Radio Frequency Lesioning is a procedure using a specialized computer controlled machine to interrupt nerve conduction on a semi-permanent basis. The nerves are usually blocked for 6-9 months (can be as short as 3 months or as long at 18 months). The first practical and commercially available Radio Frequency (RF) lesion generators were built in the early 1950s using continuous wave radio frequencies in the 1-MHZ range. RF lesioning is used when other conservative therapies such as exercise, bed rest, or medications other than narcotics, have failed. RF is only considered after a diagnostic (local anesthetic) block has been shown to be of benefit, but of short duration.
Treatments that are usually undertaken with the use of RF lesioning include, but are not limited to:
· Facet denervation (Headaches, neck pains, and upper or lower back pain)
· Sacroiliac Joint denervation (Hip Pain)
· Sympathetic blocks (upper or lower extremity pains)
· Dorsal Root Ganglion lesions (pain of spinal origin)
· RF disc procedures (Headaches, neck pains, and upper or lower back pain)
Each of these procedures may be done at various levels since there is a great deal of segmental overlap on the nerve conduction to these structures.
Radio Frequency Lesioning is offered to patients with:
· RSD/CRPS/SMP involving upper or lower extremities
· Mechanical neck or low back pain due to facet joint disease
· Occipital neuralgia (Headaches)
· Abdominal (visceral) pain responsive to splanchnic nerve blocks.
· Discogenic Pain (Low Back Pain)
· Nerve Root Pain (Radiculopathy / Radiculitis) (Arm or Leg Pain)
You must have responded well to local anesthetic blocks, to be a candidate for Radiofrequency Lesioning.
The procedure disrupts nerve conduction (such as conduction of pain signals), and it may in turn reduce pain, and other related symptoms. Approximately70-80% of patients will get good pain relief. Occasionally, after a nerve is blocked, it becomes clear that there is pain also coming from other areas as well.
Depending upon the areas to be treated, the procedure can take from about twenty minutes to an hour.
No. The procedure is
performed in our clinic as a same day surgery. Except for a few cases, most
patients will be discharged home two (2) hours after the procedure.
The procedure is usually performed under fluoroscopy (x-ray) guidance, in our clinic.
You will be scheduled for the procedure with enough time to make arrangements to get a driver, and someone to stay with you at home, the day of the procedure. You will take all of your usual medicines the morning of the procedure, except for any blood thinners, which you should have stopped with enough time for their effects to disappear form your body. (If you have any questions about specific medications, please call us for clarification. Do not wait until the day before the procedure to ask.) The day of your procedure, you will need to come in 30 to 45 minutes prior to your schedule procedure time, at which time an IV will be started and your physician will check on you, to answer any questions and to assess to see if there are any contraindications to proceed. Since nerves cannot be seen on x-ray, the needles are positioned using bony landmarks that indicate where the nerves usually are. Fluoroscopy (x-ray) is used to identify those bony landmarks. A local anesthetic (Lidocaine) is injected to numb the skin before placing the radiofrequency needles. The needles are then positioned using x-ray guidance. The radiofrequency machine is then used in the diagnostic stimulation mode to provide a small electrical pulse used to identify proper needle placement. At this point you will be asked to let us know, by saying "NOW", when you first feel any sensation different from what you normally feel in the area. This sensation could be a type of pressure, or a tingling sensation. Because we are slowly increasing the electrical output on the machine, it is important that you say "NOW", as soon as you feel this sensation. Otherwise, the magnitude of the sensation will increase to the point where it will become painful. To avoid this, simply pay attention to the change in sensations and report it as soon as you experience it. After confirmation of the needle tip position, a special needle tip is inserted.
When the needle is in good position, as confirmed by x-ray, electrical stimulation is done before any lesioning. This stimulation may produce a buzzing, tingling, pain, or pressure sensation or may be like hitting your "funny bone". Because we also do motor stimulation testing, you may also feel your muscles jump or twitch. You need to be awake during this part of the procedure so you can report what you're feeling. The tissues surrounding the needle tip are then heated when electronic current is passed using the Radio Frequency machine, for a few seconds. This "numbs" the nerves semi-permanently.
There will be some discomfort. Layers of muscle and soft tissues protect nerves. The procedure involves inserting a needle through skin and those layers of muscle and soft tissues, so there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the radiofrequency needle. In addition, an IV will be started and you will be given sedatives and pain medication. Local anesthetics will also be injected prior to the "burning" of the nerve; therefore, the actual lesion should be painless. The action of the local anesthetics should last four (4) to six (6) hours, after which, the local anesthetic will were off and the pain will return. You will probably then experience more pain than usual for five (5) to ten (10) days before it gets any better. This pain is from the procedure itself (needle sticks). You may also have pain and discomfort for up to six (6) weeks, until the lesion itself heals (the "burn"). To help you with this, you will be instructed to apply cold compresses on the day of the procedure (to minimize swelling), followed by heat, from the next day on. You will also be provided with a prescription for pain medication to have available, in case you do experience some increased pain.
No. This procedure is done under local anesthesia and sedation. Most of the patients receive intravenous sedation and analgesia, which makes the procedure easier to tolerate. The amount of sedation given generally depends upon the patient tolerance. It is necessary for you to be awake enough to communicate easily during the procedure.
It is done either with the patient lying on the stomach when working on the facet joints, low back for lumbar sympathetic nerves, and the back when lesioning the cervical (neck) area (e.g. Stellate Ganglion). The patients are monitored with EKG, blood pressure cuff, and blood oxygen-monitoring device. The skin on the back is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needles.
Most people will feel an increase in their pain, which could last up to 5weeks, after which it should go away gradually. Your physician knows this, and will therefore provide you with enough pain medications to last until then. Because of this same reason, you need not be seen in the Pain Clinic until 5-6 weeks after your RF lesioning, unless you need to see you pain specialist because of a possible complication or unexpected side effect.
Most procedures involve the use of local anesthetics (numbing medicine), steroids (anti-inflammatory medicines) and possibly sedation (relaxation or nerve medicine). Sedation may affect your memory, not allowing you to remember the procedure, or the instructions that we give you after it. Because of this, your Doctor may want to avoid providing you with important information after the procedure, since you may not remember. The Doctor will be more than happy to go over the information upon your return.
Local anesthetics, on the other hand, may cause temporary numbness and weakness of the legs or arms, depending on the location of the block. This numbness/weakness may last 4-6 hours (the duration of the local anesthetic). During this period of numbness, you must be more careful than usual, to prevent any injuries to the extremity.
Steroids will begin to work immediately after injected, but on the average, it will take 6-10 days for the swelling to come down to the point where you will be able to tell a difference in terms of the pain.
In summary, you should expect for your pain to get better within 15-20 minutes after the procedure. This relief or numbness should last 4-6 hours, after which, it will wear off. Once it wears off, you may experience more pain than usual until the steroids ěkick inî. This discomfort is due to the procedure itself. To minimize this, we recommend applying ice (fill a plastic sandwich bag with ice and wrap it on a towel to prevent frostbite) to the area, 15 minutes on and 15 minutes off, the day of the procedure. This will minimize any swelling. Starting the next day, you should then start with heat (moist or dry, it does not matter). Heat therapy should continue until the pain improves (4-6 days). Be careful not to burn yourself.
In the case of Radiofrequency procedures, you should expect more pain than usual for 5 to 6 weeks after the procedure. This is how long it takes the burned tissue to heal. We cannot assess any definite results on the success of the procedure until this recovery period has elapsed.
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.
You should be able to return to your work the next day. Sometimes soreness at the injection site causes you to be off work for a day or two.
If successful, the effects of the procedure can last from 3-18 months, usually 6-9 months.
Unfortunately, nothing available at this time is permanent. The duration of pain relief can be from 0 days to 2.7 years. There is currently no way to predict which patients will obtain long pain relief. However, it is our experience that those patients that obtain longer benefits from the diagnostic injections, tend to also attain longer benefits from the radiofrequency procedures. Keep in mind that every patient is different.
If the first procedure does not relieve your symptoms completely, you maybe recommended having a repeat procedure after re-evaluation. Because these are not permanent procedures, they may need to be repeated when the numbness wears off (often 6-12 months).
Yes. The effectiveness of subsequent repeat procedures is also variable. Some patients obtain longer duration of pain relief while others obtain shorter duration.
It is very difficult to predict if the procedure will indeed help you or not. Generally speaking, the patients who have responded to repeated local anesthetic blocks will have better results.
Although possible, it is our experience that in 85% of the patients suffering from chronic pain, the cause of the pain is usually multifactorial. Therefore, it is highly unlikely that we will be able to completely address the problem with only one type of therapy.
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The risks and complications are dependent upon the sites that are lesioned. The closer the procedure is to the spine, the more serious the risks are. Great care is taken when placing the radiofrequency needles, but sometimes complications can occur.
Everything in medicine is subject to possible side effects and complications. No two patients are alike. Side effects and complications are not the same as malpractice. Malpractice refers to an injury incurred by a patient, which occurs as a consequence of negligence in the practice of medicine. Side effects and complications, on the other hand, are untoward events, which can occur and may injure a patient, in certain percentages of the population. These events can, and do, occur even if everything seems to have taken place as planned, and in the absence of negligence or malpractice. Possible side effects and complications of RF include, but are not limited to:
· Those related to needle insertion:
- Pain or worsening of symptoms: The needles have to go through skin and soft tissues, which will cause soreness.
- Infection: (local = abscess, or generalized = sepsis), including meningitis and death. Any time there is an injection through the skin, there is a risk of infection. This is why sterile conditions are used for these blocks. There are three possible types of infection:
1. Localized skin infection.
2. Central Nervous System infection. This can be in the form of meningitis, which can be deadly.
3. Epidural Infections. This can be in the form of an epidural abscess, which can cause pressure inside of the spine, causing compression of the spinal cord with subsequent paralysis. This would require an emergency surgery to decompress, and there are no guarantees that the patient would recover from the paralysis.
- Bleeding: Bleeding is more common if the patient is taking blood thinners such as aspirin, Coumadin, Ticlid, Plavix, etc., or if he/she have some genetic predisposition such as hemophilia. Bleeding into the spinal canal can cause compression of the spinal cord with subsequent paralysis. This would require an emergency surgery to decompress and there are no guarantees that the patient would recover from the paralysis.
- Nerve damage: By working so close to the spinal cord, there is always a possibility of nerve damage, which could be as serious as a permanent spinal cord injury with paralysis.
· Those related to intentional production of heat:
- Pain or worsening of symptoms
- Permanent motor or sensory deficits (nerve damage)
· Those related to instrument failure:
- Skin burns
- Pain or worsening of symptoms
- Permanent nerve damage
· Death: Although rare, severe deadly allergic reactions known as "Anaphylactic Reaction" can occur to any of the medications used.
· Worsening of the symptoms: We can always make things worse.
· Chances of any of this occurring are extremely low. By statistics, you have more of a chance of getting killed in a motor vehicle accident driving to the Hospital, than any of the above occurring. Nevertheless, you should be aware that they are possibilities.
These occur in approximately 1 (one) in every 5,000 patient that undergo this mode of therapy.
None. There are no guarantees in medicine.
·
For headaches - approximately 60% of patients obtain more than 50% pain relief.
·
For post-traumatic neck pain - approximately 57% of patients obtain more than 50% pain relief
· For back pain due to facet disease
·
Without previous surgery - approximately 60% of patients obtain more than 50%pain relief
·
With prior surgery - approximately 40% of patients obtain more than 50% pain relief
·
For arm pain - approximately 52% of patients obtained more than 50% pain relief.
·
For chest and abdominal pain - approximately 52% of patients obtained
more than 50% pain relief.
If you are on a blood thinning medication (e.g. Coumadin, Plavix), or if you have an active infection going on, you should not have the procedure. If you have not responded to local anesthetic blocks, you may not be a candidate for this procedure. If you are taking any blood thinners, please inform your physician.
· Do not eat or drink anything, at least six hours prior to the procedure.
· Bring a driver with you. Cannot be a Taxi.
· Take all of your medicines the morning of the procedure, with just enough water to swallow them. If you have diabetes, do not take your Insulin or your sugar pills (oral hypoglycemics) until after the procedure.
· Do not take aspirin or any aspirin-containing medications, at least eleven (11) days prior to the procedure. They may prolong bleeding.
· Do not take any non-steroidal anti-inflammatory drugs, at least one day prior to the procedure. They may prolong bleeding.
· Wear loose fitting clothing that may be easy to take off and that you would not mind if it got stained with Betadine or blood.
· Take a shower the morning of the procedure, using a bactericidal soap to minimize chances of infection.
· Do not wear any jewelry or perfumes.
· During the testing phase of the procedure, you will be asked to let us know as soon as you feel the stimulation. It is imperative that you let us know the instant that you begin to feel it. This stimulation may be initially felt as a pressure or a tingling sensation. Nevertheless, because we will be increasing the intensity of the stimulation, until you tell us that you feel it, if you do not tell us the instant that you begin to feel it, we will continue to increase the intensity and it may become very painful.