Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis

Prospective study on a new combination of pulsed radiofrequency and platelet-rich plasma injections for managing grade I lumbosacral spondylolisthesis

Our study aimed to investigate the clinical benefits of combining pulsed radiofrequency (PRF) and platelet-rich plasma (PRP) techniques for treating chronic lumbosacral radicular (CLSR) pain resulting from grade I spondylolisthesis (G1SL). Ninety-six patients with CLSR pain between March 2021 and March 2023 were included in this study, 58 patients with G1SL without instability on dynamic radiographs - Group A and 38 patients with instability - Group B. Pre-procedure, Group B had higher pain levels than Group A. Post-procedure and at follow-up intervals, Visual Analog Scale (VAS) pain scores improved in both groups (p < 0.05) and there were no significant differences between the groups. Both groups also showed significant improvement in ODI scores post-procedure, which was maintained at follow-up intervals. The treatment effect, evaluated using the modified MacNab criteria, showed high rates of excellent and good outcomes in both groups, with no significant differences. Importantly, no patients experienced severe complications or required open surgery during the 6-month follow-up. Based on these findings, a new treatment combining PRF and PRP applications appears beneficial in managing pain in regenerative medicine. So, further clinical studies are necessary to support and validate our preliminary findings.

Radiofrequency treatments for lumbar facet joint syndrome: a systematic review and network meta-analysis

BACKGROUND

Lumbar facet joint syndrome (FJS) is a common cause of chronic low back pain (LBP). Radiofrequency treatments are commonly used to treat chronic LBP-related FJS that is refractory to conservative treatment, although evidence supporting this treatment is controversial.

OBJECTIVE

We explored the therapeutic effects of radiofrequency on FJS using a network meta-analysis (NMA).

EVIDENCE REVIEW

A comprehensive systematic search of multiple databases was conducted to identify randomized controlled trials (RCTs) that compared radiofrequency with other treatments (sham procedures, facet joint corticosteroid injection, and conservative treatment) for FJS. We searched PubMed, Embase, Web of Science, the Cochrane Database, and handsearching. The primary outcomes were pain score and Oswestry Disability Index (ODI). Statistical analysis included conventional pairwise meta-analysis and NMA using the frequentist method.

FINDINGS

The treatments were ranked using surface under the cumulative ranking curve (SUCRA) values. The search yielded 25 RCTs (1969 patients) and a mixed quality regarding the risk of bias, with most studies exhibiting a low risk of bias for most domains. Endoscopic neurotomy consistently ranked highest in terms of pain reduction and ODI score improvement at 1, 3, 6, and 12 months. At 1 and 6 months, endoscopic neurotomy had the highest SUCRA value for pain reduction (0.833 and 0.860, respectively), followed by medial branch thermal radiofrequency.

CONCLUSIONS

This NMA demonstrates that endoscopic neurotomy is the most effective treatment for lumbar FJS, providing superior and sustained pain relief and functional improvement compared with other treatments. Further, high-quality RCTs are needed to confirm these findings and address the existing limitations.

PROSPERO REGISTRATION NUMBER

CRD42024524657.

Radiofrequency vs Steroid Injections for Spinal Facet and Sacroiliac Joint Pain: A Systematic Review and Meta-Analysis

Purpose

Pain management for spinal facet joint (SFJ) and sacroiliac joint (SIJ) pain is challenging, often requiring interventions like radiofrequency ablation (RFA) or corticosteroid injections (CI). This study aims to assess and compare the effectiveness of CI and RFA in treating SFJ and SIJ pain. We combine these treatments due to their shared pathophysiology, similar therapeutic interventions, and the necessity for an integrated approach to spinal pain management.

Patients and methods

Literature search from PubMed, Scopus, CENTRAL and Google Scholar for published studies upto 31st December 2023, and reporting data of patients who were treated using CI of RFA for SFJ and SIJ pain. Pooled standardized mean difference (SMD) with a 95% Confidence Interval (CI) was calculated.

Results

Our meta-analysis incorporated thirteen studies. Overall, patients, treated with CI had a higher pain intensity score compared to patients treated with RFA (SMD=0.92; 95% CI: 0.19 to 1.65) at 3 months, and at 6 months (SMD=1.53; 95% CI: 0.66 to 2.40) after the treatment. No significant association was reported at 12 months (SMD=1.47; 95% CI: -0.03 to 2.97). Subgroup analysis based on joint types revealed increased pain intensity scores in patients who were treated with CI for SIJ (SMD=1.25; 95% CI: 0.39 to 2.11) and SFJ (SMD=1.33; 95% CI: 0.09 to 2.57) pain. A negative but not significant effect was detected in patients, treated with CI for cervical joint pain (SMD=-0.40; 95% CI: -0.90 to 0.10). Patients treated with CI exhibited higher functional disability score compared to patients treated with RFA at 3 months (SMD=1.28; 95% CI: 0.20 to 2.35) post-treatment.

Conclusion

This study suggests that RFA may offer superior pain relief with longer duration compared to steroid injections for spinal facet and sacroiliac joint pain. Decision regarding specific interventions should be individualized and consider patient preferences, clinical context, and potential risks.

Randomized controlled trials between dorsal root ganglion thermal radiofrequency, pulsed radiofrequency and steroids for the management of intractable metastatic back pain in thoracic vertebral body

BACKGROUND

Bone metastasis is a complication of various cancers causing severe pain. The current modalities for the treatment of metastatic axial pain include pharmacological, surgical and vertebral augmentation techniques, each of which has its own challenges.

OBJECTIVES

To evaluate the effectiveness of pulsed radiofrequency (PRF), thermal radiofrequency (RF) and steroids on dorsal root ganglion (DRG) in patients with thoracic axial pain due to vertebral metastasis.

METHODS

In this randomized controlled prospective study, 140 patients were assessed for eligibility, of which only 69 fulfilled the criteria. Patients were randomly divided into three equal groups, PRF, RF and steroid.

RESULTS

During the assessment of pain using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Opioid consumption using oral Morphine Equivalence (OME) and Analgesic Quantification Algorithm (AQA) - at baseline, 1 week, 1 month and 3 months - 81 patients were assessed for final eligibility, of which 12 were excluded before intervention due to drop-out. The remaining 69 were randomized (mean age: 53.87 ± 10.55, 55.78 ± 7.34 and 59.39 ± 13.72) for PRF, RF and steroid, respectively with no statistical difference. VAS% and ODI% decreased significantly at 3 months in RF group (p <0.001, 0.014, respectively), as did the AQA (p <0.027). Steroid group was the worst.

DISCUSSION

RF on DRG is the main stay for controlling intractable metastatic pain. PRF is a good alternative.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

The Effectiveness of Pulsed Radiofrequency on Joint Pain: A Narrative Review

BACKGROUND

Pulsed radiofrequency (PRF) stimulation has been safely and effectively applied for controlling various types of pain.

PURPOSE

We reviewed the literature on the efficacy of PRF for controlling pain in joint disorders.

METHODS

We searched PubMed for papers published prior to September 7, 2019, that used PRF to treat pain due to joint disorders. The key search phrases for identifying potentially relevant articles were (PRF AND joint) OR (PRF AND arthritis) OR (PRF AND arthropathy). The following inclusion criteria were applied for the selection of articles: (1) patients' pain was caused by joint disorders; (2) PRF stimulation was applied to manage joint-origin pain; and (3) after PRF stimulation, follow-up evaluation was performed to assess the reduction in pain intensity. Moreover, joints with more than 3 reported PRF studies were included in our review.

RESULTS

The primary literature search yielded 141 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text articles, we finally included 34 publications in this review. Based on the positive therapeutic outcomes of previous studies, PRF stimulation seems to be an effective treatment for cervical and lumbar facet, sacroiliac, knee, and glenohumeral joint pain. PRF appears to be beneficial. For confirmation of the effectiveness of PRF on joint pain, more high-quality studies are needed.

CONCLUSIONS

Our review provides insights on the degree of evidence according to pain in each joint, which will help clinicians make informed decisions for using PRF stimulation in various joint pain conditions.

Clinical Effectiveness of Intra-articular Pulsed Radiofrequency Compared to Intra-articular Corticosteroid Injection for Management of Atlanto-occipital Joint Pain: A Prospective Randomized Controlled Pilot Study

STUDY DESIGN

A prospective randomized controlled pilot study.

OBJECTIVE

We aimed to assess the effectiveness of pulsed radiofrequency (PRF) stimulation on the atlanto-occipital (AO) joint in patients with chronic joint pain. In addition, we compared the effects of AO intra-articular (IA) PRF and AO IA corticosteroid.

SUMMARY OF BACKGROUND DATA

IA injection of corticosteroids into the AO joint is widely used for the management of head and upper cervical pain, and its effectiveness has been shown in previous studies. However, little is known about the effect of PRF stimulation on the AO joint for controlling chronic head or upper cervical pain.

METHODS

Twenty-three consecutive patients with chronic upper cervical pain were enrolled according to the inclusion criteria and divided into one of two groups. Twelve patients received PRF stimulation with a PRF needle electrode in the IA space of the AO joint (PRF group) and 11 patients received AO IA corticosteroid injection (ICI group. Pain intensity was assessed using a numeric rating scale (NRS) before treatment and 1, 3, and 6 months afterward. Successful pain relief was defined as ≥50% reduction in NRS score 6 months post-treatment compared to pretreatment.

RESULTS

Mean NRS scores were significantly reduced compared to those pretreatment (P < 0.001) in both groups. Temporal changes in NRS score were not significantly different between groups (P = 0.227). Successful pain relief was achieved in 66.7% and 63.6% of patients in the PRF and ICI groups, respectively.

CONCLUSION

IA PRF stimulation significantly relieved AO joint pain and its effect persisted for at least 6 months after treatment. In addition, the degree of pain relief after IA PRF was not significantly different from that after ICI. We think that PRF stimulation of the AO joint could be a useful clinical treatment for patients with AO joint pain.

LEVEL OF EVIDENCE

2.

Radiofrequency and Methylprednisolone in Treatment of Lower Back Pain Caused by Facet Joint Syndrome: Comparison of the Outcomes

INTRODUCTION

In this trial we have discussed the outcomes of radiofrequency ablation and methylprednisolone treatment in cases diagnosed with facet syndrome; and effects of treatment modality on quality of life is evaluated by visual analogue scale and Oswestry Disability Index.

MATERIALS AND METHODS

This prospective, study was conducted with 100 patients with diagnosis of facet joint syndrome. Patients, benefited from diagnostic block, were separated into two groups, with 50 cases in each. In Group 1, 40 mg of methylprednisolone acetate were injected into each level. In Group 2, radiofrequency needle was used to apply RF to the facet joint.

RESULTS

Demographic characteristics of patients were similar (P > 0.05). VAS values of the patients in Group 1 were significantly lower than the values prior to treatment (P < 0.05). Similarly, VAS values of the patients in Group 2 were also significantly lower than the values prior to treatment (P < 0.05). When VAS scores of the patients in Group 2 at 3rd and 6th months were compared with scores of the patients in Group 1, significant differences were also observed (P < 0.01). ODI results of the patients in Group 1 were significantly lower than the values prior to treatment (P < 0.05). Additionally ODI scores of the patients in Group 1 on 9th and 12th months are recorded as significantly lower.

CONCLUSION

We consider that the steroid injection should be used as the first choice of treatment before the RF methods to be used in patients with back pain, caused by facet articulation pathology, if there are no contraindications.

Bipolar Radiofrequency Facet Ablation of the Lumbar Facet Capsule: An Adjunct to Conventional Radiofrequency Ablation for Pain Management

Radiofrequency facet ablation (RFA) has been performed using the same technique for over 50 years. Except for variations in electrode size, tip shape, and change in radiofrequency (RF) stimulation parameters, using standard, pulsed, and cooled RF wavelengths, the target points have remained absolutely unchanged from the original work describing RFA for lumbar pain control. Degenerative changes in the facet joint and capsule are the primary location for the majority of lumbar segmental pathology and pain. Multiple studies show that the degenerated facet joint is richly innervated as a result of the inflammatory overgrowth of the synovium. The primary provocative clinical test to justify an RFA is to perform an injection with local anesthetic into the facet joint and the posterior capsule and confirm pain relief. However, after a positive response, the radiofrequency lesion is made not to the facet joint but to the more proximal fine nerve branches that innervate the joint. The accepted target points for the recurrent sensory branch ignore the characteristic rich innervation of the pathologic lumbar facet capsule and assume that lesioning of these recurrent branches is sufficient to denervate the painful pathologic facet joint. This report describes the additional targets and technical steps for further coagulation points along the posterior capsule of the lumbar facet joint and the physiologic studies of the advantage of the bipolar radiofrequency current in this location. Bipolar RF to the facet capsule is a simple, extra step that easily creates a large thermo-coagulated lesion in this capsule region of the pathologic facet joint. Early studies demonstrate bipolar RF to the facet capsule can provide long-term pain relief when used alone for specific localized facet joint pain, to coagulate lumbar facet cysts to prevent recurrence, and to get more extensive pain control by combining it with traditional lumbar RFA, especially when RFA is repeated.

A comprehensive review of pulsed radiofrequency in the treatment of pain associated with different spinal conditions

OBJECTIVE

The objective of this review was to evaluate the efficacy of pulsed radiofrequency (PRF) treatment of pain associated with different spinal conditions. The mechanisms of action and biological effects are shortly discussed to provide the scientific basis for this radiofrequency modality.

METHODS

We systematically searched for clinical studies on spinal clinical conditions using PRF. We searched the MEDLINE (PubMed) database. We classified the information in one table focusing on randomized controlled trials (RCTs) and other types of studies. Date of last electronic search was October 2016.

RESULTS

We found four RCTs that evaluated the efficacy of PRF on cervical radicular pain and five observational studies. Two trials and three observational studies were conducted in patients with facet pain. For disc-related pathology, we found one RCT with PRF applied intradiscally and three RCTs for dorsal root ganglia PRF modulation lumbosacral radicular pain. For sacroiliac joint pain, spondylolisthesis, malignancies and other minor spinal pathology, limited studies were conducted.

CONCLUSION

From the available evidence, the use of PRF to the dorsal root ganglion in cervical radicular pain is compelling. With regard to its lumbosacral counterpart, the use of PRF cannot be similarly advocated in view of the absence of standardization of PRF parameters, enrolment criteria and different methods in reporting results; but, the evidence is interesting. The use of PRF in lumbar facet pain was found to be less effective than conventional RF techniques. For the other different spinal conditions, we need further studies to assess the effectiveness of PRF. Advances in knowledge: The use of PRF in lumbar facet pain was found to be less effective than conventional RF techniques. For the other different spinal conditions, we need further studies to assess the effectiveness of PRF.

Radiofrequency denervation for chronic low back pain

BACKGROUND

Radiofrequency (RF) denervation, an invasive treatment for chronic low back pain (CLBP), is used most often for pain suspected to arise from facet joints, sacroiliac (SI) joints or discs. Many (uncontrolled) studies have shown substantial variation in its use between countries and continued uncertainty regarding its effectiveness.

OBJECTIVES

The objective of this review is to assess the effectiveness of RF denervation procedures for the treatment of patients with CLBP. The current review is an update of the review conducted in 2003.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, three other databases, two clinical trials registries and the reference lists of included studies from inception to May 2014 for randomised controlled trials (RCTs) fulfilling the inclusion criteria. We updated this search in June 2015, but we have not yet incorporated these results.

SELECTION CRITERIA

We included RCTs of RF denervation for patients with CLBP who had a positive response to a diagnostic block or discography. We applied no language or date restrictions.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently selected RCTs, extracted data and assessed risk of bias (RoB) and clinical relevance using standardised forms. We performed meta-analyses with clinically homogeneous studies and assessed the quality of evidence for each outcome using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

In total, we included 23 RCTs (N = 1309), 13 of which (56%) had low RoB. We included both men and women with a mean age of 50.6 years. We assessed the overall quality of the evidence as very low to moderate. Twelve studies examined suspected facet joint pain, five studies disc pain, two studies SI joint pain, two studies radicular CLBP, one study suspected radiating low back pain and one study CLBP with or without suspected radiation. Overall, moderate evidence suggests that facet joint RF denervation has a greater effect on pain compared with placebo over the short term (mean difference (MD) -1.47, 95% confidence interval (CI) -2.28 to -0.67). Low-quality evidence indicates that facet joint RF denervation is more effective than placebo for function over the short term (MD -5.53, 95% CI -8.66 to -2.40) and over the long term (MD -3.70, 95% CI -6.94 to -0.47). Evidence of very low to low quality shows that facet joint RF denervation is more effective for pain than steroid injections over the short (MD -2.23, 95% CI -2.38 to -2.08), intermediate (MD -2.13, 95% CI -3.45 to -0.81), and long term (MD -2.65, 95% CI -3.43 to -1.88). RF denervation used for disc pain produces conflicting results, with no effects for RF denervation compared with placebo over the short and intermediate term, and small effects for RF denervation over the long term for pain relief (MD -1.63, 95% CI -2.58 to -0.68) and improved function (MD -6.75, 95% CI -13.42 to -0.09). Lack of evidence of short-term effectiveness undermines the clinical plausibility of intermediate-term or long-term effectiveness. When RF denervation is used for SI joint pain, low-quality evidence reveals no differences from placebo in effects on pain (MD -2.12, 95% CI -5.45 to 1.21) and function (MD -14.06, 95% CI -30.42 to 2.30) over the short term, and one study shows a small effect on both pain and function over the intermediate term. RF denervation is an invasive procedure that can cause a variety of complications. The quality and size of original studies were inadequate to permit assessment of how often complications occur.

AUTHORS' CONCLUSIONS

The review authors found no high-quality evidence suggesting that RF denervation provides pain relief for patients with CLBP. Similarly, we identified no convincing evidence to show that this treatment improves function. Overall, the current evidence for RF denervation for CLBP is very low to moderate in quality; high-quality evidence is lacking. High-quality RCTs with larger patient samples are needed, as are data on long-term effects.