Comparison of tibial nerve pulsed radiofrequency and intralesional radiofrequency thermocoagulation in the treatment of painful calcaneal spur and plantar fasciitis: A randomized clinical trial

OBJECTIVE

Ultrasound-guided tibial nerve pulsed radiofrequency (US-TN PRF) and fluoroscopy-guided intralesional radiofrequency thermocoagulation (FL-RFT) adjacent to the painful calcaneal spur are two interventions for pain management in painful calcaneal spur (PCS) and plantar fasciitis (PF). This study aimed to compare the effectiveness of the two procedures.

DESIGN

A prospective, randomized, single-blind study.

SETTING

Single-center pain clinic.

SUBJECTS

Forty-nine patients who met the inclusion criteria were randomized into two groups.

METHODS

25 patients (group U) received US-TN PRF at 42 °C for 240 s, while 24 patients (group F) received intralesional FL-RFT at 80 °C for 90 s. The most severe Numeric Rating Scale (NRS) score during the first morning steps and the American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot scores were used to evaluate the effectiveness of the procedures. The study's primary outcome assessed treatment effectiveness using the NRS, whereas the secondary outcomes included changes in the AOFAS score and the incidence of procedure-related mild adverse events.

RESULTS

NRS and AOFAS scores significantly improved in groups U and F at 1 and 3 months compared to baseline (p < 0.05), and there was no significant difference between the groups. At month 1, 50% or greater pain relief was achieved in 72% of patients in group U and 75% in group F. No significant difference was observed in the incidence of mild adverse events between the groups.

CONCLUSIONS

US-TN PRF and intralesional FL-RFT have shown significant effectiveness in the treatment of PCS and PF. Larger randomized controlled trials are needed.

Spinal Cord Stimulation in Refractory Postherpetic Neuralgia in Portugal: A Case Report

Postherpetic neuralgia is one of the most severe complications after herpes zoster infection. Patients who experience persistent pain despite conservative treatment may benefit from interventional therapies, such as spinal cord stimulation. We present the case of a patient with severe refractory postherpetic neuralgia in the right T8 to L1 distribution who responded effectively to spinal cord stimulation. After its implantation, the patient had improvements in pain intensity, pain-related interference, quality of life, and satisfaction, with a simultaneous reduction of previous medications. This case report highlights the role of spinal cord stimulation in refractory neuropathic pain secondary to herpes zoster.

Neuromodulation of the median nerve in carpal tunnel syndrome, a single-blind, randomized controlled study

Background

This study aimed to evaluate the efficacy of pulsed radiofrequency applied using transcutaneous electrodes in carpal tunnel syndrome (CTS).

Methods

After randomization, the patients received two cycles of noninvasive pulsed radiofrequency (NiPRF), once weekly, or splinting (the control group) for three months. Clinical evaluations were recorded at baseline and weeks 4 and 8. The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to determine the functional status and symptom severity.

Results

Sixty-two patients were followed up for three months. There was no difference between the groups in the BCTQ scores before and after treatment. The NiPRF group found a significant difference between the BCTQ measurements at all time intervals (paired sample t -test; P < 0.001). In the splint group, there was a significant difference only between the basal-1st month and basal-3rd month (paired samples t -test; P < 0.001). The main effect of the time variable was statistically significant (ANOVA; P < 0.001), but the group variable was not. There was no correlation between the BCTQ results measured at any time and the electroneuromyelogragphy findings in either group.

Conclusions

NiPRF effectively improves symptoms and functionality in patients with CTS for up to 3 months. Thus, NiPRF can be considered an easy, safe, and useful alternative treatment modality for CTS.

Comparison of ultrasound guided pulsed radiofrequency of genicular nerve with local anesthetic and steroid block for management of osteoarthritis knee pain

Background

To compare ultrasound-guided pulsed radiofrequency (PRF) of the genicular nerve with the genicular nerve block using local anesthetic and steroid for management of osteoarthritis (OA) knee pain.

Methods

Thirty patients with OA knee were randomly allocated to receive either ultrasound-guided PRF of the genicular nerve (PRF group) or nerve block with bupivacaine and methylprednisolone acetate (local anesthetic steroid [LAS] group). Verbal numeric rating scale (VNRS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were measured at pre-procedure and 1-, 4-, and 12-weeks post-procedure.

Results

VNRS scores decreased significantly (P < 0.001) in both the groups at 12 weeks and other follow up times compared to baseline. Seventy-three percent of patients in the PRF group and 66% in the LAS group achieved effective pain relief (≥ 50% pain reduction) at 12 weeks (P > 0.999). There was also a statistically significant (P < 0.001) improvement in WOMAC scores in both groups at all follow up times. However, there was no intergroup difference in VNRS (P = 0.893) and WOMAC scores (P = 0.983). No complications were reported.

Conclusions

Both ultrasound-guided PRF of the genicular nerve and blocks of genicular nerve with local anesthetic and a steroid provided comparable pain relief without any complications. However, PRF of the genicular nerve is a procedure that takes much more time and equipment than the genicular nerve block.

Effects of Pulsed Radiofrequency on a Standard Model of Muscle Injury in Rats

Background

Pulsed radiofrequency (PRF) affects animal and plant tissues; however, the mechanism has not been defined. We hypothesized that the magnetic field produced by PRF exerts its effects by the magnetic sensitivity of transitions between spin states -a spin-correlated radical-pair mechanism (SCRPM)- which, in turn, affects the rates of chemical reactions with participation of paramagnetic species.

Objectives

This study aimed to evaluate the effects of PRF on redox equilibrium and inflammatory status in a standard model of muscle injury in rats.

Methods

Twenty-four animals were subjected to a single impact trauma to the left quadriceps and the groups exposed and not exposed to PRF were compared. On day 7 of the experiment, the animals were killed and the quadriceps muscles were removed for analysis.

Results

There was a significant increase in the concentration of thiobarbituric acid reactive substances (TBARS) in the muscle of animals from the trauma group (+233%), and this increase was eliminated by PRF administration. Superoxide dismutase (SOD) activity was increased (+411%) by trauma, resulting in significantly higher consumption of catalase (-72%), while PRF administration brought both of these markers back to levels close to those of the control group. Trauma induced considerable production of interleukins TNF-α, IL-1β, and IL-6 (+215%, +262%, and +326% vs. controls, respectively) and these effects were also significantly reduced by PRF administration.

Conclusions

In total, PRF inhibits oxidative stress and restores antioxidant enzymes to control levels and may block production of inflammatory markers in muscles of animals subjected to trauma. By modulating redox equilibrium, PRF treatment might block production of noxious mediators involved in development of trauma-induced injury.

The effect of needle tip position on the analgesic efficacy of pulsed radiofrequency treatment in patients with chronic lumbar radicular pain: a retrospective observational study

Background

Pulsed radiofrequency (PRF) is a treatment modality that alleviates radicular pain by intermittently applying high-frequency currents adjacent to the dorsal root ganglion. There has been no comparative study on analgesic effect according to the position of the needle tip in PRF treatment. The objective of this study is to evaluate the clinical outcomes of PRF according to the needle tip position.

Methods

Patients were classified into 2 groups (group IP [group inside of pedicle] and group OP [group outside of pedicle]) based on needle tip position in the anteroposterior view of fluoroscopy. In the anteroposterior view, the needle tip was advanced medially further than the lateral aspect of the corresponding pedicle in group IP; however, in group OP, the needle tip was not advanced. The treatment outcomes and pain scores were evaluated at 4, 8, and 12 weeks after applying PRF.

Results

At 4, 8, and 12 weeks, there were no significant differences between the successful response rate and numerical rating scale score ratio.

Conclusions

The analgesic efficacy of PRF treatment did not differ with the needle tip position.

New concept for treating female stress urinary incontinence with radiofrequency

PURPOSE

To evaluate the clinical response and adverse effects of radiofrequency on the urethral meatus in the treatment of stress urinary incontinence in women.

MATERIALS AND METHODS

This phase one study included ten women with Stress Urinary Incontinence (SUI). The evaluation consisted of 1 hour Pad tests to quantify urine loss and to assess the degree of procedure satisfaction by using the Likert scale. To evaluate safety, we observed the number of referred side effects.

RESULTS

Average age was 53.10 years±7.08 years. In assessing the final Pad Test, 70% showed a reduction and 30% a worsening of urinary loss. Using the Pad Test one month later, there was a reduction in all patients (p=0.028). The degree of satisfaction was 90% and no side effects have been observed. One patient reported burning sensation.

CONCLUSION

The treatment of SUI with radiofrequency on the urethral meatus has no adverse effects, being a low risk method that reduces urinary loss in women. However, to increase the validity of the study, larger clinical trials are warranted.

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.

A new technique to treat facet joint pain with pulsed radiofrequency

INTRODUCTION

Facet joint pain affects 5% to 15% of the population with low back pain and the prevalence increases with age due to progression of arthritis. While conservative treatments are often unsuccessful, the scientific evidence on minimally invasive therapies such as intra-articular steroid infiltration and continuous and pulsed radiofrequency (PRF) of the medial branches is contradictory. Since PRF has recently been reported to successfully treat joint pain, a new application of this method is proposed for facetogenic lumbar pain via an intra-articular subcapsular approach. Here we reported two cases with successful treatment.

CASE PRESENTATION

A 71-year-old patient presented because of persisting pain in the left gluteal region radiating to the lateral thigh and calf when standing. Anti-inflammatory drugs produced only short-lasting insufficient relief. A 52-year-old employee was admitted in June 2012 because of axial lower lumbar pain with intermittent diffuse radiation to the right lower extremity that worsened during walking and lying down despite receiving analgesics and physiotherapy.

CONCLUSIONS

A new approach to treat lumbar facet joint pain with PRF is simple to perform and without serious complications. In view of the good long-lasting results obtained with the two reported cases, randomized control trials are necessary to validate this new approach.

Caudal Epidural of Pulsed Radiofrequency in Post Herpetic Neuralgia (PHN); Report of Three Cases

Introduction:

Postherpetic neuralgia (PHN) is a frequently occurring neuropathic pain, its pathophysiology is not fully understood. There are only few evidence based therapeutic options; sympathetic nerve block can be considered for patients with PHN refractory to conservative treatment, but long-term effects are poor. Application of pulsed radiofrequency was effective to treat a variety of pain syndromes without neurological complications or other sequelae.

Case Presentation:

We observed a remarkable long-lasting pain relief in patients with post herpetic neuralgia (PHN) treated with caudal epidural PRF. We described the technique of caudal epidural PRF and three case reports.

Conclusions:

The mode of action of PRF is far from being completely elucidated. The high frequency current induces an electric field that in turn seems to influence the immunity, the inflammation and other pain conducting mechanisms. Our findings suggest an effect distal from the application of the current. It reaches targets that are difficultly attainable by any other means of current application. The observations of pain relief in the difficult to treat patients with PHN justifies further investigation.

Ultrasound-guided greater occipital nerve blocks and pulsed radiofrequency ablation for diagnosis and treatment of occipital neuralgia

Occipital neuralgia is a condition manifested by chronic occipital headaches and is thought to be caused by irritation or trauma to the greater occipital nerve (GON). Treatment for occipital neuralgia includes medications, nerve blocks, and pulsed radiofrequency ablation (PRFA). Landmark-guided GON blocks are the mainstay in both the diagnosis and treatment of occipital neuralgia. Ultrasound is being utilized more and more in the chronic pain clinic to guide needle advancement when performing procedures; however, there are no reports of ultrasound used to guide a diagnostic block or PRFA of the GON. We report two cases in which ultrasound was used to guide diagnostic greater occipital nerve blocks and greater occipital nerve pulsed radiofrequency ablation for treatment of occipital neuralgia. Two patients with occipital headaches are presented. In Case 1, ultrasound was used to guide diagnostic blocks of the greater occipital nerves. In Case 2, ultrasound was utilized to guide placement of radiofrequency probes for pulsed radiofrequency ablation of the greater occipital nerves. Both patients reported immediate, significant pain relief, with continued pain relief for several months. Further study is needed to examine any difference in outcomes or morbidity between the traditional landmark method versus ultrasound-guided blocks and pulsed radiofrequency ablation of the greater occipital nerves.

Intravenous application of pulsed radiofrequency-4 case reports

It has been suggested that PRF might possibly have an effect on the immune cells. We considered using the intravenous route to apply PRF in conditions that are caused by an unresolved immune action or connected to allostatic load, implicating an abnormally reacting immune system to obtain a systemic effect that could possibly be an additional tool in treating some of these conditions. These manuscript reports four cases that illustrate the wide variety of conditions where this new technique might be helpful.

Pulsed radiofrequency treatment for trigeminal neuralgia

Background:

Pulsed radiofrequency (PRF) treatment is defined as the delivery of short pulses of radiofrequency via a needle tip, which does not result in an actual thermal lesions. There are mixed views regarding the use of PRF for trigeminal neuralgia (TN). In our opinion, one of the main reasons for the contrasting views is the insufficient PRF dose employed in previous studies. In a recent study on the effects of PRF on resiniferatoxin-induced neuropathic pain in an animal model, the anti-allodynic effects of PRF were significantly greater when the PRF exposure duration was increased from 2 to 6 minutes.

Objectives:

The primary objective of this retrospective study is to report the results for 36 consecutive patients who underwent PRF treatment for TN, for 6 minutes at 45 V at a pulsed frequency of 4 Hz and a pulse width of 10 ms.

Patients and Methods:

For the study, we obtained procedural records of 36 consecutive patients. Their current state of pain was evaluated over a telephonic survey and the post-procedural data at 2, 6, and 12 months were retrieved thereafter from the patient records. The main outcome measure was excellent pain relief (more than 80%), which was assessed at 2, 6, and 12 months.

Results:

The percentages of patients who showed excellent pain relief (> 80% pain relief) at 2, 6, and 12 months were 73.5% (25/34), 61.8% (21/34), and 55.9% (19/34), respectively. The percentages of patients showing satisfactory pain relief (50–80% pain relief) at 2, 6, and 12 months were 14.7% (5/34), 17.6% (6/34), and 17.6% (6/34), respectively, and those of patients showing less than satisfactory pain relief (< 50% pain relief) at 2, 6, and 12 months were 11.8% (4/34), 20.6% (7/34), and 23.5% (8/34), respectively. No complications were reported, and none of the patients required hospitalization.

Conclusions:

PRF of the trigeminal ganglion should be further evaluated as an alternative treatment method for TN.

Evaluation of pulsed radiofrequency denervation in the treatment of chronic facetjoint pain: an observational study

Background:

Low back disorder is the most common problem in the entire spinal axis. About two-thirds of adults suffer from low back pain (LBP) at some time. Pain generators in the lumbar spine include the annulus of the disc, the posterior longitudinal ligament, a portion of the dural membrane, the facet joints, the spinal nerve roots and ganglia, and the associated paravertebral muscle fascia. There is no doubt that the facet joint is a potential source of chronic LBP. Facet joints are true synovial joints that have a joint space, hyaline cartilage surfaces, a synovial membrane, and a fibrous capsule. Two medial branches of the dorsal rami innervate the facet joints. If conservative measures fail in the treatment of facet joint pain, pulsed radiofrequency (PRF) of the medial branches can be administered.

Objectives:

The aim of this observational study was to evaluate the efficacy of PRF in the treatment of lumbar chronic facet joint pain.

Patients and Methods:

In this prospective observational study, we selected 300 patients who suffered from lumbar facet joint pain, were referred to the Pain Therapy Department, and underwent PRF treatment of the lumbar medial branches. We analyzed patients with facet joint pain that was unresponsive to conventional treatment, with a positive response to diagnostic medial branch block, who underwent PRF of the lumbar area for 18 months at San Giovanni Hospital of Rome.

Results:

Three hundred patients were eligible for the study. After 1 month, 62% of patients (186 patients) reported good pain relief [95% confidence interval (CI) 0.53, 0.7]; 8.6% (26 patients) reported excellent pain relief (95% CI 0.07-0.09); 20. 4% (61 patients) reported poor pain relief (95% CI 0.18-0.22), and 9% (27 patients) reported no pain relief (95% CI 0.08-0.099). The average pain numeric rating scale (NRS) score before the procedure was 6 (range 4-9), decreasing to 2 after the procedure (range 0-4). SF-36 physical and mental parameters improved significantly after the treatment [≥ 1 standard deviation (SD)]. Results after 6 months were similar to those obtained after 1 month.

Conclusions:

This study suggests that PRF treatment of the lumbar medial branches provides good pain relief for at least 6 months in 70% of patients who suffer from lumbar facet joint pain.

Whiplash patients with cervicogenic headache after lateral atlanto-axial joint pulsed radiofrequency treatment

Background:

Whiplash patients regard cervicogenic headache (CEH) as the most burdensome symptom of their condition. Sufferers experience a significant degree of disability from headache, associated neck pain and disability, and sleep disturbance. Lateral C1/2 joint pulsed radiofrequency (PRF) treatment has been shown to produce significant relief from headache in patients with CEH.

Objectives:

The objective of this retrospective questionnaire study of 45 consecutive whiplash patients with CEH who had undergone antero-lateral atlantoaxial joint pulsed radiofrequency treatment (AA PRF) was to evaluate the treatment’s long-term effects on pain-related disability and health-related quality of life.

Patients and Methods:

Four questionnaires were sent to all 45 patients who had undergone AA PRF: 1) The short form-36 (SF-36); 2) The neck disability index (NDI); 3) The medical outcome scale-sleep scale (MOS-SS); 4) The headache impact test-6 (HIT-6). All 45 patients received AA PRF under fluoroscopic guidance. PRF treatment was conducted at 45 V with a pulsed frequency of 4 Hz and a pulsed width of 10 ms for 4 minutes .

Results:

Patients who responded to the procedure reported lower pain scores at 2, 6, and 12 months of follow-up compared to nonresponders. More important, patients reported marked improvements in headache impact (P < 0.01), neck-disability scores (P < 0.01), awakening due to headache (P < 0.01), and sleep problems (9-item; P < 0.05) on the MOS-SS. Responders to the procedure also reported a significantly higher health-related quality of life in terms of bodily pain (P < 0.05) and health change (P < 0.01) on the SF-36.

Conclusions:

In light of the inherent limitations of our retrospective study, AA PRF treatment can only be tentatively viewed as a promising treatment modality for whiplash patients with CEH and is subject to validation in future studies.

Pulsed radiofrequency of lumbar dorsal root ganglion for chronic postamputation phantom pain

Chronic pain following lower-limb amputation is now a well-known neuropathic, chronic-pain syndrome that usually presents as a combination of phantom and stump pain. Controlling these types of neuropathic pain is always complicated and challenging. If pharmacotherapy does not control the patient’s pain, interventional procedures have to be taken.

The aim of this study was to evaluate the efficacy of using pulsed radiofrequency (PRF) on the dorsal root ganglia at the L4 and L5 nerve roots to improve phantom pain.

Two patients with phantom pain were selected for the study. After a positive response to segmental nerve blockade at the L4 and L5 nerve roots, PRF was performed on the L4 and L5 dorsal root ganglia.

Global clinical improvement was good in one patient, with a 40% decrease in pain on the visual analogue scale (VAS) in 6 months, and moderate in the second patient, with a 30% decrease in pain scores in 4 months. PRF of the dorsal root ganglia at the L4 and L5 nerve roots may be an effective therapeutic option for patients with refractory phantom pain.