Article

Radiofrequency and pulsed radiofrequency treatment of chronic pain syndromes: the available evidence.

Department of Anesthesiology and Pain Therapy, St. Jozefkliniek, Bornem and Willebroek, Belgium.
Pain Practice (Impact Factor: 2.18). 09/2008; 8(5):385-93. DOI: 10.1111/j.1533-2500.2008.00227.x
Source: PubMed

ABSTRACT There are currently 6 reviews on (pulsed) radiofrequency (RF) for the management of spinal pain. Two reviews on interventional pain management techniques in general also discuss RF. The outcomes of those reviews depend on the type of studies included and the opinion of the reviewers, which may result in different evidence levels. Radiofrequency denervation at the cervical and lumbar level has produced the most solid evidence. The differences in treatment outcome registered in the 5 randomized controlled trials (RCTs) regarding lumbar facet denervation can be attributed to differences in patient selection and/or inappropriate technique. There is not sufficient evidence supporting the use of RF facet denervation for the management of cervicogenic headache. The studies examining the management of cervical radicular pain suggest a comparable efficacy for RF and pulsed RF (PRF). The PRF treatment is supposed to be safer and therefore should be preferred. The superiority of RF treatment adjacent to the lumbar dorsal root ganglion for the management of lumbar radicular pain has not been demonstrated in an RCT. Information regarding RF treatment of sacroiliac joint pain is accumulating. No randomized sham-controlled trials on the value of RF treatment of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia have been published. One RCT indicates superiority of RF over PRF for the management of idiopathic trigeminal neuralgia. Future research to confirm or deny the efficacy of (P)RF should be conducted in carefully selected patient populations. The tests used for patient inclusion in such a trial could potentially help the clinician in selecting patients for this type of treatment. The value of PRF treatment of the peripheral nerves also needs to be confirmed in well-designed trials.

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    ABSTRACT: Pain Physician: November/December 2014; 17:E783-E806 E790 www.painphysicianjournal.com An Old Complication of a New Technique: Pneumorrhachis from Caudal Epidural Pulsed Radiofrequency To the Editor: Pulsed radiofrequency (PRF) has been used to manage various chronic pain conditions, such as cervical, dorsal, and lumbar radicular pain; post herpetic neuralgia; idiopathic trigeminal neuralgia; shoulder pain; meralgia paresthetica (1); pudendal neuralgia; coxal pain; phantom pain; facet syndrome; sacroiliac pain; arthrogenic pain; and coccygodynia. PRF is usually applied adjacent to the root ganglion, peripheral nerve, or intraarticularly (2,3). Caudal epidural PRF (CEPRF) is a new approach (4) that could be indicated for the simultaneous treatment of several roots in patients with failed back surgery syndrome plus arthrodesis or in those in whom anatomical distortion makes the transforaminal route impossible. A 70-year-old woman presented with a one-year history of low back pain radiating posteriorly to the left thigh and leg; in the 3 weeks prior, the pattern had changed to include the anterior leg and parethesia. The pain appeared on walking several steps and subsided on sitting. The pain was unresponsive to analgesics, nonsteroidal anti-inflammatory drugs, and corticosteroids. Two epidural injections, at another center, resulted in temporary relief. Physical examination revealed radiating pain and lumbar spine stiffness on flexion and on left lateral bending as well as tenderness on the L3 spinal process. Spinal reflexes were present without motor or sensory deficits. The anterior straight-leg-raising test was negative and the posterior straight-leg-raising was positive on the left side. Plain-film x-rays showed grade I degenerative spondylolisthesis at the L3-L4 level, magnetic resonance imaging (MRI) also showed disc pseudobulging, facet hypertrophy, and lateral recess stenosis at the same level. After PRF applied to the dorsal root ganglion of the left L3 root was unsuccessful the patient provided informed consent for CEPRF on the left L3 root. After the procedure, we injected a solution of 40 mg triamcinolone in 2 mL 0.25% bupivacaine and 5 mL saline via the Racz catheter (Fig. 1). Two weeks later, pain had decreased by 75%. However, after a second L3-L4 CEPRF procedure performed with the same protocol, the patient experienced paraplegia, consisting of bilateral weakness and anesthesia of the lower limbs and pudendal area that lasted several hours. She also had transient minor headache. Computed tomography (CT) showed pneumorrhachis at the L3-L4 level (Fig. 2). Six weeks later, the patient was free of pain without air outside the dura mater spinalis. Eight months later, a surgical procedure was done at another center for pain recurrence. Pneumorrhachis, or free air on the inside or the outside of the dura mater spinalis, is uncommon; it was first described in 1977 (5) and the term was coined in 1987 (6). Other terms for this phenomenon include intraspinal pneumocele, spinal epidural and subarachnoid pneumatosis, spinal and epidural emphysema, aerorachia, or pneumosaccus (7). The technique of intentionally introducing air into the spinal canal for diagnostic purposes is called air myelography or pneumomyelography. Various conditions can cause pneumorrhachis, in- Fig. 1. Racz catheter in place on left L3 root. cluding trauma, respiratory complications, and condiwww. painphysicianjournal.com E791 Letters to the Editor tions that produce high intrathoracic pressure, malignancy and its therapy, and diagnostic or therapeutic procedures. As in our case, peridural or epidural administration of anaesthesia involving lumbar puncture can also cause pneumorrhachis (7-15). The air can dissect between the paraspinal soft tissues into the epidural or intradural space, becoming entrapped due to a oneway air valve mechanism or it can penetrate directly into the spinal canal by traumatic or medical manipulations, as in the present case. Furthermore, in the case reported, the transient neurological deficit and headache suggest leakage of cerebrospinal fluid and subdural local anesthetic penetration into the subdural space. Unfortunately we didn’t inject a contrast agent. Our experience suggests it would be useful to inject contrast agents during all CEPRF procedures. Pneumorrhachis is usually benign and the air reabsorbs spontaneously, as in our case. Although neurological complications have been reported only in exceptional cases, they might be more common than reported (13). Kennedy et al (12) reported a case of lumbar root compression and bilateral L2-L3 sensory and motor deficit secondary to epidural air resulting from repeated air injection during administration of epidural analgesia via a continuous infusion pump; neurological symptoms resolved after decompression by percutaneous epidural air aspiration. Nay et al (15) reported a case of unilateral L2-L4 motor and sensory deficit due to nerve root displacement after injecting 40 mL of air to locate the extradural space by the “loss of resistance to air” technique for anesthesia. Gracia et al (10) reported a case of acute radicular pain attributed to air trapped in the epidural space after using the “loss of resistance saline” technique with epidural catheterization for epidural anaesthesia, suggesting that using saline instead of air is no guarantee against this complication. Finally, Krishnan and Mallick (13) reported a case of reversible sensory deficit and weakness in dermatomes L4-L5 attributed to epidural air after the “loss of resistance to air” technique (13). Other authors have suggested that epidural bubbles may be a cause of incomplete analgesia during epidural anesthesia (8,9). If entrapped intraspinal air under pressure enters the cranio-spinal compartment it might cause tension pneomorrhachis and pneumocephalus requiring intervention. CT and MRI are the most reliable techniques to detect pneumorrhachis (10). In conclusion, we report a case of pneumorrhachis that developed after CEPRF and resolved spontaneously. Joan Dalmau-Carolà, MD Bisbe Lorenzana, 39,3-3 Girona, Catalonia, Spain E-mail: jdalmauc@acmcb.es
    Pain physician 12/2014; 17(6):E790-E792. · 4.77 Impact Factor
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    ABSTRACT: Objective Cervical radicular pain is defined as pain arising in the arm caused by irritation of a cervical spinal nerve or its roots. Although many treatment modalities are described in the literature, the available evidence for efficacy is not sufficient to allow definitive conclusions. The goal of this study was to establish the benefits and prognostic factors of pulsed radiofrequency (PRF) on the adjacent cervical dorsal root ganglia (DRG) of cervical radicular pain patients. Methods A retrospective study of PRF treatment of patients with cervical radicular pain was carried out. Two times diagnostic block of cervical DRG were performed before PRF. PRF was applied for 2 minutes at a setting of 2 Hz and 45 V by two times on the same targets, with the end point being an electrode tip temperature 42℃. Numerical rating scale (NRS) score was evaluated post-treatment 2 week, 1 month, 3 months and 6 months, which were compared with pretreatment value. A successful outcome was defined that NRS change was improved more than 50% at 6 months. Results The mean age was 54 years. The success rate was 68%(15/22) after six months of follow-up. PRF induced complications were not observed. Between success and failure group, we do not find any positive outcome prognostic factor. Interestingly, PRF treatment on foraminal stenosis is better outcome than herniated cervical disc. Conclusion PRF on adjacent cervical DRG is effective and safe treatment option for cervical radicular pain patients. However, more long-term follow up and larger patients are needed to establish effectiveness PRF treatment on cervical radicular pain patients.
    09/2014; 11(3):109-12. DOI:10.14245/kjs.2014.11.3.109
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    ABSTRACT: Optimization of clinical outcomes of lateral branch radiofrequency ablation or blocks for sacroiliac joint (SIJ) pain requires precise nerve localization; however, there is a lack of comprehensive morphological studies. The objectives of this cadaveric study were to document SIJ innervation relative to bony landmarks in 3 dimensions and to identify reference points visible under ultrasound and fluoroscopy for optimal needle placement.

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