Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN)

Abstract

Radiofrequency neurotomy (RFN), also known as radiofrequency ablation (RFA), is a common interventional procedure used to treat pain from an innervated structure. RFN has historically been used to treat chronic facet-joint mediated pain. The use of RFN has more recently expanded beyond facet-joint mediated pain to peripherally innervated targets. In addition, there has also been the emergence of different radiofrequency modalities, including pulsed and cooled RFN. The use of RFN has been particularly important where conservative and/or surgical measures have failed to provide pain relief. With the emergence of this therapeutic option and its novel applications, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidance. The authors formed a multidisciplinary work group tasked to examine the latest evidence-based medicine for the various applications of RFN, including cervical, thoracic, lumbar spine; posterior sacroiliac joint pain; hip and knee joints; and occipital neuralgia. Best practice guidelines, evidence and consensus grading were provided for each anatomical target.

Anatomical study of the medial branches of the lumbar dorsal rami: implications for image-guided intervention

“…Based on this anatomy, the inferior aspect of the mammillary process, seen from a lateral perspective, could be used to fluoroscopically guide cranial-to-caudal angulation of the electrode (figure 11D–F). This finding suggests that to achieve parallel alignment along the maximal available length of the medial branch, cranial-to-caudal angulation of the electrode tip may need to be greater than the currently used technique as determined from published lateral radiographs 7 11 12 19 24. Conceivably, there are subtle differences in placement techniques between clinicians however, based on published radiographs,7 11 12 19 24 placed needles commonly do not achieve a sufficient cranial-to-caudal angulation to position the needle parallel to the medial branch as reported in the current study (figure 11D,E).…”

“…This finding suggests that to achieve parallel alignment along the maximal available length of the medial branch, cranial-to-caudal angulation of the electrode tip may need to be greater than the currently used technique as determined from published lateral radiographs 7 11 12 19 24. Conceivably, there are subtle differences in placement techniques between clinicians however, based on published radiographs,7 11 12 19 24 placed needles commonly do not achieve a sufficient cranial-to-caudal angulation to position the needle parallel to the medial branch as reported in the current study (figure 11D,E). Therefore, the length of the nerve being coagulated would be less than optimal as current techniques would be considered near parallel.…”

Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review

“…Lumbar RFA has been shown to improve pain, function, and QoL at 6-months; however results were not significantly different when compared to intraarticular facet injections ( 41 ). There is moderate level I evidence supporting the use of LMBN RFA as a palliative interventional treatment for chronic facet-mediated pain in selected patients ( 42 , 43 ). Yet, LMBN RFA may have deleterious effects, particularly from the dual innervation of the dorsal ramus of the LMBN to the facet joint and toward the multifidus muscle.…”

Cooled radiofrequency ablation for pain related to Perthes’ disease: a novel application

“…Conservative management of degenerative joint diseases includes analgesia, physiotherapy and, more recently, nerve radiofrequency ablation (RFA). Since 2008, there have been increasing evidence supporting the use of cooled RFA (CRFA) for management of chronic hip, knee and back pain 3. Although there have been reports of successful treatment of avascular necrosis and osteoarthritis related hip pain, to our knowledge, this is the first case report describing the successful application of CRFA in the treatment of Perthes’ disease in a patient who developed secondary osteoarthritis following a late diagnosis at the age of 40 years.…”