Radiofrequency Neuroablative Procedures. Max Eckmann, M.D. Director, Pain Medicine Associate Professor UTHSCSA Dept. of Anesthesiology October 2016

Transcription

1 Max Eckmann, MD Dr. Eckmann is Associate Professor of Anesthesiology and Pain Medicine at the University of Texas Health Science Center at San Antonio (UTHSCSA). He has served on faculty since 2008, becoming the Director of Pain Medicine in Dr. Eckmann is active in post-graduate education as the UTHSCSA Pain Medicine Fellowship Program Director, as a member of the American Society of Anesthesiologists (ASA) Pain and Regional Anesthesia Education Track Committees, and as an Oral Board Examiner for the American Board of Anesthesiologist (ABA). Dr. Eckmann also serves the American Society of Regional Anesthesia and Pain Medicine (ASRA) planning committee, for which he will be the ASRA Pain Meeting Program Chair in He became a Texas Pain Society (TPS) Board Member in Dr. Eckmann has disclosed that he has received educational grants from Medtronic, St. Jude s, and Boston Scientific.

2 Radiofrequency Neuroablative Procedures Max Eckmann, M.D. Director, Pain Medicine Associate Professor UTHSCSA Dept. of Anesthesiology October 2016

3 Radiofrequency Ablation (RFA) Cosman ER. Neurosurgery 1984;15(6): Ahadian FM. Current Pain and Headache Reports 2004;8:34-40

4 Creating Lesions in Tissue Heat Direct Heating RF Heating (indirect) Organ LW. Applied Neurophysiology 1976/77;39:69-76 Cosman ER. Neurosurgery 1984;15(6):

5 Optimal Lesions Optimal Excessive Current Rapid Heating Low Current Excessive Current: Steam formation, unpredictable Rapid Heating: Char formation, rise in impedance Low Current: Small lesion, heat generation insufficient Organ LW. Applied Neurophysiology 1976/77;39:69-76

6 Advantages of Modern RFA Technical Advancements Advantages Control of tip temperature Impedance testing Increases in lesion size Multiple outputs Materials Smooth boundary Low complication rate Confirmation Flexible / Percutaneous ~Durable

7 Lesion Size Estimation SMK RRE w 0.7mm 1.6 mm Needle Gauge Lesion Diameter (mm) r 2.3 w +/ w +/ d 1.4 w 0.4 w % confident of coagulating tissues within electrode widths radially from probe. d w r Practice Guidelines, Spinal Diagnostic and Treatment Proc., 2004, first ed., p 192.

8 Latest: Factors Affecting Lesions Fluid Pre-injection and time to 180 sec Bone Proximity Provenzano DA, et. al. Reg Anesth Pain Med Mar-Apr;40(2): Eckmann MS, et. al. Reg Anesth Pain Med May-Jun;40(3):270-5.

9 Bipolar Lesions Cosman ER Jr. Pain Practice 2011; 11(1):3-22.

10 Cooled RF Cooled RF now applied to spine ablation Has been used elsewhere for increasing size of solid organ lesions to 30-50mm. Now being applied to joint denervation for pain management. Fluid Pre-injection apparently does not affect lesion size 1 1. Wang H, et. al. Spine (Phila Pa 1976) Jun 15. RF Cooled RF

11 Cooled RFA: Pain Applications Sacroiliac Joint Hip Knee Spine Tumors Transdiscal Thoracic Lumbar Cervical

12 Multi-tined Probes

13 Multi-tined Probes L5 DR S1 Lateral Branches

14 Multi-polar RFA

15 Lumbar Facet Denervation Long term treatment for facetogenic low back pain: Segmental tenderness of the low back Pain with loading of the facet joints (quadrant loading, prone hip extension) Concordant, positive response to controlled diagnostic medial branch blocks Absence of radicular pain

16 Lumbar Medial Branch RFA Proper selection and proper orientation of the probe = long term results not due to placebo. Early efforts by Rees and Shealy anatomically incorrect. Some studies with perpendicular probe placement. Patient selection a problem in some studies. Bogduk N, Dreyfuss P, Govind J. Pain Physician 2009; 10(6): When performed parallel to the target nerve, more effective than placebo at 6 months and 1 year. Levin J. The Spine Journal 2009; 9:

17 Lumbar Medial Branch RFA Double Blind, Sham Control RCT 3 controlled blocks > 80% pain relief n=40 from 376 screened candidates Results at 6 months: Improved Back/Leg pain, Analgesic Consumption, Quality of life measures, and Back extension and other back/hip movement. Nath S, et al. Spine 2008; 33(12);

18 Lumbar Facet Denervation Jasper JF. Pain Physician 2008; 11:

19 Lumbar Cooled RFA

20 Lumbar Cooled RFA

21 Sacral Lateral Branches Cox RC. Pain Physician Sep-Oct;17(5):

22 Sacral Lateral Branches Yin W, Willard F, Carreiro J, Dreyfuss P. Spine (Phila Pa 1976) Oct 15;28(20):

23 SIJ Cooled RFA Neurotomy Ramasubba C. Pain Physician Jan;16(1):1-8.

24 SIJ Cooled RFA Neurotomy Stelzer W. Pain Med Jan;14(1):29-35.

25 SIJ Cooled RFA RCT Patel N. Pain Med Mar;13(3):

26 SIJ Linear Multi-polar RFA Identify Start: 1 cm lateral and inferior to S4 Localize Path, from mid SIJ to Sacral Ala

27 SIJ Linear Multi-electrode RFA AP Advance Along Periosteum LATERAL

28 Multi-polar RFA for SIJ Pain

29 Thoracic Facet Denervation Less vigorously studied than Lumbar and Cervical Facet Denervation. Lack of significant high level evidence for TRFA Same principles of selection and proper procedural technique apply. Additional possible risk of pneumothorax Chua WH, Bogduk N. 1995;136(3-4):140-4.

30 Thoracic Facet Denervation Medial Branch (MB) passes fairly laterally to the tip of the Transverse Process as it comes inferior and dorsal Chua WH, Bogduk N. 1995;136(3-4): T1-4, 9-10 Lateral on TP T5-8 Superior and Medial to tip TP T11, T12 Near root of SAP

31 Thoracic Medial Branches Chua WH, Bogduk N. 1995;136(3-4):140-4.

32 Renditions: Thoracic Medial Branches Chua WH, Bogduk N. 1995;136(3-4):140-4.

33 Thoracic Facet Denervation: Medial to Lateral Approach Jasper JF. Pain Physician 2008; 11:

34 Thoracic Facet Denervation: Cooled RFA

35 Complications: Cooled RFA 61 y/o patient T1-4 thoracic facet pain H/O posterior fusion C3-T1 Probes placed at superiorlateral aspect of T2-T5 transverse process RFA 60 deg C, 150 seconds During RFA, patient complains of severe local pain at 90 sec Skin blanching noted Healing ultimately took 5 months Walega D, Roussis C. Pain Pract Jul;14(6):e154-8.

36 Cervical Facet Denervation Level II-A, II-B evidence 58-74% pain relief at 12 months in prospective studies Falco F, et al. Pain Physician 2009; 12: Paraspinal tenderness only clinical factor that predicts better success (vs. opioids, pain w/extension or occipital radiation) Cohen S, et al. Reg Anesth Pain Med 2007;32: Double Blind, Sham Controlled RCT, n=24 from 54 3 controlled blocks (normal saline, lidocaine, bupivacaine), target = complete relief of pain. C3/4 through C6/7 eligible; C2/3 excluded. Extensive 3 hour procedure w/multiple lesions per level Lord S, et al. N Engl J Med 1996;335:1721-6

37 Cervical Facet Denervation Double Blind, Sham Controlled RCT Median Time of at least 50% pain relief = 263 days vs. 8 days for sham group. Lord S, et al. N Engl J Med 1996;335:1721-6

38 Cervical Facet Denervation Pain Physician 2008; 11: Above C2/3, joints innervated by ventral rami C1 dorsal ramus, lies b/t posterior arch atlas inferiorly and vertebral artery superiorly DANGEROUS TO ACCESS C2 dorsal ramus, lies dorsal and lateral AA joint, deep to obliquus inferior No clear radiologic landmark for C2 DR or Greater Occipital N. Third occipital nerve, curves dorsally and medial around the SAP of C3 vertebra. Bogduk, Spine 1982;7(4):

39 Cervical Cooled RFA AP LATERAL Deep Ascending Cervical Arteries: Unpublished Case Report of Temporary Blindness Swain AR, et. al. American Society of Regional Anesthesia and Pain Medicine, Medically Challenging Case Abstract. Fall 2010 (26).

40 Genicular Nerves -Sensory branches that provide innervation of knee joint and ligaments. -Many are of sciatic origin -Saphenous, and Nerve to Vastus Medialis probably contribute to a genicular nerve plexus, with a small amount from Obturator N. Burckett-St Laurant D, Peng P, Girón Arango L, Niazi AU, Chan VW, Agur A, Perlas A. The Nerves of the Adductor Canal and the Innervation of the Knee: An Anatomic Study. Reg Anesth Pain Med May-Jun;41(3): Choi 2009 (RFA) Ikeuchi 2009 (RFA) Protzman 2013 (RFA post TKA) Menzies 2015 (CRFA post TKA) Franco 2015 Bellini 2015 (CRFA) Shen 2016 (RFA) Tibial Nerve Origin -Superior medial genicular n -Inferomedial genicular n Common Peroneal Nerve Origin -Superolateral genicular n -Inferolateral genicular n

41 Genicular nerves of the Knee Franco CD, et. al. Reg Anesth Pain Med Jul-Aug;40(4):363-8.

42 Genicular Nerves and Arteries

43 Genicular nerves of the Knee Choi WJ, et. al. Pain Mar;152(3):481-7.

44 Genicular Blocks and Radiofrequency

45 Emerging: Genicular Branch Ultrasound Kim SY, et. al. Pain Physician Jul;19(5):E Yasar E, et. al. Pain Physician Sep- Oct;18(5):E Kesikburun S, et. al. Pain Physician Jul;19(5):E751-9.

46 Ultrasound Views for Genicular Block Superomedial (Coronal/Longitudinal) View) (Transverse Inferomedial (Coronal/Longitudinal) View) (Transverse Superolateral (Coronal/Longitudinal) View) (Transverse Superior Mid-Femoral (Caution) Inferolateral*

47 Anterior Hip Articular Branches Kawaguchi M, et. al. Reg Anesth Pain Med Nov-Dec;26(6): Malik A, et. al. Pain Physician Oct;6(4): Chye CL, et. al. Clin Interv Aging Mar 16;10: Wu H, Groner J. Pain Pract Dec;7(4):341-4.

48 Anterior Hip Articular Branches Kawaguchi M, et. al. Reg Anesth Pain Med Nov-Dec;26(6):

49 Anterior Hip Innervation

50 Future: Posterior Hip Innervation 1 2? 1? 2 1) Superior Gluteal N?) Inferior Gluteal N 2) Nerve to Quad Fem

51 Cooled, Bipolar / Unipolar RF for Disc Biacuplasty Probe separation of 20-30mm can safely heat disc Inner 2/3 annulus C Outer 1/3 to 45 Pauza K. Pain Physician 2008 Nov- Dec;11(5): Technique: 45 degree approach Posterior 1/3 disc One Bipolar Lesion Two Unipolar Lesions

52 Kapural L, et. al. Pain Med Mar;14(3): Disc Biacuplasty

53 Disc Biacuplasty: Outcomes Kapural L, et. al. Pain Med Mar;14(3): Kapural L, et. al. Pain Med Mar;16(3):

54 Lumbar Disc Denervation via L2 Gray Rami Communicantes Sinuvertebral Nerves (SVN) are branches of the Rami Comminicantes (RC) which relay information to the sympathetic chain Branches of SVN traced to the Posterior Longitudinal Ligament, the outer layers of the Annulus Fibrosus and the Anterior Dura Chiba group s work shows that innervation of the disc is relayed via the sympathetic trunk to the L2 RC and L2 root Human studies show the SVN is only from the RC, relaying info to the sympathetic trunk Diseased discs have proliferation of nerve fibers deep into the disc. Nerves size suggested A and/or C fibers

55 Technique for L2 Rami Communicantes Target

56

57

58

59 Thank you for your Interest and Attention, Remember to always put Safety first! Maxim Eckmann, M.D.