Radiofrequency Ablation in St. Louis

We perform radiofrequency ablation here at our Woodson facility under live imaging, as a same-day outpatient procedure. Most people come to us after diagnostic facet injections proved the joint was the pain source, and then the relief wore off.

In long-term facet joint pain, the relief from shots can be short. Then we can do a procedure called Radiofrequency Rhizotomy, facet neurotomy, or just RF. Small nerves leave the facet joints and carry pain signals to the brain. Heating these nerves with radiofrequency waves can block that signal.

Facet neurotomy cuts off the nerve supply to a facet joint. A radio-frequency probe heats the 2 small nerve branches to each facet joint to do this. That shutdown is called denervation. These nerves are called the medial branches.

You lie face down (prone, on your stomach). We numb the skin and use live x-ray (fluoroscopy) to guide a radio-frequency needle to the base of the bony side wings of the spine (the transverse processes). The needle is placed along the path of the medial branch. The needle is heated to 80° C for 90 seconds. At least 2 branches for each joint are treated the same way. Sometimes we use cold radio frequency, mostly for neck facets. It does not heat the nerve. It uses a special pulsed radio wave instead. We do not use sedation for this procedure. You must stay awake and able to answer the whole time, because your feedback during needle placement is part of how we find the right nerves.

The neurotomy takes 10 to 45 minutes, depending on how many levels we treat. Then you rest in the observation area for 30 minutes to 1 hour.

Right after the procedure, you will get up and walk. You will try to copy a move that would normally set off your usual pain. Then you will tell us the percent of pain relief. You will also track your relief over the next week. Most patients drive themselves home. If your legs feel weak or numb, have someone else drive until it wears off.

• Eat a light meal within a few hours before your procedure. If you are diabetic and take insulin, do not change your normal eating before the procedure. Please take your usual medicines (for example, blood pressure and diabetes medicines).
• Do not take pain pills or anti-inflammatory drugs the day of your procedure. You need to be hurting before this procedure. Please do not take any medicine that may ease or dull your usual pain. You can restart these medicines after the procedure if you need them.
• If you take Coumadin, Heparin, Plavix or any other blood thinner (including Aspirin), or the diabetes drug Glucophage, you must tell this office. We will explain when to stop and restart them. You will be at the clinic for about 1-3 hours for your procedure.
• You will be awake under local anesthetic, with no sedation, so most patients drive themselves home. Arrange a driver only if your arm or leg feels weak or numb, and only until that wears off. Normal activity, including work, resumes within two to four hours.

Expect more back pain, leg pain or both in the treated area for several days to several weeks, and rarely several months. The facet joint can become less stable. Training after the procedure to strengthen the back muscles that straighten the spine can prevent this. There is a rare risk of lasting nerve injury with weakness or loss of feeling. There is also a rare risk of a problem from the numbing medicine used to keep you comfortable during the procedure.

As with any procedure, there is a risk of serious complications. The most common side effects from RF include (but are not limited to):

• Allergic reactions to medications.
• Infection (occurs in less than 1 per 15,000 injections).
  Post-injection flare (joint swelling and pain several hours after treatment, which may last days or weeks).
• Depigmentation (a whitening of the skin).
• Local fat atrophy (thinning of the skin).
• Destruction of an unexpected motor or sensory nerve in the path of the radiofrequency needle.
• Bleeding, nerve injury, organ injury and death are rare but possible.
• Neuritis, an inflamed nerve with pain and tenderness that lasts three to six weeks. This can happen in 10 to 15 percent of patients.
• Neuroma, a growth of nerve cells and fibers. It forms around the area destroyed during radiofrequency ablation and can itself cause pain.
  Numbness-nerve damage.
• Lack of pain relief even though a test block was beneficial.

After the neurotomy, there is a 60 to 80% chance of pain relief. It usually lasts 3 months to 2 years. The nerve grows back in time, and the procedure can be repeated. While you have relief, hard physical therapy is a must to strengthen the treated facet joint(s). Expect no pain relief for the first 72 hours. Relief peaks 6 weeks later.

A related but different procedure: radiofrequency ablation of the medial branch nerves treats the facet joints. Sometimes the pain comes from the vertebral endplate (the top or bottom face of the spine bone) and not the joint. That pain is deep, in the middle of the back, worse with sitting, with Modic changes on MRI. Then the target is the basivertebral nerve instead. See Intracept basivertebral nerve ablation. The two use the same energy on different nerves for different pain.