Radiofrequency Ablation for Posterior Sacroiliac Joint Complex Pain: A Narrative Review

Clinical Radiofrequency Ablation Outcomes of Combined Sensory Nerve Branch and Dorsal Entry Root Zone Complex Lesions for Sacroiliac Joint Complex Pain

BACKGROUND

Chronic lower back pain (LBP) with or without leg pain (LP) is the most commonly reported anatomical site of pain among Canadian adults with chronic pain. A common cause for LBP and LP arises from dysfunction of the sacroiliac joint (SIJ) complex. When conventional medical management or rehabilitative efforts for SIJ-related LBP and LP fail to provide analgesia, pulsed radiofrequency (PRF) and/or radiofrequency ablation (RFA) of the dorsal entry root zone complex lesions (DREZC) and/or their more peripheral branches can also be a suitable means for treatment. Both PRF and RFA are interventional techniques that utilize heat to attenuate or ablate transmission of painful signals, respectively. The purpose of this chart review is to explore the clinical outcomes of patients experiencing SIJ-related pain who have undergone procedures with combined sensory nerve branch RFA and DREZC PRF lesions targeting the SIJ complex.

METHODS

Following institutional review board approval, a retrospective chart review was performed from June 2018 to February 2021 for patients with LBP and/or LP refractory to physical rehabilitative efforts and medical management that underwent combined PRF and RF treatments for a diagnosis of SIJ complex pain. RF and PRF procedures were anatomically guided with the addition of sensory stimulation to ensure appropriate needle placement. Charts were reviewed for percentage of analgesia at final follow-up, duration of effect, degree of analgesia, patients' functional improvements, and changes in medication use patterns.

RESULTS

Data was reviewed from 180 patients with LBP or LP who underwent combined PRF and RF treatments for a diagnosis of SIJ complex pain. The group consisted of 69 men and 111 women with a mean age of 59 years. All patients had lesions to their dorsal roots and/or branches (lumbar medial and sacral lateral), as determined using their pain profile as well as sensory stimulation. In the sample of 180 patients a total of 276 SIJs were treated over the period of data collection. Overall, 85.0% (n = 234) of procedures were considered successful with more than 50% analgesic relief at final follow-up. Of 234 successful outcomes, 110 reported ongoing analgesia (mean = 80.3% pain relief, SD ± 18.0) on the last date of follow up (mean = 53.2 days, SD ± 41.8) prior to being lost to follow-up. For patients not lost to follow-up, the mean amount of analgesia was reported to be 83.9% with an average duration of 86.3 days. Among all treatments, 6.9% (n = 19) provided no analgesic effect. Among the successful procedure outcomes, 54.4% (n = 150) reported increased activity/mobility, 24.3% (n = 67) reported improved sleep, 49.3% (n = 136) reported improved mood, and 11.6% (n = 32) reported decreased medication usage. Nine patients reported complications following the procedure. Complications included transient soreness, bruising, tenderness, myofascial pain, and two mild vagal responses without lasting sequelae.

CONCLUSION

This review suggests that combined sensory nerve branch RFA and DREZC PRF lesions targeting the SIJ complex is a suitable intervention to treat SIJ-related LBP and/or LP refractory to physical rehabilitative efforts and medical management. Approximately 85% of these cases were successfully treated with the majority of patients report lasting analgesic effects with minimal complications, supporting the use of sensory stimulation-guided combined RF and PRF lesions for treatment of refractory SIJ complex pain.

Review of Sacroiliac Joint Injection Techniques

PURPOSE OF REVIEW

The purpose of the review is to evaluate the current evidence on techniques for sacroiliac joint (SIJ) injections using landmark, ultrasound, fluoroscopy, and computed tomography (CT) guidance.

METHODS

A literature search was performed to find all relevant retrospective, prospective, and randomized controlled (RCT) studies where SIJ injections were performed under ultrasound, fluoroscopy, and CT guidance.

RECENT FINDINGS

A total of eight studies were identified with suitable data for inclusion. There were two RCTs, four prospective, and two retrospective studies included. Case reports or case series were excluded. A total of 420 patients were enrolled across all eight studies. CT guidance provided the most accurate needle placement in the SIJ injections followed by fluoroscopy, which was more accurate than ultrasound. Landmark-guided injections were not accurate. Accurate needle placement in SIJ confirms SIJ-mediated pain and injection of corticosteroids leads to improvement in pain and/or disability outcome measures regardless of guidance technique. Diagnostic CT-guided SIJ injections should be performed prior to consideration of SIJ fusion.

Adjacent segment syndrome after failed back surgery: biomechanics, diagnosis, and treatment

The adjacent segment syndrome is defined as the changes in the adjacent structures of an operated spinal level that produce symptoms of pain and disability, which worsen the quality of life of a patient. Pain management specialists must be aware of these biomechanical changes brought by spinal surgeries, as well as of the symptoms associated with pain after surgery, to reach an appropriate diagnosis and provide an adequate treatment. Specialized pain literature contains few reports on specific management of patients using the terms "adjacent segment syndrome, degeneration or disease"; most of the literature comes from surgical journals. It is necessary to perform studies with a population sample comprising patients with adjacent segment syndrome after spinal surgery, since almost all treatments applied in this group are extrapolated from those used in patients with pain originating in the same area but who have not previously undergon spine surgery. Therefore, we consider necessary for pain physicians to understand the underlying biomechanics, promote the diagnosis of this condition, and analyze possible treatments in patients with adjacent segment disease to alleviate their pain and improve their quality of life.

Low back pain

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

Minimally Invasive Sacroiliac Joint Fusion with Triangular Titanium Implants: Cost-Utility Analysis from NHS Perspective

OBJECTIVE

The aim was to identify the cost-effectiveness of minimally invasive sacroiliac joint fusion (MI SIJF) surgery with titanium triangular implants for patients with sacroiliac joint (SIJ) pain who have failed conservative management, compared to non-surgical management (NSM) from a National Health Service (NHS) England perspective.

METHODS

Over a time horizon of 5 years, a cohort state transition model compared the costs and outcomes of treating patients with MI SIJF to those of traditional NSM treatment pathways. The NSM arm included two treatments: grouped physical therapy and corticosteroid injections (PTSI) or radiofrequency ablation (RFA). Three different strategies were considered: (1) a stepped pathway, (2) patients split between PTSI and RFA, and (3) RFA only. The outcome measure was incremental cost-effectiveness ratio (ICER), reported in 2018 British pounds per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were used to test the robustness of the model results.

RESULTS

Patients undergoing MI SIJF accrued total procedure-related and pain-management costs of £8358, while NSM treatment strategy 1 had total costs of £6880. The MI SIJF cohort had 2.98 QALYs compared to strategy 1 with 2.30 QALYs. This resulted in an ICER for MI SIJF versus strategy 1 of £2164/QALY gained. Strategy 2 of the NSM arm had lower costs than strategy 1 (£6564) and 2.26 QALYs, and this resulted in an ICER of £2468/QALY gained for MI SIJF. Strategy 3 of the NSM arm had lower costs than strategy 1 (£6580), and this resulted in 2.28 QALYs and an ICER of £2518/QALY gained for MI SIJF. Probabilistic sensitivity analysis shows that at a threshold of £20,000/QALY gained, MI SIJF has a probability of being cost-effective versus NSM strategies of 96%, 97%, and 91% for strategies 1, 2, and 3, respectively.

CONCLUSION

MI SIJF appears to be cost-effective over a 5-year time horizon when compared to traditional NSM pathways in an NHS context.

Platelet-Rich Plasma Versus Corticosteroid Injection for Lumbar Spondylosis and Sacroiliac Arthropathy: A Systematic Review of Comparative Studies

This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.

[Interdisciplinary position paper: the value of radiofrequency denervation in the treatment of chronic pain]

Radiofrequency denervation has been established for many years as an important minimally invasive procedure for the treatment of chronic pain conditions. Positive experiences of many users for various indications are contrasted by a nonuniform evidence. With meticulous patient selection and correct assessment of the indications a longer term reduction of pain, a reduced need for analgesics and an improvement in the quality of life can be achieved. The aim of this interdisciplinary position paper is to present the value of radiofrequency denervation in the treatment of chronic pain. The summarized recommendations of the expert group are based on the available evidence and on the clinical experiences of Austrian centers that frequently implement the procedure. The position paper contains recommendations on patient selection and proven indications. We discribe safety aspects, complications, side effects and contraindications.

International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

The Effectiveness of Platelet-Rich Plasma Injection for the Treatment of Suspected Sacroiliac Joint Complex Pain; a Systematic Review

Objective

To determine the effectiveness of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) for the treatment of suspected sacroiliac joint complex (SIJC) pain.

Design

Systematic review.

Subjects

Persons aged ≥18 with suspected SIJC pain.

Comparison

Sham, placebo procedure, or active standard of care treatment.

Outcomes

The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement of ≥30% at three or more months after the treatment intervention.

Methods

Publications in PubMed, MEDLINE, Embase, Scopus, and Cochrane Databases were reviewed up to April 3, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Grades of Recommendation, Assessment, Development, and Evaluation system and the joint consensus American Academy of Orthopedic Surgery/National Institutes of Health recommendations were used for quality assessment and reporting standards.

Results

Query identified 151 publications; three were appropriate for inclusion. There were no studies of BMAC that met inclusion criteria. There were three eligible PRP studies: one randomized comparative trial (RCT) and two case series. In the single RCT comparing ultrasound-guided PRP with corticosteroid injection for suspected SIJC pain, the PRP group had a significantly increased likelihood of achieving ≥50% improvement of pain at three months (adjusted odds ratio = 37, 95% confidence interval [CI] = 4.65–298.69). Pooled pain outcomes from two studies showed that 28/30, 93% (95% CI = 93–100%), experienced ≥50% pain improvement at three months.

Conclusions

The literature supporting the effectiveness of PRP for SIJC pain is very low-quality according to the GRADE system. Well-designed RCTs and large cohort studies with consistent selection protocols and reporting characteristics are needed to determine the effectiveness of PRP and BMAC for the treatment of SIJC pain.