clinical predictors of success in individuals receiving radiofrequency ablation (RFA) of the medial branches for facet joint arthropathy. To determine the clinical factors associated with success and failure of RFA of lumbar facet joints at 1-year follow-up. Clinical data were gathered from 500 consecutive patients with an International Classification of Diseases (ICD)-10 diagnosis of lumbar spondylosis. VAS pain scores for patients undergoing lumbar medial branch RFA procedures were recorded at multiple time points, up to the 1-year follow-up visit. A responder was defined ashaving ≥30% improvement in VAS score from the pre-procedural VAS score. For our primary analysis, regression analysis was conducted to identify associations between responder status and patient characteristics, including age, gender, body mass index (BMI), hormone use, opiate dose, and smoking history at multiple time points, up to the 1-year follow-up visit. A total of 500 patients were included in the study. At the 1-year post-RFA follow-up visit, responder status was associated with a lower rate of prior opioid use (43.22% vs. 55.76%, odds ratio 0.60 [95% confidence interval (CI) 0.40 to 0.92], P=0.018), lower pre-procedural opioid consumption in oral morphine equivalents (10.16±16.02 vs. 14.67±20.65, β -4.50 [95% CI -8.57 to -0.44], P=0.030), and a higher pre-VAS pain score (6.36±2.17 vs. 5.85±2.17, β 0.50 [95% CI 0.06 to 0.95], P=0.028). There were no significant associations between responder status and age, gender, BMI, hormone use, and smoking history at the 1-year follow-up visit. Our results suggest that patients prescribed opioids, particularly at higher dosages, may find less pain relief 1 year following RFA for facetogenic pain. Additionally, patients with higher pre-procedural VAS pain scores may be more likely to have a positive response at 1 year.

Opioid Fills for Lumbar Facet Radiofrequency Ablation Associated with New Persistent Opioid Use.

Zygapophyseal (facet) joint interventions are the second most common interventional procedure in pain medicine. Opioid exposure after surgery is a significant risk factor for chronic opioid use. The aim of this study was to determine the incidence of new persistent use of opioids after lumbar facet radiofrequency ablation and to assess the effect of postprocedural opioid prescribing on the development of new persistent opioid use. The authors conducted a retrospective cohort study using claims from the Clinformatics Data Mart Database (OptumInsight, USA) to identify opioid-naïve patients between 18 and 64 yr old who had lumbar radiofrequency ablation. Patients who had either subsequent radiofrequency ablation 15 to 180 days or subsequent surgery within 180 days after the primary procedure were excluded from the analysis. The primary outcome was new persistent opioid use, defined as opioid prescription fulfillment within the 8 to 90 and 91 to 180 day periods after radiofrequency ablation. The authors then assessed patient-level risk factors for new persistent opioid use. A total of 2,887 patients met the inclusion criteria. Of those patients, 2,277 (78.9%) had radiofrequency ablation without a perioperative opioid fill, and 610 (21.1%) patients had the procedure with a perioperative opioid fill. The unadjusted rate of new persistent opioid use was 5.6% (34 patients) in the group with a perioperative opioid fill versus 2.8% (63 patients) for those without an opioid fill. Periprocedural opioid prescription fill was independently associated with increased odds of new persistent use (adjusted odds ratio, 2.35; 95% CI, 1.51 to 3.66; P < 0.001). Periprocedural opioid use after lumbar radiofrequency ablation was associated with new persistent use in previously opioid-naïve patients, suggesting that new exposure to opioids is an independent risk factor for persistent use in patients having radiofrequency ablation for chronic back pain. Opioid prescribing after radiofrequency ablation should be reevaluated and likely discontinued in this population.

Lumbar Radiofrequency Ablation: Procedural Technique.

Lumbar radiofrequency ablation is indicated for the treatment of chronic axial low back pain that is mediated by facet arthropathy which has failed more conservative treatment options. This article details proper equipment and medications, patient positioning and setup, step-by-step instructions for multiplanar fluoroscopic visualization, cannula placement, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A90) accompanies this paper.

Trends in lumbar radiofrequency ablation utilization from 2007 to 2016

BACKGROUND CONTEXTLumbar radiofrequency ablation (RFA) is an intervention used to treat facet-mediated chronic low back pain. In some studies with methods consistent with clinical practice guidelines, RFA results in improvements in pain and functional limitations. However, in other studies, RFA demonstrates limited benefit. Despite unanswered questions regarding efficacy of RFA, its use is widespread. PURPOSETo describe trends in the utilization and cost of lumbar RFA and lumbar facet injections. STUDY DESIGN/SETTINGRetrospective cohort study. PATIENT SAMPLEThe sample was derived from the IBM/Watson MarketScan Commercial Claims and Encounters Databases from 2007 to 2016. OUTCOME MEASURESLongitudinal trends in the distribution and quantity of lumbar facet injections before lumbar RFA, corticosteroid administration during lumbar facet injections, progression to lumbar RFA after lumbar facet injections, lumbar RFA utilization, and costs of these interventions. METHODSTwo primary cohorts were identified from patients who received lumbar RFA or lumbar facet injection procedures. Utilization rates per 100,000 enrollees were determined for both cohorts. The mean, median, and interquartile ranges of the number of facets targeted and costs per procedure were calculated by year and laterality, as well as overall. Costs in 2018 dollars were estimated by summing gross payment totals from patients and insurance plans. This study was supported by funds from the NIH, and has no conflict of interest associated biases. RESULTSFrom 2007 to 2016, lumbar RFA sessions performed per 100,000 enrollees per year increased from 49 to 113, a 130.6% overall increase (9.7% annually). Lumbar facet injection use increased from 201 to 251 sessions per 100,000 enrollees, a 24.9% overall increase (2.5% annually). In the year after a lumbar facet injection, 26.7% of patients received lumbar RFA; 28.6% received another injection but not RFA; and 44.7% received neither. The number of patients receiving two lumbar facet injection procedures prior to lumbar RFA grew from 51.1% in 2010 to 58.8% in 2016. For lumbar RFA, the cost per 100,000 enrollees went from $94,570 in 2007 to $266,680 in 2016, a 12.2% annual increase. For lumbar facet injections, the cost per 100,000 enrollees went from $257,280 in 2007 to $396,580 in 2016, a 4.9% annual increase. CONCLUSIONSThis analysis showed consistent growth in both the frequency and procedure cost of lumbar RFA and facet injections among a large, national, commercially insured population from 2007 to 2016.

The Science of Conventional and Water-Cooled Monopolar Lumbar Radiofrequency Rhizotomy: An Electrical Engineering Point of View

Radiofrequency ablation (RFA) is a safe and effective pain therapy used to create sensory dysfunction in appropriate nerves via thermal damage. While commonly viewed as a simple process, RF heating is actually quite complex from an electrical engineering standpoint, and it is difficult for the non-electrical engineer to achieve a thorough understanding of the events that occur. RFA is highly influenced by the configuration and properties of the peri-electrode tissues. To rationally discuss the science of RFA requires that examples be procedure-specific, and lumbar RFA is the procedure selected for this review. Adequate heating of the lumbar medial branch has many potential failure points, and the underlying science is discussed with recommendations to reduce the frequency of failure in heating target tissues. Important technical details of the procedure that are not generally appreciated are discussed, and the status quo is challenged on several aspects of accepted technique. The rationale underlying electrode placement and the limitations of RF heating are, for the most part, commonly misunderstood, and there may even need to be significant changes in how lumbar radiofrequency rhizotomy (RFR) is performed. A new paradigm for heating target tissue may be of value. Foremost in developing best practices for this procedure is avoiding pitfalls. Good RF heating and medial branch lesioning are the rewards for understanding how the process functions, attention to detail, and meticulous attention to electrode positioning. Key words: Electrical equipment and supplies, zygapophyseal joint, catheter ablation, lumbar vertebrae, low back pain, lumbar vertebrae/innervation, radiofrequency ablation, water-cooled radiofrequency ablation, conventional radiofrequency ablation, radiofrequency electrode behavior