March 21, 2016

Radiofrequency Ablation for Low Back Pain

An option that lies between injections and surgery

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By Russell DeMicco, DO

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A major advantage of large multispecialty spine care practices such as Cleveland Clinic’s Center for Spine Health is the broad scope of treatment options that are available to treat low back pain.

The treatment continuum includes:

  • Education and observation (i.e., “the tincture of time”)
  • Physical therapy with home exercises
  • Medications
  • Injections and other nonsurgical interventional treatments, such as radiofrequency ablation
  • Nontraditional/integrative medicine approaches (e.g., acupuncture, pain psychology, manipulation)
  • Surgery

Conservative treatments for low back pain

Patients hoping to have a low back pain problem “fixed” often seek the advice of specialists, including spine surgeons. Whereas the most successful spine surgeries are done to relieve limb pain, the majority of patients with axial low back pain can be treated with nonsurgical measures. Maintenance of a healthy weight, smoking cessation and aerobic conditioning are stressed for spine health and for general well-being.

For subacute to chronic low back pain, an adequate trial of movement-based physical therapy and an independent home program are paramount. Medications and injections are used for pain beyond what can be controlled with exercise, or to allow enough pain relief for active participation in therapy and home programs. Injections may be diagnostic or therapeutic in nature.

Radiofrequency ablation: Longer-lasting pain relief

Radiofrequency ablation (RFA) lies in the midrange of the treatment continuum for persistent low back pain.

Over the past decade, RFA has gained traction as an effective treatment for low back pain. Heat generated by radiofrequency electrical pulses is delivered through needles placed in the patient’s body to ablate, in a controlled fashion, the nerves that are conducting the pain.

RFA is considered a longer-lasting treatment than injections. Nerves will regenerate, but relief following RFA should average from about six to 12 months.

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Patient selection for RFA

Prior to RFA, the clinician uses anesthetic injections to diagnose which zygapophysial joints are generating pain in the spine. The standard of care requires that image-guided techniques be used for these procedures — most commonly fluoroscopy.

Patients are considered suitable candidates for RFA when they experience “adequate improvement” in painful symptoms for the expected amount of time following two separate anesthetic injections. Adequate improvement may be defined as more than 50 percent or more than 70 percent, depending on the patient’s geographic area and/or insurance coverage. These injections are diagnostic and only a temporary measure.

Comprehensive care for better outcomes

At the Center for Spine Health, we strive to use the most clinically effective methods and foster collaborative relationships within the spine continuum of care and across all medical disciplines. Using treatments such as RFA and/or injections as part of a comprehensive spine care path, rather than as isolated treatments, leads to better patient outcomes and satisfaction.

RFA CASE EXAMPLES

The following cases and images illustrate the successful use of RFA in two patients:

Patient A is a competitive power lifter in her 20s with low back pain who was evaluated for and determined to be a candidate for fusion surgery. Her pain ranged from 4 to 8 on a scale of 1 to 10. She reported that her symptoms often worsened with extended lifting, bending and twisting.

Rather than opting for surgery, the patient decided to try diagnostic anesthetic injections. She underwent bilateral L4 medial branch and L5 dorsal rami injections on two separate occasions. The treatments resulted in excellent relief of her pain. Subsequently, she underwent bilateral L4 medial branch and L5 dorsal rami RFA (images below). The patient has done quite well and reports that she is able to work out regularly and compete as a power lifter.

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(Left) AP fluoroscopic view with RFA needles in place for bilateral L4 medial branch and L5 dorsal rami RFA procedure. (Right) Lateral fluoroscopic view with RFA needles in place for bilateral L4 medial branch and L5 dorsal rami RFA procedure.

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Patient B had been seen by multiple specialties for his back pain, including rheumatology, neurology and spine surgery. He was not deemed a surgical candidate. He experienced relief of his buttock pain, but not low back pain, with prior sacroiliac joint injections. Previously, the patient also underwent diagnostic bilateral L3 and L4 medial branch and L5 dorsal rami injections on two separate occasions, with excellent pain relief.

The patient underwent right L3 and L4 medial branch and L5 dorsal rami RFA (images below). He has experienced relief of his right-sided pain and is planning to undergo a procedure on the left side in the near future.

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(Left) AP fluoroscopic view with RFA needles in place for right L3 and L4 medial branch and L5 dorsal ramus RFA procedure. (Center) Lateral fluoroscopic view with RFA needles in place for right L3 and L4 medial branch and L5 dorsal ramus RFA procedure. (Right) AP fluoroscopic view after contrast administration to confirm position of RFA needles for right L3 and L4 medial branch and L5 dorsal ramus RFA procedure.

Dr. DeMicco is a medical spine specialist in the Center for Spine Health, and Program Director, Spine Medicine Fellowship. He can be reached at demiccr@ccf.org or 216.444.0229.

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