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      Comparison of Quadrapolar™ radiofrequency lesions produced by standard versus modified technique: an experimental model

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          Abstract

          Lower back pain (LBP) is a global public health issue and is associated with substantial financial costs and loss of quality of life. Over the years, different literature has provided different statistics regarding the causes of the back pain. The following statistic is the closest estimation regarding our patient population. The sacroiliac (SI) joint pain is responsible for LBP in 18%–30% of individuals with LBP. Quadrapolar™ radiofrequency ablation, which involves ablation of the nerves of the SI joint using heat, is a commonly used treatment for SI joint pain. However, the standard Quadrapolar radiofrequency procedure is not always effective at ablating all the sensory nerves that cause the pain in the SI joint. One of the major limitations of the standard Quadrapolar radiofrequency procedure is that it produces small lesions of ~4 mm in diameter. Smaller lesions increase the likelihood of failure to ablate all nociceptive input. In this study, we compare the standard Quadrapolar radiofrequency ablation technique to a modified Quadrapolar ablation technique that has produced improved patient outcomes in our clinic. The methodology of the two techniques are compared. In addition, we compare results from an experimental model comparing the lesion sizes produced by the two techniques. Taken together, the findings from this study suggest that the modified Quadrapolar technique provides longer lasting relief for the back pain that is caused by SI joint dysfunction. A randomized controlled clinical trial is the next step required to quantify the difference in symptom relief and quality of life produced by the two techniques.

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          Most cited references 16

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          Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.

          This prospective study consisted of the evaluation of a double sacroiliac block in patients with low back pain. To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain, and to assess certain pain provocation tests. Previous studies have implicated the sacroliac joint as a potential etiology of back and leg pain, but none has tested double anesthetic blocks in a prospective fashion. Fifty-four patients with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the sacroiliac joint, and no obvious source of pain in the lumbar spine were selected for a double anesthetic block. The procedure consisted of a through clinical examination with a visual analog scale, testing of sacroiliac pain provocation tests followed by a first screening block with a short-acting anesthetic. A second examination consisting of the same tests assessed the efficacy of the first block. If results were positive, a confirmatory block was performed. All blocks were performed under fluoroscopic guidance. Nineteen patients had a positive response to the first block. Among them, 10 (18.5%) were temporarily relieved by the confirmatory block. No pain provocation test reached statistical significance. The present study suggests the sacroiliac joint is an uncommon but real source of low back pain. The accuracy of some of the presumed "sacroiliac pain provocations tests" is questioned.
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            Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain.

            Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain. A randomized placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology after a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who did not respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology. One, 3, and 6 months after the procedure, 11 (79%), 9 (64%), and 8 (57%) radiofrequency-treated patients experienced pain relief of 50% or greater and significant functional improvement. In contrast, only 2 patients (14%) in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3 months after the procedure. In the crossover group (n = 11), 7 (64%), 6 (55%), and 4 (36%) experienced improvement 1, 3, and 6 months after the procedure. One year after treatment, only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief. These results provide preliminary evidence that L4 and L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain. Larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this poorly understood disorder.
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              Sensory stimulation-guided sacroiliac joint radiofrequency neurotomy: technique based on neuroanatomy of the dorsal sacral plexus.

              A retrospective audit and examination of anatomic findings. To examine the effectiveness of sensory stimulation-guided radiofrequency neurotomy for the treatment of recalcitrant sacroiliac joint pain. Sacroiliac joint-mediated pain is a distinct clinical entity. The prevalence of intra-articular pain arising from the sacroiliac joint in patients with low back pain has been estimated at 15% to 30%. Unfortunately, the clinical success of current treatment methods for chronic sacroiliac pain is discouraging. Based on the anatomy of the sacral posterior primary rami and their lateral branch nerves, an anatomically based sensory stimulation-guided radiofrequency technique was developed to overcome the inherent challenge posed by the variable topography of the sacral lateral branch nerves. MATERIALS AND METHODS ANATOMIC STUDY: Meticulous dissection exposing the dorsal sacral plexus and lateral branch nerves entering the sacroiliac joint complex was performed on three cadaveric specimens. Small-gauge wires were placed adjacent to the lateral branch nerves entering the joint and over the dorsal sacrum to the dorsal sacral foramina. Fluoroscopic images were obtained correlating the location and number of these branches arising from the posterior primary rami of S1-S3 to identifiable bony landmarks. A retrospective chart review was performed selecting patients who underwent sensory stimulation-guided sacral lateral branch radiofrequency neurotomy after dual analgesic sacroiliac joint deep interosseous ligament analgesic testing between February 17, 1998 and March 15, 1999. A total of 14 patients met inclusion criteria for this retrospective study. Success was defined as greater than 60% consistent subjective relief and greater than a 50% consistent decrease in visual integer pain score, maintained for at least 6 months after the procedure. Sixty-four percent of patients experienced a successful outcome, with 36% experiencing complete relief. Fourteen percent of patients did not achieve any improvement. No patients experienced a complication or worsening of their pain from the procedure. A sensory stimulation-guided approach toward the identification and subsequent radiofrequency thermocoagulation of symptomatic sacral lateral branch nerves appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic sacroiliac joint complex pain.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2017
                02 June 2017
                : 10
                : 1377-1382
                Affiliations
                Allevio Pain Management Clinic, Toronto, ON, Canada
                Author notes
                Correspondence: Ramin Safakish, Allevio Pain Management Clinic, 240 Duncan Mill Road, Suite 101, Toronto, ON M3B 3S6, Canada, Tel +1 416 8405990, Email ramin.safakish@ 123456gmail.com
                Article
                jpr-10-1377
                10.2147/JPR.S129478
                5476609
                © 2017 Safakish. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

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