CT-guided pulsed radio frequency treatment of the lumbar dorsal root ganglion (DRG) in patients with acute and subacute radicular low back pain

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1 CT-guided pulsed radio frequency treatment of the lumbar dorsal root ganglion (DRG) in patients with acute and subacute radicular low back pain Poster No.: B-1263 Congress: ECR 2017 Type: Authors: Keywords: DOI: Scientific Paper A. Napoli, R. Scipione, M. Anzidei, C. Marrocchio, H.-P. Erasmus, C. Catalano; Rome/IT Interventional non-vascular, Musculoskeletal spine, Percutaneous, Efficacy studies, Inflammation /ecr2017/B-1263 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Purpose Low back pain is an extremely common problem that affects at least 80% of all individual at some point in their lifetime [1]. Lumbosacral disc herniation with dorsal nerve root compression represents an important causes of acute low back pain (defined by a duration < 4 weeks) and can be really debilitating, with a heavy impact on quality of life. Radicular pain typically shows a gradual onset (1-2 days), worsens with cough or sneeze and improves with recumbency, is described as sharp/burning and is distributed along single or multiple dermatomes [2]. Pulsed radiofrequency (PRF) is a relatively new technique [3] that uses intermittent administration of high frequency current, avoiding temperature rise above the critical level of 42 C (described as the threshold that causes neuronal damage), in contrast to conventional radiofrequency (RF), where the temperature easily rises above the critical threshold; for that reason, since the introduction of PRF, treatment-related adverse events have not been reported yet (Figure 1). PRF is based on neuromodulation on dorsal root ganglion; therapeutic principles are not fully understood, but the technique has shown promising results in many fields of application, including chronic post-surgical thoracic pain, chronic low back pain and chronic radicular pain [4-6]. The CT guidance allows an accurate location of target ganglion and an optimal planning of needle path, ensuring high safety and efficacy profile to the whole procedure. The purpose of our study is to determine the clinical impact of Pulsed Radiofrequency in the treatment of patients with acute or sub-acute neuro-radicular low back pain. Images for this section: Page 2 of 10

3 Fig. 1: Scheme of Pulsed Radio-Frequency treatment for lumbar and sciatic pain. The target of the procedure is the specific dorsal root ganglion, which is identified through clinical presentation and imaging (MRI) features. Radiological, Oncological and Anatomopatological Sciences, Sapienza University of Rome - Rome/IT Page 3 of 10

4 Methods and materials This single-center prospective development study was approved by our institutional review board and was independently audited by hospital research and development officials. All patients gave written informed consent. Patients were eligible for this study if they presented acute or sub-acute neuro-radicular low back pain, confirmed by EMG, refractory to usual treatments, and if they could safely undergo Pulsed Radiofrequency procedure. At baseline, clinical evaluation was conducted with both Visual Analogue Scale (VAS) for pain assessment and Owestry Disability Index (ODI) for quality of life assessment. Treatment was performed using a G needle-electrode with probe tip directed to the symptomatic DRG and pulsed radiofrequency was generated for 10 min at 45V with constant local T of 42 C. For all patients, follow-up was planned at 1 week, 1 month and 1 year. During each control, both VAS and ODI questionnaires were repeated and compared with previous results. Results Over a 3-year period, 80 patients fulfilled the established criteria and could undergo Pulsed Radiofrequency procedure (Cosman). At baseline, VAS had a median value of 8.0 ( ), while ODI median was 78.0 ( ). After treatment, VAS scores decreased to 3.5 at 1-week follow-up, to 2.5 at 1 month and 1.5 at 1 year (p<0.01); median ODI scores decreased to 12.5 at 1 week, to 6.0 at 1 month and 5.5 at 1 year (p<0.01). Overall, 72 (90.0%) of patients reached a 0 VAS score within the first month after treatment, and 78 (97.5%) had a decrease of at least 20 points in ODI score in the same interval. Page 4 of 10

5 6 patients (7.5%) were considered as partial responders at 1 month and required a second PRF session. At final 1-year control, this group had a median VAS score of 2 at 1 month and a median ODI score of remaining patients (2.5%) did not show significant improvement from baseline conditions and were considered as therapeutic failures. Conclusion In this study Pulsed Radiofrequency has shown to be a promising and effective percutaneous treatment option for patients with acute or sub-acute neuro-radicular low back pain (Figure 2, 3). Our results are not inferior to those reported from literature for usual care strategies or injections [7] and may avoid surgery for a substantial number of patients with sciatic disc compression. The high safety profile ensured by CT guidance, combined with the fact that this procedure aims to dorsal root ganglion and avoids the intervertebral disc or other structures of the spine, makes PRF particularly attractive and versatile, and its repetition can be easily performed in each case of unsatisfactory results. Images for this section: Page 5 of 10

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7 Fig. 2: T2-weighted MRI sagittal view highlighting a herniation of the intervertrbral disc between L5 and S1, with the compression of the corresponding dorsal root. Radiological, Oncological and Anatomopatological Sciences, Sapienza University of Rome - Rome/IT Page 7 of 10

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9 Fig. 3: Resolution of the herniation in the same patient, 3 months after the procedure. Radiological, Oncological and Anatomopatological Sciences, Sapienza University of Rome - Rome/IT Page 9 of 10

10 Personal information References 1. Hoy D, Brooks P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24: # 2. Hooten WM, Cohen SP. Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists. Mayo Clin Proc 2015;90(12): Dworkin RH, O'Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain 2007;132(3): Cohen SP, Sireci A, Wu CL et al. Pulsed Radiofrequency of the Dorsal Root Ganglia is Superior to Pharmacotherapy or Pulsed Radiofrequency of the Intercostal Nerves in the Treatment of Chronic Postsurgical Thoracic Pain. Pain Physician. 2006;9: , ISSN Hsi-Kai Tsou, Shao-Ching Chao, Caao-Jan Wang, et al. Percutaneous pulsed radiofrequency applied to the L-2 dorsal root ganglion for treatment of chronic low-back pain: 3-year experience. J Neurosurg Spine 12: , Shanthanna H, Chan P, McChesney J, et al. Pulsed radiofrequency treatment of the lumbar dorsal root ganglion in patients with chronic lumbar radicular pain: a randomized, placebo-controlled pilot study. Journal of Pain Research 2014: Fritz JM, Magel JS, McFadden M, et al. Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial. JAMA. 2015;314(14): Page 10 of 10