Shoulder terminal sensory articular nerve radiofrequency ablation for non-surgical refractory shoulder pain due to rotator cuff pathology and osteoarthritis: A technical note.

BACKGROUND: Given the high prevalence of chronic shoulder pain and encouraging early results of terminal sensory articular branch (TSAB) radiofrequency ablation to treat shoulder pain, research is warranted to refine the procedural technique based on updated neuroanatomical knowledge with the goal of further improving patient outcomes. OBJECTIVE: We describe an updated radiofrequency ablation protocol that accounts for varied locations of the TSABs of suprascapular, axillary, subscapular and lateral pectoral nerves within individual patients. DESIGN: Technical note. METHODS: Cadaveric studies delineating the sensory innervation of the shoulder joint were reviewed, and a more comprehensive radiofrequency ablation (RFA) protocol is proposed relative to historical descriptions. CONCLUSIONS: Based on neuroanatomical dissections of the shoulder joint, the proposed RFA protocol will provide a safe means of more complete sensory denervation and potentially improve clinical outcomes compared to historical descriptions, which must be confirmed in prospective studies.

A pragmatic randomized prospective trial of cooled radiofrequency ablation of the medial branch nerves versus facet joint injection of corticosteroid for the treatment of lumbar facet syndrome: 12 month outcomes.

BACKGROUND: Lumbar medial branch radiofrequency ablation (LRFA) and intraarticular facet steroid injections (FJI) are commonly performed for recalcitrant facet joint-mediated pain. However, no study has compared clinical outcomes of the two treatments in patients selected using dual medial branch blocks (MBBs) with an 80% relief threshold. OBJECTIVE: Compare the effectiveness of cooled LRFA (C-LRFA) to FIJ as assessed by pain and functional improvements. DESIGN: Prospective randomized comparative trial. METHODS: Patients with dual MBB-confirmed facet joint-mediated pain were randomized to receive C-LRFA or FIJ. Outcomes were assessed at 1, 3, 6, and 12 months. The primary outcome was ≥50% improvement in numerical pain rating scale (NPRS) score at 3 months. Secondary outcomes included ≥30% Oswestry Disability Index (ODI) improvement and Patient Global Impression of Chance (PGIC) ≥6 points, among others. Data were analyzed using contingency tables and mixed-effects logistic regression models. RESULTS: Of 1128 patients screened, 32 met eligibility criteria, were randomized, and received their allocated study treatment. In total, 20 (62.5%) and 12 (37.5%) participants received C-LRFA and FIJ, respectively. In the C-LRFA group, 70% (95% CI 48-85), 55% (95% CI 34-74), and 45% (95% CI 26-66) of participants met the NPRS responder definition, compared to 25% (95%CI 9-53), 25% (95% CI 9-53), and 17% (95% CI 5-45) in the FJI group at 3, 6, and 12 months, respectively (P = .014 at 3 months). The PGIC responder proportion was higher in the C-LRFA compared to FJI group at 3 and 6 months (P < .05). CONCLUSIONS: C-LRFA demonstrated superior success rates compared to FJI across pain and functional outcome domains. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov (NCT03614793); August 3, 2018.

Magnetic Resonance Imaging Characteristics Associated with Treatment Success from Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trials Data.

OBJECTIVE: Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN: Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials. METHODS: Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA. RESULTS: The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success. CONCLUSIONS: In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA.

The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebrogenic Low Back Pain: An Updated Systematic Review with Single-Arm Meta-analysis.

OBJECTIVE: To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP). DESIGN: Systematic review with single-arm meta-analysis. POPULATION: Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes. INTERVENTION: Intraosseous BVN RFA. COMPARISON: Sham, placebo procedure, active standard care treatment, or none. OUTCOMES: The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score. METHODS: Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence. RESULTS: Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively. CONCLUSION: According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure.

Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data.

OBJECTIVE: Develop pain location "maps" and investigate the relationship between low back pain (LBP)-exacerbating activities and treatment response to basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN: Aggregated cohort study of 296 patients treated with BVN RFA at 33 centers in three prospective trials. METHODS: Participant demographics, pain diagrams, and LBP-exacerbating activities were analyzed for predictors using stepwise logistic regression. Treatment success definitions were: (1) ≥50% LBP visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3 months post-BVN RFA. RESULTS: Midline LBP correlated with BVN RFA treatment success in individuals with clinically-suspected VEP. Duration of pain ≥5 years (OR 2.366), lack of epidural steroid injection within 6 months before BVN RFA (OR 1.800), lack of baseline opioid use (OR 1.965), LBP exacerbation with activity (OR 2.099), and a lack of LBP with spinal extension (OR 1.845) were factors associated with increased odds of treatment success. Regressions areas under the curve (AUCs) were under 70%, indicative of low predictive value. CONCLUSIONS: This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients where VEP should be more strongly suspected. The use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain remain the most useful patient selection factors for BVN RFA.

Sacroiliac Joint Diagnostic Block and Radiofrequency Ablation Techniques.

Radiofrequency ablation (RFA) is a potential treatment for those with sacroiliac joint (SIJ) pain. There is no consensus on the optimal procedural techniques for SIJ diagnostic blocks, or RFA. This article describes different techniques for SIJ diagnostic blocks and RFA, including the relevant innervation that underlies these techniques. SIJ RFA techniques differ in important ways, including lesioning techniques, needle placements, and type of RFA cannula used. Clinicians utilize a variety of image guidance modalities for SIJ RFA; fluoroscopic guidance is standard, although endoscopic and ultrasound-guided techniques are described. Additional studies are necessary to delineate potential differences between SIJ RFA techniques.

Effect of hand warming on electrodiagnostic testing results and diagnosis in patients with suspected carpal tunnel syndrome.

UNLABELLED: Burnham RS, Burnham TR. Effect of hand warming on electrodiagnostic testing results and diagnosis in patients with suspected carpal tunnel syndrome. OBJECTIVES: To evaluate the effects of hand warming on electrodiagnostic (EDX) parameters of carpal tunnel syndrome (CTS). Specifically, to evaluate the type and magnitude of change in EDX values; to determine whether warming can change the EDX diagnosis of CTS and, if so, to determine whether specific EDX tests are more vulnerable to the effects of warming. DESIGN: Interventional before-after trial. SETTING: Community EDX laboratory. PARTICIPANTS: Consecutive patients (N=33) referred for EDX evaluation of suspected CTS. INTERVENTION: Each upper limb was tested at room temperature (average hand temperature, 31.9 degrees C) and retested after 20 minutes of heating pad warming (average hand temperature, 33.5 degrees C). MAIN OUTCOME MEASURES: Median and ulnar nerve motor and sensory latency, conduction velocity, and amplitude. RESULTS: Warming resulted in significantly faster transcarpal tunnel sensory and motor conduction (6%-10%), reduced median: ulnar sensory latency to digit 4 difference (23%), and reduced sensory nerve and compound motor action potential amplitude (10% and 13%, respectively). The changes resulted in 15% fewer limbs meeting the EDX conduction velocity criteria of CTS and 9% fewer by median: ulnar sensory latency to digit 4 difference. Waveform amplitudes became abnormally low after warming in 12% of limbs. CONCLUSIONS: Hand warming using a heating pad for 20 minutes increases median nerve transcarpal tunnel conduction velocity and reduces amplitude. These phenomena introduce potential sources of diagnostic error, particularly in borderline cases. Generally, within hand, between nerve, and within nerve comparison techniques are less susceptible to the conduction velocity effects of warming.