1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
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2. Ablation Johnathan Goree, MD Director of Chronic Pain Division
Assistant Professor
Department of Anesthesiology
University of Arkansas for Medical Sciences

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4. Disclosures
I have no financial interests to disclose related to this presentation
I will present some currently off label uses of Radiofrequency Ablation technologies

7. What is radiofrequency ablation?
Use of radiofrequency (RF) electrical currents to create quantifiable and predictable thermal lesions
Passage of RF currents through an electrode placed adjacent to a nociceptive pathway to interrupt the pain impulses → pain relief

8. Technology of radiofrequency ablation
Ideal neuroablation target
Purely sensory distal afferent nerve
Possibly mixed sensory motor nerve
Anatomically reliable landmarks
Minimal risk of injury to overlying or adjacent visceral and neurovascular structures
Neuroablation targets to avoid
Mixed sensory motor nerve with important motor function

9. Temperature
Tissue is heated at a specified temperature for a specified period of time
Early cytotoxic temperatures for nervous tissue is 50°C
Recommended temperatures of greater than 70-80°C to create irreversible lesions
Recommended temperature of less than 90°C to avoid boiling tissues (100°C)
Typical temperature & time for lumbar RF → 80°C for 90 seconds

11. High frequency electrical current runs through an insulated needle
Needle provides thermal energy
Small lesion within a nerve

12. Types of Ablation Thermal Ablation Cooled Ablation Pulsed Ablation
Use of high temperature 80 C (180 F) to cause a thermal lesion in tissue
Cooled Ablation
High temperature probe is continually cooled with circulating water allowing for increased lesion time without adjacent tissue damage
More expensive technology
Similar re-imbursement
Pulsed Ablation
Short bursts (20 milliseconds) of mild temperature increase 42 C (107F) followed by a quiet phase (480 milliseconds)

15. Ablation Targets Spine Joints Lumbar Thoracic Cervical Knee Hip
Sacroiliac Joint

16. Treatment Algorithm Clinical diagnosis
Consider Ablation after failed conservative management
Test effects of Test blocks (0.25cc – 1cc of local anesthetic)
Two benefits
Ensure improvement from treatment
Ensure that no injury to adjacent structures
If effective, proceed with Radiofrequency Ablation

17. Spine

18. Spine Anatomy Superior articular process Transverse process
Vertebral body
Disc
Inferior articular process
Spinous
process
Zygapophysial “facet” joint
Rev A

19. Why Examine? Dr. James Andrews Founder of Andrews Institute
“If you want an excuse to operate on a pitchers throwing shoulder, just get an MRI”
- James Andrews MD

20. Why Examine?
“If you want an excuse to do a series of three L4-5 transforaminal epidural steroid injections, two sets of L4-5, L5-S1 facet blocks, a L3-5 medial branch block, L3-5 radiofrequency ablation, start someone on Oxycontin 30mg TID, do an L3-L5 Posterior laminectomy and fusion, AND place a spinal cord stimulator/Intrathecal pump… Do an MRI”
- Johnathan Goree MD

21. Facet Arthropathy

22. Medial Branch Anatomy

23. Needle placement
Rev A

24. Greater than 50% pain relief for:
Historical Results
Region of spine
Study
No. of patients
Greater than 50% pain relief for:
3 months
6 months
12 months
Lumbar
Dreyfus et al. Efficacy and Validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000; 25: 15
93%
87%
Thoracic
Stolker et al. Percutaneous facet denervation in chronic thoracic pain. Acta Neurochir. 1993; 122:82-90. 40
83%
Cervical
McDonald et al. Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery. 1999; 45:61-68. 28
71%
Rev A

25. Knee

26. Chronic knee osteoarthritis pain
Treatment
Non pharmacological
Exercise
Weight loss
Physical Therapy
Pharmacological
Topical NSAIDs, capsaicin, local anesthetics
Glucosamine, chondroitin (no evidence)
Interventional
Hyaluronans (no evidence)
Platelet rich plasma (no evidence)
Peripheral nerve stimulation (no evidence)
DRG/ dorsal column/ nerve root stimulation (superior for neurogenic pain)

28. knee joint is innervated by the articular branches of various nerves, including the femoral, common peroneal, saphenous, tibial and obturator nerves [13,18]. These articular branches around the knee joint are known as genicular nerves
The knee joint is innervated by the articular branches of various nerves, including the femoral, common peroneal, saphenous, tibial and obturator nerves.
Hirasawa Y, et al. Nerve Distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop 2000; 24:1-4.
The cutaneous and articular sensory innervation of the knee region is complex and displays considerable variation.
Lund J, et al. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 2011; 55: 14-19

30. current randomized controlled study was designed to test the hypothesis that CRFA was noninferior or superior to intraarticular steroid (IAS) injection at 6 months to treat OA-related knee pain. The primary efficacy end point was the proportion of subjects whose knee pain was reduced by 50% or greater from baseline at 6 months after treatment. Secondary end points included change in knee function, subjects' perception of treatment effect, and analgesic drug use 6 months following study interventions
prospective, randomized, open-label, multicenter (eleven sites) clinical study with a parallel-group design to compare CRFA utilizing the Coolief System
Davis T et al. Prospective, Multicenter, Randomized Crossover Clinical Trial Comparing the Safety and Effectiveness of Cooled Radiofrequency Ablation with Corticosteroid Injections in the Management of Knee Pain From Osteoarthritis. Regional Anesthesia and Pain Medicine. Volume 43, Number 1, January 2018

33. Hip

34. Malik, A et al. Percutaneous Radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of non-operable hip pain. Pain Physician. 2003; 6:

37. Take Home Points
Radiofrequency Ablation for the palliation of arthritis is SAFE and EFFECTIVE in trained hands
Improvements average about 400 days from most RF procedures
Improved outcomes when combined with physical therapy and rehabilitation
Increased mobilization
Break pain avoidant behavior
Patient selection is KEY and most diagnoses are clinical

38. Questions?

39. Cases?

40. Discussion
Patient is a 54 y/o male with severe axial back pain for 1 month after lifting a bag of mulch from his trunk. Patient has taken ibuprofen and tramadol without much relief. Patient said that this pain has gotten worse over the past 2 weeks and it is limiting his mobility.
How do we treat this patient?

41. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
Event ID: