Treatment of chronic lumbosacral radicular pain using adjuvant pulsed radiofrequency: a randomized controlled study

A meta-analysis of modern neuro-stimulation modalities-Advances in neuro-stimulation techniques

Background

Chronic pain is a debilitating condition that affects about 3% of the population globally. Conventionally, pharmacologic approaches, psychotherapy, and surgery have been used in the management of chronic refractory pain. However, over the past decades, advances in neurotechnology have enabled modern novel techniques of neurostimulation, such as spinal cord stimulation (SCS) and dorsal root ganglion (DRG), to be used in the management of chronic neuropathic pain that does not respond to conventional management. This review, therefore, aims to establish the efficacy of these two novel technologies in the management of chronic neuropathic pain compared to conventional medical management (CMM) techniques.

Methods

A systematic search was conducted on three electronic databases, PubMed, Science Direct, and CENTRAL, for all relevant articles to the study topic. After a detailed review by two independent reviewers, only the articles that met the inclusion criteria were included. The Review Manager 5.4 software was utilized to conduct a meta-analysis of the outcomes of pain reduction.

Results

Our online search yielded 345 articles; however, only eight studies were included in the analysis according to our inclusion criteria. The results from our pooled analysis indicated that SCS and dorsal root stimulation both resulted in a significant reduction in the rating of chronic pain mean difference (MD) (-4.73; 95% confidence interval [CI] [-4.76, -4.71] P < 0.00001) and MD (-1.09; 95% CI [-1.29, -0.90] P < 0.00001), respectively. Similarly, for the studies that reported percentage change in pain rating, the pooled analysis showed that SCS resulted in a higher percentage reduction in pain rating compared to CMM MD (69.47; 95% CI [64.31, 74.64] P < 0.00001).

Conclusion

Based on the results of our analysis, we conclude that advances in neurostimulation techniques, such as SCS and DRG stimulation, have resulted in better management of chronic neuropathic pain compared to conventional pain management techniques.

Modified transforaminal epidural steroid injection combined with pulsed radiofrequency: an effective treatment measure for lumbar radiculopathy

Background

Lumbar disc herniation (LDH) is a prevalent condition encountered in the clinical diagnosis and management of spinal surgery. Certain people may experience excruciating radicular pain in the lower extremities. If these symptoms are not promptly alleviated, they may progressively deteriorate, ultimately resulting in radiating pain in the lower extremities, advancing neurological impairments, and potential trouble in standing, significantly impairing the patient's quality of life. Consequently, clinicians require an expedited and efficacious approach to address radicular discomfort resulting from lumbar radiculopathy and promptly reinstate the patient's normal functionality.

Objectives

This study seeks to assess the effectiveness of a modified transforaminal epidural steroid injection (TFESI) in conjunction with pulsed radiofrequency (PRF) for treating lumbar radiculopathy using a retrospective analysis.

Methods

Our study examined patients with unilateral lower limb radicular pain persisting for three months or more due to LDH, in whom conservative therapies were ineffective, from January 1, 2023, to October 31, 2023. This trial comprised 106 patients who received modified TFESI alongside PRF. We evaluated clinical efficacy and follow-up at baseline and at 1 week, 1 month, 3 months, 6 months, and 12 months post-surgery primarily using the Visual Analog Scale (VAS), Oswestry disability index (ODI), and modified MacNab score.

Results

Patients who received modified TFESI in conjunction with PRF exhibited substantial enhancements across all three assessment instruments (VAS, ODI, MacNab) when compared to pre-treatment evaluations (p < 0.0001). The alleviation of radicular discomfort was notably enduring, meeting the patients' expectations. At the 12-month follow-up, we noted that patients often achieved substantial pain alleviation within 6 months, and only a minor proportion of patients encountered pain recurrence by the 12th month, with no notable problems detected.

Conclusions

The modified TFESI in conjunction with PRF is a safe, cost-efficient, and successful therapy modality. Our findings indicated that this method can efficiently and swiftly relieve patients' radicular discomfort and produce enduring therapeutic effects.

Effects of Pulsed Radiofrequency Duration in Patients With Chronic Lumbosacral Radicular Pain: A Randomized Double-Blind Study

OBJECTIVES

We hypothesized that the duration of pulsed radiofrequency (PRF) application may affect the effectiveness of PRF in patients with chronic lumbosacral radicular pain (LRP).

MATERIALS AND METHODS

In this prospective, double-blind, randomized study, 68 patients were randomly allocated to two groups: a 6-minute group, in which PRF was applied at 42 °C for 2 minutes followed by a 2-minute pause, repeated three times; and a 12-minute group, with a continuous application at 42 °C for 12 minutes. The total application time in each group was equal. After PRF, 2 to 3 mL of 1% lidocaine with 5 mg of dexamethasone was injected. The primary outcome was the intensity of leg pain measured using a numerical rating scale (NRS) three months after the procedure. The secondary outcomes were intensities of leg and back pain, the Oswestry Disability Index (ODI), the Medication Quantification Scale III (MQS), the Global Perceived Effect of Satisfaction (GPES), and the incidence of adverse events during follow-up. Primary and secondary outcomes were analyzed using a linear mixed-effect model in the modified intention-to-treat population.

RESULTS

Each group comprised 34 patients. Three patients in each group did not receive the allocated intervention owing to alleviation of pain. The estimated NRS mean of leg pain at three months was 4.0 (95% CI, 3.2-4.9) and 4.5 (95% CI, 3.6-5.4) in the 6- and 12-minute groups, respectively, with no significant difference between groups (estimated mean difference, -0.5; 95% CI, -1.8 to 0.8; p = 0.436). Regarding the intensities of leg and back pain, ODI, MQS, and GPES, there was no significant difference between the two groups except for GPES at six months. No adverse events were observed in the groups.

CONCLUSIONS

Among patients with chronic LRP, a prolonged PRF application of 12 minutes, compared with 6 minutes, caused no significant difference in leg pain intensity.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number under the Clinical Trial Registry of Korea for the study is KCT0003850; https://cris.nih.go.kr.

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.

Effect of Caudal Epidural Steroid Injection on Transforaminal Epidural Steroid Injection and Dorsal Root Ganglion Pulsed Radiofrequency in Recurrent Lumbar Disc Herniation

Background/Objectives: Recurrent lumbar disc herniation (RLDH) refers to a lumbar disc herniation (LDH) that recurs at the same level, location, and side following surgical repair. This study aimed to evaluate the efficacy of transforaminal epidural steroid injection (TESI) and dorsal root ganglion pulsed radiofrequency (DRG PRF) therapy with and without caudal epidural steroid injection (CESI) for the treatment of lumbar radicular pain (LRP) associated with RLDH. Methods: This retrospective cohort study included 57 patients treated for RLDH in a hospital pain clinic between September 2022 and February 2024. A total of 27 patients received TESI and DRG PRF therapy (Group 1) and 30 patients received TESI, DRG PRF, and CESI therapy (Group 2). We evaluated patient age, sex, symptom duration, pain medication use, number of prior LDH operations, presence of stabilization on magnetic resonance imaging (MRI), intervention received, lumbar level and side of the intervention, and Numeric Rating Scale (NRS) pain scores before and at 1, 3, and 6 months post-procedure. Treatment success was defined as an NRS score at least 50% or 4 points lower than the pre-procedure score at post-procedure 6 months. Results: There was no significant difference in NRS scores between the groups during the 6-month follow-up period. Moreover, NRS scores did not differ based on the presence of stabilization on MRI or the use of pain medication (p > 0.05). Conclusions: TESI and DRG PRF therapy were effective in the treatment of LRP associated with RLDH over a 6-month follow-up period, and adding CESI did not increase treatment success.

Ultrasound combined with DSA-guided pulsed radiofrequency for perineal herpes zoster pain management: clinical outcomes and complications

Background

Herpes zoster (HZ) in the perineal area is a rare disease. There are limited treatment options for this disease. This study aimed to assess the efficacy of ultrasound combined with digital subtraction angiography (DSA)-guided pulsed radiofrequency (PRF) for perineal herpes zoster-related pain.

Methods

Two hundred and twelve patients with perineal HZ were enrolled at the pain department. From January 1, 2018 to December 30, 2019, patients with HZ in the perineal area were treated with PRF under DSA guidance, and from January 1, 2020 to October 30, 2023, patients with HZ in the perineal area were treated with PRF under ultrasound combined with DSA guidance. The included patients were divided into two groups: DSA group and ultrasound + DSA group. The visual analog scale (VAS), central sensitization inventory (CSI), sleep quality scores (SQS), the 36-Item Short Form Health Survey questionnaire (SF-36) at baseline and after the PRF treatment were analyzed to evaluate clinical efficacy.

Results

The mean VAS scores, CSI scores, SQS, and SF-36 scores were statistically significantly lower after treatment compared to baseline (p < 0.001). There was no significant change in VAS scores, CSI scores, SQS, and SF-36 scores between the DSA group and the ultrasound + DSA group (p > 0.05). The time it took from the start of the puncture to the successful puncture was significantly shorter in the ultrasound + DSA group compared to the DSA group (41.2 ± 21.2 vs. 48.1 ± 20.3, p = 0.035). The ultrasound + DSA group had a higher percentage of satisfaction with the procedure than the DSA group (90/99, 90.9% vs. 62/78, 79.5%, p = 0.030). A total of 27 postoperative complications occurred. The incidence of puncture site hematoma was significantly higher in the DSA group (10/78, 12.8%) than that in the ultrasound + DSA group (4/99, 4.0%) (p = 0.032).

Conclusion

PRF can reduce pain from HZ in the perineal region, alleviate central sensitization, enhance sleep quality, and improve overall quality of life. When PRF is performed under ultrasound guidance combined with DSA, it shortens the puncture time and reduces the risk of hematoma formation at the puncture site, making it the recommended method for clinical use.

Ultrasound-guided thermal radiofrequency ablation of the genicular nerves after total knee replacement

The rate of refractory chronic pain after total knee replacement (TKR) is 20-25%, with no identifiable etiology in 6% of cases. Without an etiologic diagnosis, the surgeon is unlikely to consider revision, but pain poses a therapeutic challenge for achieving satisfaction and an acceptable quality of life. Genicular nerve radiofrequency ablation (GNRFA) was recently developed as a non-drug analgesic option. It is minimally invasive and safe, with few adverse effects, opening a new perspective for management of refractory chronic pain after TKR. LEVEL OF EVIDENCE: IV.

Transforaminal Steroid Injection After Dorsal Root Ganglion Pulsed Radiofrequency (DRG-PRF): Impact on Pain Intensity and Disability

INTRODUCTION

Dorsal root ganglion pulsed radiofrequency (DRG-PRF) is frequently used for the treatment of chronic lumbar radicular pain with good outcomes in terms of pain management. Transforaminal epidural steroid injection (TFESI) is often administered immediately after DRG-PRF to increase the anti-inflammatory effects, but support for the synergic mechanism is lacking in the literature. The aim of this study was to investigate the potential role of TFESI immediately after DRG-PRF and its possible role on pain intensity and patient disability.

METHODS

A database of patients who underwent DRG-PRF with or without TFESI immediately after DRG-PRF was retrospectively analysed; propensity score matching was applied to the analysis to reduce possible bias. Pain intensity (numerical rating scale [NRS]) and Oswestry disability index (ODI) were recorded pre-operatively and at the 1- and 3-month follow-up in the two groups of patients.

RESULTS

A total of 252 patients were included in this retrospective analysis, 126 patients in the DRG-PRF + TFESI group and 126 patients in the DRG-PRF group after propensity score matching. Both groups displayed a significant reduction in pain intensity (NRS score reduction; p < 0.0001) and improvement in the ODI (p < 0.0001) from baseline at the 3-month follow-up. Interestingly, the use of TFESI after DRG-PRF was not associated with any clinical benefit as no difference in NRS and ODI was found between the two groups at the 1- and 3-month follow-ups.

CONCLUSIONS

Our study revealed a significant pain reduction and disability improvement after DRG-PRF in patients with lumbar radicular pain. Interestingly, no positive role of TFESI immediately after DRG-PRF was observed. These findings suggest that DRG-PRF provides substantial pain relief, and no added benefit is obtained with subsequent steroid injection. Future prospective studies with expanded follow-up periods are needed to confirm these findings.

Exploring Pathways for Pain Relief in Treatment and Management of Lumbar Foraminal Stenosis: A Review of the Literature

BACKGROUND

Lumbar foraminal stenosis (LFS) involves the narrowing of neural foramina, leading to nerve compression, significant lower back pain and radiculopathy, particularly in the aging population. Management includes physical therapy, medications and potentially invasive surgeries such as foraminotomy. Advances in diagnostic and treatment strategies are essential due to LFS's complexity and prevalence, which underscores the importance of a multidisciplinary approach in optimizing patient outcomes.

METHOD

This literature review on LFS employed a systematic methodology to gather and synthesize recent scientific data. A comprehensive search was conducted across PubMed, Scopus and Cochrane Library databases using specific keywords related to LFS. The search, restricted to English language articles from 1 January 2000 to 31 December 2023, focused on peer-reviewed articles, clinical trials and reviews. Due to the heterogeneity among the studies, data were qualitatively synthesized into themes related to diagnosis, treatment and pathophysiology.

RESULTS

This literature review on LFS analyzed 972 articles initially identified, from which 540 remained after removing duplicates. Following a rigorous screening process, 20 peer-reviewed articles met the inclusion criteria and were reviewed. These studies primarily focused on evaluating the diagnostic accuracy, treatment efficacy and pathophysiological insights into LFS.

CONCLUSION

The comprehensive review underscores the necessity for precise diagnostic and management strategies for LFS, highlighting the role of a multidisciplinary approach and the utility of a unified classification system in enhancing patient outcomes in the face of this condition's increasing prevalence.

Pulsed radiofrequency of lumbar dorsal root ganglion for lumbar radicular pain: A systematic review and meta-analysis

BACKGROUND

Pulsed radiofrequency (PRF) of the lumbar dorsal root ganglion (DRG) has been widely used as a method to relieve lumbar radicular pain (LRP). However, the value of PRF application in LRP patients remains uncertain. This systematic review aimed to compare the effects of PRF of lumbar DRG and LEI in patients with LRP.

METHODS

A literature search was performed using well-known databases for articles published up to May 2023. We included randomized controlled trials (RCTs) that evaluated the effects of PRF compared to LEI with or without steroids. We screened articles, extracted data, and assessed risk of bias in duplicate. The pain scores and Oswestry Disability Index (ODI) scores at 1, 3, and 6 months after procedures were obtained. A random-effects meta-analysis model was applied for outcomes. We evaluated evidence certainty for each outcome using the GRADE scoring system. This review was registered in the PROSPERO (ID: CRD42021253628).

RESULTS

A total of 10 RCTs were included and data of 613 patients were retrieved. We assessed the overall quality of the evidence as very low to moderate. PRF showed no difference in pain scores at 1 (mean difference [MD] -0.80, 95% confidence interval [CI] -1.59 to 0.00, low certainty) and 6 months (MD -2.37, 95% CI -4.79 to 0.05, very low certainty), and significantly improved pain scores at 3 months (MD -1.31, 95% CI -2.29 to -0.33, low certainty). There was no significant difference in ODI score at any interval (very low to low certainty). In the subgroup who underwent a diagnostic block, did not use steroids, and PRF duration greater than 360 s, PRF significantly reduced pain scores at 3 months after procedures.

CONCLUSIONS

We found low quality of the evidence supporting adjuvant PRF to the lumbar DRG has a greater analgesic effect at 3 months after procedures in patients with LRP than LEI. We identified no convincing evidence to show that this treatment improves function. High-quality evidence is lacking, and data were largely derived from short-term effects. Given these limitations, high-quality trials with data on long-term effects are needed.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

The dorsal root ganglion as a target for neurorestoration in neuropathic pain

Neuropathic pain is a severe and chronic condition widely found in the general population. The reason for this is the extensive variety of damage or diseases that can spark this unpleasant constant feeling in patients. During the processing of pain, the dorsal root ganglia constitute an important region where dorsal root ganglion neurons play a crucial role in the transmission and propagation of sensory electrical stimulation. Furthermore, the dorsal root ganglia have recently exhibited a regenerative capacity that should not be neglected in the understanding of the development and resolution of neuropathic pain and in the elucidation of innovative therapies. Here, we will review the complex interplay between cells (satellite glial cells and inflammatory cells) and factors (cytokines, neurotrophic factors and genetic factors) that takes place within the dorsal root ganglia and accounts for the generation of the aberrant excitation of primary sensory neurons occurring in neuropathic pain. More importantly, we will summarize an updated view of the current pharmacologic and nonpharmacologic therapies targeting the dorsal root ganglia for the treatment of neuropathic pain.

Efficacy of High-Voltage Pulsed Radiofrequency of the Dorsal Root Ganglion for Treatment of Chronic Lumbosacral Radicular Pain: A Randomized Clinical Trial

BACKGROUND

Pulsed radiofrequency (PRF) is an efficacious treatment for patients with lumbosacral radicular pain, but the optimal radiofrequency parameters are inadequately described. We hypothesized that high-voltage radiofrequency therapy around the dorsal root ganglion can be more effective and enduring than the standard voltage PRF therapy.

MATERIALS AND METHODS

This was a prospective and randomized study. Patients were divided into two groups. In group 1 (high-voltage group), PRF was applied at 60 V to the patients. Patients in group 2 (low-voltage group) received PRF treatment at 45 V. The patients were evaluated using a numeric rating scale (NRS) and the Oswestry Disability Index (ODI). Evaluation scales were repeated before the intervention and at the first and sixth months after the treatment.

RESULTS

The study included 41 analyzed patients. There was no statistically significant difference between the groups at the first-month NRS (p > 0.05). Sixth-month NRS scores were lower in the high-voltage group (p = 0.016). The groups showed no statistically significant differences in the one-month ODI scores (p > 0.05). When the NRS values were analyzed with linear regression, a positive correlation was found between the sixth-month NRS values and high-voltage PRF (odds ratio: 0.385; p = 0.013). Comparison of the treatment success in terms of time showed statistically significant results in both groups in the first and sixth months (p < 0.05).

CONCLUSIONS

The results of our study revealed that both low- and high-voltage PRF are effective. Because of the lower sixth-month NRS values in the high-voltage group and the similar complication rate, it was considered that high-voltage PRF can be a promising application.

Spinal Injections: A Narrative Review from a Surgeon's Perspective

Spinal pain is one of most frequent complaints of the general population, which can cause decreased activities of daily living and absence from work. Among numerous therapeutic methods, spinal injection is one of the most effective treatments for spinal pain and is currently widely applied in the clinical field. In this review, spinal injection is discussed from a surgeon's perspective. Recently, although the number of spinal surgeries has been increasing, questions are arising as to whether they are necessary. The failure rate after spinal surgery is high, and its long-term outcome was reported to be similar to spinal injection. Thus, spinal surgeries should be performed conservatively. Spinal injection is largely divided into diagnostic and therapeutic blocks. Using diagnostic blocks, such as the diagnostic selective nerve root block, disc stimulation test, and diagnostic medial branch block (MBB), the precise location causing the pain can be confirmed. For therapeutic blocks, transforaminal nerve root injection, therapeutic MBB, and percutaneous epidural neuroplasty are used. When unbearable spinal pain persists despite therapeutic spinal injections, spinal surgeries can be considered. Spinal injection is usefully used to identify the precise location prior to a patient undergoing injection treatment or surgery and can reduce pain and improve quality of life, and help to avoid spinal surgery. Pain physicians should treat patients with spinal pain by properly utilizing spinal injection.

Comparison of efficacy according to voltage of pulsed radiofrequency treatment to lumbar dorsal root ganglion in patient with lumbar radiculopathy: Pilot study

BACKGROUND

Lumbar radicular pain (LRP) is a common symptom, but a challenging clinical problem. Pulsed radiofrequency (PRF) is a more recently developed technique that uses short pulses of radiofrequency current with intervals of longer pauses to prevent temperature from rising to the level of permanent tissue damage and has been advocated in treatment of such patients. But there were no comparative studies on the analgesic effects according to output voltage during PRF in patients with LRP. The goal of this study is to determine the clinical effect of high-voltage (60V) versus standard-voltage (45V) PRF of lumbar dorsal root ganglion.

METHODS/DESIGN

This study will be a prospective, double-blind randomized controlled pilot study. In this study, total 20 patients will be recruited and distributed equally into 2 groups: high-voltage (60V) PRF, low-voltage (45V) PRF. Outcomes will be radicular pain intensity; physical functioning; global improvement and satisfaction with treatment; and adverse events. The assessments will be performed at the 3-month follow-up period after the end of the treatments. The findings will be analyzed statistically considering a 5% significance level (P ≤ .05).

DISCUSSION

The results of this trial will help determine which voltage could be applied for PRF to dorsal root ganglion in LRP and be a basis for subsequent trials.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions

BACKGROUND

Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS.

METHODS

Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted.

RESULTS

Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I² = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms.

CONCLUSIONS

Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Dorsal root ganglion pulsed radiofrequency using bipolar technology in patients with lumbosacral radicular pain duration ≥ 2 years

BACKGROUND

Transforaminal epidural steroid injection (TFESI) or dorsal root ganglion pulsed radiofrequency (PRF) are alternative treatments for lumbosacral radicular pain (LSRP). This study aimed to investigate the clinical efficacy of TFESI combined with dorsal root ganglion PRF using bipolar technology to treat LSRP in patients with pain duration ≥ 2 years.

METHODS

This prospective single-armed cohort study included 20 patients with LSRP duration ≥ 2 years, who underwent treatment of TFESI combined with bipolar PRF. The primary outcomes included numerical rating scale (NRS) and successful treatment rate (pain relief ≥50%). The secondary outcomes included Oswestry Disability Index (ODI), patient satisfaction using the modified MacNab criteria, severe complications, hospital stay and total costs. The final follow-up was 6 months postoperatively.

RESULTS

The successful treatment rate and average pain relief at 6 months postoperatively were 80% and 73.0% ± 17.5%, respectively. The successful treatment rates in patients with and without prior intervention history at 6 months postoperatively were 77.8% and 81.8%, respectively. The mean NRS score significantly decreased from 6.5 ± 0.8 to 1.1 ± 0.7 at 2 weeks postoperatively, to 1.3 ± 0.7 at 3 months postoperatively, and to 1.7 ± 1.0 at 6 months postoperatively (all P < 0.001), while the mean ODI score significantly decreased from 43.5 ± 2.5 to 22.5 ± 4.3 at 2 weeks postoperatively, to 20.0 ± 3.5 at 3 months postoperatively, and to 19.5 ± 3.6 at 6 months postoperatively (all P < 0.001). The excellent and good patient satisfaction at 6 months postoperatively was 85%. No severe complications were observed in this cohort. The average hospital stay and total costs were 3.0 ± 0.5 days and 3.36 ± 0.77 thousand dollars, respectively.

CONCLUSION

The treatment of TFESI combined with PRF using bipolar technology might be an alternative option to treat chronic LSRP in patients with pain duration ≥ 2 years after a failure of conservative treatments, with a favorable 6-month efficacy and inexpensive total costs. However, long-term outcomes and superiority of bipolar procedure over monopolar procedure in patients with longer pain duration should be further investigated in future studies.

Safety of Conventional and Pulsed Radiofrequency Lesions of the Dorsal Root Entry Zone Complex (DREZC) for Interventional Pain Management: A Systematic Review

Study Design

Systematic literature review.

Objective

The goal of this systematic review is to assess the clinical safety and potential complications of conventional and pulsed radiofrequency ablations targeting dorsal root entry zone complex (DREZC) components in the treatment of chronic pain.

Background

There is a growing popularity for the use of radiofrequency ablation (RFA) techniques targeting DREZC components by pain management physicians for an increasing variety of indications. To date, we lack a systematic review to describe the safety and the type of complications associated with these procedures.

Methods

This was a systematic literature review. This systematic search was limited to peer-reviewed literature using “radiofrequency ablation” as a search keyword using PubMed’s database for manuscripts published between inception and December 2020. Abstracts that involved the application of radiofrequency currents, of any modality, to DREZC components for the treatment of pain were included for full-text review. Search was limited to original data describing clinical outcomes following RFA performed for pain indications only, involving the DREZC components outlined above, in human subjects, and written in English. The primary outcomes were complications associated with conventional RFA and pulsed radiofrequency ablation (PRF). Complications were categorized as type 1 (persistent neurological deficits or other serious adverse events, defined as any event that resulted in permanent of prolonged injury; type 2 (transient neuritis or neurological deficits, or other non-neurological non-minor adverse event); type 3 (minor adverse events (e.g., headache, soreness, bruising, etc.).

Results

Of the 62 selected manuscripts totaling 3157 patients, there were zero serious adverse events or persistent neurological deficits reported. A total of 36 (1.14%) transient neurological deficits, cases of transient neuritis, or non-minor adverse events like uncomplicated pneumothorax were reported. A total of 113 (3.58%) minor adverse events were reported (bruising, transient site soreness, headache).

Conclusions

This systematic review indicates that the use of RFA lesion of the DREZC for interventional pain management is very safe. There were no serious adverse effects with a sizable sample of randomized controlled trial (RCT), prospective observational, and retrospective studies.

Efficacy of Radiofrequency as Therapy and Diagnostic Support in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Radiofrequency (RF) is a minimally invasive procedure used to interrupt or alter nociceptive pathways for treating musculoskeletal pain. It seems a useful tool to relieve chronic pain syndromes, even if, to date, solid evidence is still needed about the effectiveness of this therapy. By this systematic review and meta-analysis, we aimed to evaluate the efficacy of RF in treating musculoskeletal pain. PubMed, Medline, Cochrane, and PEDro databases were searched to identify randomized controlled trials (RCTs) presenting the following: patients with chronic musculoskeletal pain as participants; RF as intervention; placebo, anesthetic injection, corticosteroid injection, prolotherapy, conservative treatment, physiotherapy, and transcutaneous electrical nerve stimulation as comparisons; and pain and functioning as outcomes. Continuous random-effect models with standardized mean difference (SMD) were used to compare the clinical outcomes. Overall, 26 RCTs were eligible and included in the systematic review. All of them analyzed the efficacy of RF in four different regions: cervical and lumbar spine, knee, sacroiliac (SI) joint, shoulder. The outcomes measures were pain, disability, and quality of life. A medium and large effect in favor of the RF treatment group (SMD < 0) was found for the shoulder according to the Visual Analogical Scale and for the SI joint according to the Oswestry Disability Index. A small effect in favor of the RF treatment group (SMD > 0) was found for the spine according to the 36-item Short Form Survey. Non-significant SMD was found for the other outcomes. RF represents a promising therapy for the treatment of chronic musculoskeletal pain, especially when other approaches are ineffective or not practicable. Further studies are warranted to better deepen the effectiveness of RF for pain and joint function for each anatomical region of common application.

Clinical Outcome of Pulsed-Radiofrequency Combined With Transforaminal Epidural Steroid Injection for Lumbosacral Radicular Pain Caused by Distinct Etiology

BACKGROUND

Lumbosacral radicular pain (LSRP) can be caused by disc herniation, spinal stenosis, and failed back surgery syndrome. The clinical effect of pulsed-radiofrequency (PRF) combined with transforaminal epidural steroid injection (TESI) for radiating pain in different population remains unclear.

METHODS

We retrospectively reviewed the medical recordings of patients with LSRP caused by different etiologies, who underwent PRF and TESI treatment. The primary clinical outcome was assessed by a 10-point Visual Analog Scale (VAS) pre- and post-treatment.

RESULTS

A total of 34 LSRP patients were identified and classified into 3 subgroups (disc herniation, spinal stenosis, and failed back surgery syndrome). The overall immediate pain reduction was 4.4 ± 1.1 after procedure. After a median follow-up of 9.5 months, the VAS decreased from 6.5 ± 1.0 to 2.4 ± 1.9 at the last follow-up.

CONCLUSION

PRF combined with TESI is an effective approach to treat persistent LSRP in distinct population.

Efficacy and Safety of Pulsed Radiofrequency as a Method of Dorsal Root Ganglia Stimulation in Patients with Neuropathic Pain: A Systematic Review

OBJECTIVE

Pulsed radiofrequency (PRF) is a nonablative pain treatment that uses radiofrequency current in short high-voltage bursts, resulting in interruption of nociceptive afferent pathways. We conducted a systematic review with the aim to create a synthesis of evidence about the efficacy and safety of PRF applied to the dorsal root ganglion (DRG) for the treatment of neuropathic pain.

METHODS

We searched MEDLINE, CINAHL, Embase, and PsycINFO through January 8, 2019, as well as ClinicalTrials.gov and the clinical trial register of the World Health Organization. All study designs were eligible. We assessed risk of bias using the Cochrane tool for randomized controlled trials and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I). We assessed level of evidence using the Oxford tool and quality of evidence with GRADE.

RESULTS

We included 28 studies with participants suffering from lumbosacral, cervical, or thoracic radicular pain, post-herpetic neuralgia, neuropathicbone pain in cancer patients, or carpal tunnel syndrome. Only five studies were randomized controlled trials (RCTs), while others were of nonrandomized designs, predominantly before and after comparisons. A total of 991 participants were included, with a median number (range) of 31 (1-101) participants. Only 204 participants were included in the RCTs, with a median number (range) of 38 (23-62) participants. The overall quality of evidence was low, as the majority of the included studies were rated as evidence level 4 or 5. The quality of evidence was very low.

CONCLUSIONS

Evidence about the efficacy and safety of PRF of the DRG for the treatment of neuropathic pain is based mainly on results from very small studies with low evidence quality. Current research results about the benefits of PRF of the DRG for the treatment of neuropathic pain should be considered preliminary and confirmed in high-quality RCTs with sufficient numbers of participants.

The Effect of Pulsed Radiofrequency on Radicular Pain in Lumbal Herniated Nucleus Pulposus: A Systematic Review and Meta-analysis

Context

Radiofrequency therapy is a medical procedure mainly used to reduce pain with a low complication rate (less than 1%), ease of application, and low cost. This review's objective was to (1) evaluate the pulsed radiofrequency (PRF) effectiveness in treating radicular pain and (2) assess the PRF procedure's safety in managing radicular pain in lumbar herniated nucleus pulposus (HNP).

Methods

A systematic review and meta-analysis. A tertiary care center and an academic medical center. Six full articles with the following features were selected for this review: (1) Articles published in English; (2) studies on the PRF effect on radicular pain in lumbar HNP; and (3) randomized control trials.

Results

The studies showed that the PRF group had a reduction in pain scores at each evaluation. In four of the studies, the PRF group showed a more significant reduction in pain scores than the control, and in two of the studies, the reduction in pain scores was not significant in the PRF group compared to the control. An adverse effect was reported in one patient experiencing increased radicular pain after PRF. Lack of data required for statistical analysis, and lack use of a uniform duration for the PRF procedure by all the studies.

Conclusions

PRF can be used as a promising clinical recommendation for pain management with minimally invasive radicular pain techniques due to lumbar HNP.

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 Outcome of Pulsed Radiofrequency Treatment According to Electodiagnosis in Patients with Intractable Lumbosacral Radicular Pain

BACKGROUND

Radicular pain is related to lesions that either directly compromise the dorsal root ganglion (DRG) or indirectly compromise the spinal nerve and its roots by causing ischemia or inflammation of the axons.

OBJECTIVE

Our study aimed to assess the outcomes of pulsed readiofrequency treatment (PRF) according to electrodiagnosis results in patients with chronic intractable lumbosacral radicular pain.

METHODS

A total of 82 failed back surgery syndrome (FBSS) patients were included in this study. All of them underwent electromyography/nerve conduction studies before pulsed radiofrequency (PRF) treatment at the DRG, and they were classified according to the electrodiagnostic results as: group 1, no definite finding (normal); group 2, radiculopathy; and group 3, neuropathy. Pain intensity was assessed according to a numeric rating scale score and the Oswestry Disability Index (ODI) before treatment and at one, three, six, and 12 months after treatment, and successful treatment was defined as a pain score reduction of ≥50% at 12 months, as compared with the pretreatment score.

RESULTS

Pretreatment electrodiagnosis identified 28 patients with no definite findings, 31 patients with radiculopathy, and 23 patients with neuropathy. The patients with neuropathy had less pain relief after treatment than those with no definite findings and those with radiculopathy. The prevalence of pain reduction of at least 50% was lower in the neuropathy group than in the other groups. There was no statistically significant difference in ODI between group.

CONCLUSION

Outcomes after PRF at the DRG did not show strong differences according to electrodiagnostic findings in FBSS patients with chronic intractable lumbosacral radicular pain.

Pharmacological and non-pharmacological treatments for neuropathic pain: Systematic review and French recommendations

Neuropathic pain remains a significant unmet medical need. Several recommendations have recently been proposed concerning pharmacotherapy, neurostimulation techniques and interventional management, but no comprehensive guideline encompassing all these treatments has yet been issued. We performed a systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018. The main inclusion criteria were chronic neuropathic pain for at least three months, a randomized controlled methodology, at least three weeks of follow-up, at least 10 patients per group, and a double-blind design for drug therapy. Based on the GRADE system, we provide weak-to-strong recommendations for use and proposal as a first-line treatment for SNRIs (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants and, for topical lidocaine and transcutaneous electrical nerve stimulation specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a second-line treatment for pregabalin, tramadol, combination therapy (antidepressant combined with gabapentinoids), and for high-concentration capsaicin patches and botulinum toxin A specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a third-line treatment for high-frequency rTMS of the motor cortex, spinal cord stimulation (failed back surgery syndrome and painful diabetic polyneuropathy) and strong opioids (in the absence of an alternative). Psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies. An algorithm encompassing all the recommended treatments is proposed.

Pulsed Radiofrequency Neuromodulation Contributes to Activation of Platelet-Rich Plasma in In Vitro Conditions

OBJECTIVES

Recent years have brought new developments in interventional chronic pain management, namely regenerative orthopedics utilizing platelet-rich plasma (PRP) as well as further evolution of pulsed radiofrequency neuromodulation (PRF). Both methods have been used separately. Here, we investigated whether PRF may potentiate the activation of platelets in PRP samples when both these techniques are combined together in in vitro conditions.

MATERIALS AND METHODS

Studies were performed on concentrated PRP samples (PRPs) obtained from acid citrate dextrose-treated blood taken from 11 healthy volunteers. PRPs were divided into four groups: 1) nonactivated PRP; 2) thrombin-activated PRP as a positive control for maximal platelets activation; 3) PRF-treated PRP exposed for 20 min to PRF energy generated by neurotherm radio frequency generator at 500 kHz, with a voltage of 40 V and maximal temperature of 42°C; and 4) a combination of groups 2 and 3.

RESULTS

PRF-induced platelet activation measured by platelet factor 4 (PF4) and ATP release from PRPs was significantly higher compared to nonactivated PRPs, and similar to PF4 and ATP release from thrombin-activated PRPs. Thrombin activation did not potentiate PF4 release in PRF samples and even reduced ATP level. Additionally, PRF neither induced any platelet membrane damage measured by lactic dehydrogenase release from PRP nor modified any platelets viability or metabolism measured by MTT.

CONCLUSIONS

We confirmed that PRF may activate PRP without additional platelet activators. So, a combination of both methods PRF and PRP application may provide a more effective opportunity for tissue regeneration in dentistry, surgery, dermatology, or in orthopedics.

Electrocatheter-mediated High-voltage Pulsed Radiofrequency of the Dorsal Root Ganglion in the Treatment of Chronic Lumbosacral Neuropathic Pain: A Randomized Controlled Study

OBJECTIVES

Despite the interest in scientific community, there is still poor evidence about pulsed radiofrequency (PRF) efficacy in the treatment of neuropathic pain. In order to determine whether high-voltage PRF and epidural adhesiolysis (PRF-EA) showed better results than epidural adhesiolysis alone (EA), a randomized, double-blind, comparative-effectiveness study was conducted in patients with chronic lumbosacral radiating pain and neuropathic features.

MATERIALS AND METHODS

A total of 41 patients were randomly allocated to 2 groups. Twenty-one patients were randomized to receive 2 cycles of 240 seconds high-voltage PRF followed by the injection of local anesthetics, hyaluronidase, and betamethasone, whereas 20 patients underwent sham stimulation followed by adhesiolysis. The treatment was delivered at the affected lumbosacral roots and patients, treating physicians and assessors were blinded to intervention.

RESULTS

A significant reduction of radiating pain was observed in mean Numeric Rating Scale score at follow-up. A change of -3.43 versus -1.75 (P=0.031) after 1 month and -3.34 versus -0.80 (P=0.005) after 6 months was reported in patients undergoing PRF-EA in comparison with EA, respectively. After 1 month, 57% of patients in the PRF-EA group experienced a pain reduction of ≥50% versus only 25% of patients allocated to EA (P=0.037). Improvement decreased to 48% in the PRF-EA group whereas only 10% of EA reported significant pain relief after 6 months (P=0.008).

DISCUSSION

High-voltage PRF of dorsal root ganglion delivered through multifunctional electrode provided significant pain relief and may be considered a valuable treatment in chronic lumbosacral radicular pain with neuropathic features.

Clinical effectiveness of caudal epidural pulsed radiofrequency stimulation in managing refractory chronic leg pain in patients with postlumbar surgery syndrome

BACKGROUND AND OBJECTIVE

We evaluated the effect of caudal epidural pulsed radiofrequency stimulation in patients with chronic lumbosacral radicular pain due to postlumbar surgery syndrome who were unresponsive to at least two epidural steroid injections through the interlaminar, transforaminal, or caudal route.

METHODS

We recruited 25 patients with chronic persistent radicular pain in one or both legs (⩾ 4 on the Numeric Rating Scale [NRS]) despite spinal surgery. They were unresponsive to at least two epidural steroid injections. We retrospectively conducted this study. Electrode needles were placed into the epidural space (S2-3 intervertebral level) through the sacral hiatus, and pulsed radiofrequency stimulation was administered. The outcomes were evaluated using the NRS scores for radicular pain before treatment and 1-3 months after treatment. Successful pain relief was defined as a ⩾ 50% reduction in the scores at 3 months after treatment.

RESULTS

The pain scores changed significantly over time (p< 0.001): pretreatment, 4.9 ± 0.9; 1 month, 3.6 ± 1.4; 2 months, 3.8 ± 1.4; and 3 months, 3.9 ± 1.4. At 1, 2, and 3 months after pulsed radiofrequency (PRF) procedure, the NRS scores were significantly reduced compared with the scores before the treatment. Eight patients (32%) reported successful pain relief at 3 months after treatment.

CONCLUSIONS

Although only 32% of the patients with postlumbar surgery syndrome showed successful pain relief after treatment, the result is encouraging because we recruited only patients unresponsive to repeated epidural steroid injections.

Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in Lumbar Radicular Pain: A Randomized, Triple-Blind, Active-Control Trial

BACKGROUND

Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG).

METHODS

Our study is a prospective, triple-blind, randomized, activecontrol trial (CTRI/2016/02/006666) comparing transforaminal epidural local anesthetic (LA) injection and pulsed radiofrequency treatment of DRG in patients with chronic LRP. Patients with LRP after failed conservative management for >3 months received selective diagnostic nerve root block with 1 mL 2% lidocaine. Fifty patients showing positive responses were divided into groups of 25 each. The LA group received transforaminal epidural injection of 1 mL 0.5% bupivacaine. The lumbar pulsed radiofrequency (LPRF) group received transforaminal epidural injection of 1 mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the DRG for 180 seconds RESULTS: Both groups were compared by observing pain intensity on a 0- to 100-point VAS and improvement in functional status by the Oswestry Disability Index (ODI version 2.0) at 2 weeks and 1, 2, 3, and 6 months. All baseline variables were comparable between the 2 groups. Statistically significant reduction in both outcomes was seen in the LPRF group compared to the LA group from 2 weeks to 6 months. One hundred percent of patients in the LPRF group had a ≥20- point decrease in VAS and significant percentage reduction in ODI at all time intervals up to 6 months, whereas it was seen in 80% and 28% of patients in the LA group at 3 and 6 months, respectively. No complications were seen in any patients CONCLUSION: Pulsed radiofrequency of the DRG applied for longer duration results in long-term pain relief and improvement in the functional quality of life in patients with chronic LRP.

Combined epidural adhesiolysis and balloon decompression can be effective in intractable lumbar spinal stenosis patients unresponsive to previous epidural adhesiolysis

Moderate evidence exists regarding percutaneous epidural adhesiolysis (PEA) being an effective treatment for lumbar spinal stenosis (LSS). Although PEA is successfully performed using balloon-less epidural catheters, many patients with severe adhesions cannot obtain satisfactory results. Combined treatment with balloon-inflatable catheters for PEA and balloon decompression recently demonstrated sufficient pain relief and functional improvement in patients with intractable LSS. We compared the effects of PEA and balloon decompression in patients with intractable LSS who did not undergo PEA and those who were unresponsive to previous PEA with a balloon-less catheter.We examined 315 patients who underwent PEA and balloon decompression with balloon-inflatable catheters. Patients with intractable LSS were divided into those without previous PEA (No-PEA) and those unresponsive to previous PEA using balloon-less catheters (Prev-PEA). The numeric rating scale, Oswestry disability index, and global perceived effect of satisfaction scale were measured at 0, 1, 3, and 6 months after the intervention. Responder analysis was performed based on changes in measured scales and indices.A successful treatment response was observed at 1, 3, and 6 months after the intervention in 56.4%, 42.7%, and 32.9%, respectively, of the No-PEA group and in 48.9%, 37.8%, and 25.6%, respectively, of the Prev-PEA group. No significant between-group differences were detected. Pain intensities and functional status improved and were maintained throughout follow-up after PEA with balloon decompression using balloon-inflatable catheters.This modality may represent a useful alternative to overcome the limitations of preexisting adhesiolysis procedures.

Predictors of the analgesic efficacy of pulsed radiofrequency treatment in patients with chronic lumbosacral radicular pain: a retrospective observational study

Background

Pulsed radiofrequency (RF) targeting the adjacent dorsal root ganglion (DRG) is one treatment option for lumbosacral radicular pain. However, the analgesic efficacy of this procedure is not always guaranteed. The aim of this retrospective study was to identify the predictors of the analgesic efficacy of pulsed DRG RF treatment in patients with chronic lumbosacral radicular pain.

Methods

Patients who underwent pulsed DRG RF treatment from 2006 to 2017 at our clinic were enrolled. Positive response was defined as a ≥50% reduction in pain score from baseline at day 30. Patient demographics, pain-related factors, and clinical factors were evaluated using logistic regression analysis to identify the predictors of a positive response to the treatment.

Results

A total of 60 patients satisfied the study protocol requirements. Twenty-eight patients (46.7%) had a positive outcome. Multivariate logistic regression analysis revealed that the absence of comorbid musculoskeletal pain (OR=0.518, 95% CI=0.029-0.858, P=0.033) and positive response to previous epidural steroid injection (OR=3.269, 95% CI=1.046-10.215, P=0.042) were independent predictors of the analgesic efficacy of pulsed DRG RF treatment.

Conclusion

Comorbid musculoskeletal pain and previous epidural injection response appear to affect the outcome of pulsed DRG RF treatment in patients with chronic lumbosacral radicular pain.

Pulsed radiofrequency in chronic pain

PURPOSE OF REVIEW

The increasing number of publications on pulsed radiofrequency (PRF) treatment of chronic pain reflects the interest for this technique. We summarize the literature for PRF in five indications: radicular pain, trigeminal neuralgia (TN), occipital neuralgia, shoulder and knee pain.

RECENT FINDINGS

The efficacy and safety of PRF adjacent to the dorsal root ganglion was documented on cervical and on lumbar level.PRF has been used for the treatment of TN. The observed duration of effect is shorter than that of conventional radiofrequency, but no neurological complications are reported with PRF.PRF of the nervi occipitales is superior to steroid injections in occipital neuralgia.Several studies showed that PRF of the nervus suprascapularis may relief shoulder pain and can improve mobility of the shoulder joint.For the treatment of knee pain, different nerves have been targeted for PRF treatment.

SUMMARY

PRF treatment has progressively gained a place in the management of chronic pain syndromes. The concept is appealing because long-lasting effects are reported without complications. Future research is needed with high quality randomized controlled trials and identification of the optimal parameters of PRF in clinical practice.

Neuropathic Pain Related with Spinal Disorders: A Systematic Review

Systematic literature review. To review the evidence from high-quality studies regarding the treatment of neuropathic pain originating specifically from spinal disorders. In general, treatment guidelines for neuropathic pain cover all its various causes, including medical disease, peripheral neuropathy, and cancer. However, the natural history of neuropathic pain originating from spinal disorders may differ from that of the pain originating from other causes or lesions. An expert research librarian used terms related to neuropathic pain and spinal disorders, disc herniation, stenosis, and spinal cord injury to search in MEDLINE, Embase, and Cochrane CENTRAL for primary research from January 2000 to October 2015. Among 2,313 potential studies of interest, 25 randomized controlled trials (RCTs) and 21 systematic reviews (SRs) were included in the analysis. The selection was decided based on the agreement of two orthopedic surgeons. There was a lack of evidence about medication for radiculopathy arising from disc herniation and stenosis, but intervention procedures, including epidural block, showed positive efficacy in radiculopathy and also limited efficacy in spinal stenosis. There was some evidence based on the short-term follow-up regarding surgery being superior to conservative treatments for radiculopathy and stenosis. There was limited evidence regarding the efficacy of pharmacological and electric or magnetic stimulation therapies for neuropathic pain after spinal cord injury. This review of RCTs and SRs with high-quality evidence found some evidence regarding the efficacy of various treatment modalities for neuropathic pain related specifically to spinal disorders. However, there is a need for much more supportive evidence.

Comparison between bipolar pulsed radiofrequency and monopolar pulsed radiofrequency in chronic lumbosacral radicular pain: A randomized controlled trial

BACKGROUND

Chronic lumbosacral radicular pain is a challenging medical problem with respect to therapeutic management. Many patients with lumbosacral radicular pain complain of persistent leg pain after transforaminal epidural steroid injection. Nowadays, pulsed radiofrequency (PRF) stimulation on the dorsal root ganglion (DRG) is widely used for controlling lumbosacral radicular pain.

METHODS

We evaluated the effect of bipolar PRF on the DRG for the management of lumbosacral radicular pain. In addition, we compared the effect of bipolar PRF to monopolar PRF. Fifty patients with chronic lumbosacral radicular pain were included in the study and randomly assigned to 1 of 2 groups, the bipolar or monopolar PRF group (n = 25 per group). Pain intensity was evaluated using a numeric rating scale (NRS) at pretreatment, and 1, 2, and 3 months after treatment.

RESULTS

When compared to the pretreatment NRS scores, patients in both groups showed a significant decrease in NRS scores at 1, 2, and 3 months after treatment. Reductions in the NRS scores over time were significantly larger in the bipolar PRF group. Three months after treatment, 19 patients (76.0%) in the bipolar PRF group and 12 patients (48.0%) in the monopolar PRF group reported successful pain relief (pain relief of ≥50%).

CONCLUSION

The use of bipolar PRF on the DRG can be an effective and safe interventional technique for chronic refractory lumbosacral radiculopathy, particularly in patients whose pain are refractory to epidural steroid injection or monopolar PRF stimulation.

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.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

The Effect of Pulsed Radiofrequency Combined with a Transforaminal Epidural Steroid Injection on Chronic Lumbar Radicular Pain: A Randomized Controlled Trial

Background. Pulsed radiofrequency lesioning (PRFL) of the dorsal root ganglion (DRG) can modulate neural pathways and provide prolonged relief of neuropathic pain, with limited evidence for chronic lumbosacral radicular pain (CLRP). Objective. This study compared the effect of PRFL combined with transforaminal epidural steroid injection (TFESI) to TFESI alone on CLRP. Methods. Forty adults with chronic radicular pain of at least six-month duration were randomly allocated to undergo either a PRFL of the affected DRG followed by a TFESI (treatment group) or a TFESI alone (control group). Participants and assessors were blinded to the allocation and outcomes were assessed at 1, 2, 3, and 4 months. Outcomes. Pain intensity (visual analog score, VAS) was the primary outcome and quality of life (QOL) as measured by the SF-36 was a secondary outcome. Results. There was no difference in baseline characteristics between groups. VAS was significantly lower in the treatment group at 2-month and 3-month but not 4-month follow-up. QOL measurements did not differ between groups. Conclusions. PRFL of the lumbosacral DRG combined with TFESI showed a modest advantage over TFESI alone in reducing pain intensity; however, this did not persist beyond the 3-month follow-up. There was no effect on QOL.

Effectiveness and Factors Associated with Epidural Decompression and Adhesiolysis Using a Balloon-Inflatable Catheter in Chronic Lumbar Spinal Stenosis: 1-Year Follow-Up

OBJECTIVES

This study aimed to investigate the efficacy of the combined balloon decompression with a balloon-inflatable catheter (ZiNeu) in addition to conventional epidural adhesiolysis, and to identify factors that predict patient responses.

STUDY DESIGN

An institutional single-armed prospective observational study.

SUBJECTS

Chronic refractory lumbar spinal stenosis.

METHODS

This study was performed in 61 patients with spinal stenosis who suffered from chronic (at least 3 months) lumbar radicular pain with or without lower back pain. Patients had failed to maintain improvement for more than 1 month with conventional epidural injection. The numeric rating scale (NRS) and Oswestry disability index (ODI) were each measured at 1, 3, 6, and 12 months after percutaneous epidural adhesiolysis and balloon decompression with a ZiNeu catheter.

RESULTS

The percentage of successful responders was 72.1%, 60.7%, 57.4%, and 36.1% of patients at 1, 3, 6, and 12 months, respectively. A single combined treatment of percutaneous epidural adhesiolysis and balloon decompression with a ZiNeu catheter provided sufficient pain relief and functional improvement in patients with chronic refractory lumbar spinal stenosis, and the improvement was maintained for 12 months (P < 0.001). Multivariate logistic regression analysis showed that absence of diabetes independently predicted successful response at 12 months after percutaneous epidural decompression and adhesiolysis with the balloon catheter (Odds ratio = 0.080; 95% confidence interval = 0.009-0.676; P = 0.020).

CONCLUSIONS

The combined epidural adhesiolysis and balloon decompression with a ZiNeu catheter led to significant pain relief and functional improvement in a subset of patients with refractory spinal stenosis.