The etiology of back pain is often multifactorial. There are all sorts of causes: muscles, ligaments, nerve roots, discs, and these pesky little things known as facet (zygapophysial) joints. This is why it’s very important you visit with either your primary care or a pain physician to establish a diagnosis prior to embarking on a treatment plan.
The facet joints are tiny little joints in your back that can cause significant pain (primarily in your back but potentially down your legs), and interventional pain docs can actually burn the nerves supplying those joints, providing long-lasting relief.
It is important to bear in mind that I do not promote injections as a sole form of therapy. A multidisciplinary approach, founded upon exercise, stress reduction and good nutrition, is essential to optimize outcomes. However, in the right patient, these therapies can offer substantial relief (>60% x 6-12 months) and allow someone to wean off medications, exercise, and improve their quality of life.
What is an ablation?
We typically target the nerves in the facet joints of the neck and low back, because these commonly are a source of severe pain. For the radiofrequency ablation (RFA) procedure, we use a needle with a tip that emits radiofrequency waves, or heat, to destroy the functionality of the nerve that supplies sensation to those joints. These nerves do not control any motor function so the procedure allows us to specifically target the nerves causing pain. It is done as an outpatient in an office or operating room using fluoroscopy (X-ray) guidance. The procedure takes about 15-30 minutes. It typically requires a total of three visits for an RFA. We do two “test” blocks, where we numb the joints with local anesthetic to make sure that the joints are indeed the source of pain. This is one of those times when keeping a pain diary– ADD LINK is so important. If patients respond with excellent relief to the first test block, we test it again just to be extra sure. We then bring them back for a third visit where we burn, or ablate, the nerves.
Before we burn the nerves, we do testing to make sure the needles are in the optimal position. The testing also ensures the needle is nowhere near a motor nerve, so we can avoid any nerve damage. When testing is done, this is a safe and effective procedure. Despite this, rare complications can happen, such as post-denervation neuritis (nerve pain), transient numbness, nerve injury, and infection. These nerves, unfortunately, grow back, so these procedures typically last about 6-12 months.
Research supporting RFA
A review study examined twenty-three randomized controlled trials and found moderate evidence for favorable results with denervation (1). A study of 61 patients also showed favorable results with low back RFA for function, pain scores and need for extra pain meds (2). A recent meta-analysis of randomized controlled trials also found RFA resulted in significant reductions in low back pain compared to sham and epidural nerve blocks (3).
As in everything with pain medicine, plenty of poorly designed studies exist. However, in my experience, I have seen that in the right patient, these procedures can provide months of relief.
If there’s a nerve causing pain, chances are, I have tried to burn it!
Different forms of RFA (with varying degrees of heat) have been used with success for a number of pain conditions: post-mastectomy pain, facial pain, knee pain, hip pain, ilioinguinal neuralgia, groin pain, sacroiliac joint pain, occipital neuralgia headaches, etc. Some of these are still considered experimental, and results vary, but I am optimistic we will see more studies in the near future.
- Maas ET, Ostelo RV, Niemisto L et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev. 2015. Oct 23;(10).
- McCormick ZL, Marshall B, Walker J, McCarthy R, Walega DR. Long-term function, pain and medication use outcomes of radiofrequency ablation for lumbar facet syndrome. Int J Anesth. 2015; 2 (2).
- Lee CH, Chung CK, Kim CH. The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine Journal. 2017. S1529-9430(17).
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