Episode 7: Radiofrequency Ablation - A Novel OHIP Covered Treatment for Back Pain

In this episode, Dr Karmy explores the world of radiofrequency ablation—a novel, OHIP-covered treatment for chronic back pain. He goes over the differences between radiofrequency ablation, pulsed radiofrequency, and cooled radiofrequency ablation, uncovering how each technique works and when they should be considered viable treatment options.
 
Join Dr Karmy as he breaks down these advanced procedures and helps you determine if they could be the key to managing your chronic pain effectively.
 
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Chapters

• 1:17 Background of Radiofrequency Ablation (RFA)
• 3:02 Advantages: OHIP Coverage, Response, Research Publications
• 5:33 Disadvantages: Complications, Side Effects, Radiation Exposure, Diminishing Response
• 10:59 Targeted Mechanism of Action: Facet Joints
• 14:32 Other Types of RFA: Pulsed and Cooled
• 16:14 Political and Economic Considerations

Transcript

Dr Karmy: 0:00

Having said all of that, the number of publications and radiofrequency ablation in terms of pure quantity,, and I'm not talking quality, I'm talking quantity, is fairly high. So it is one of the most researched approaches to pain management.

Raveena: 0:17

Welcome to Chronic Pain Chronicles with Dr. Karmy, where we delve into the complexities of managing chronic pain and explore the most effective treatments available today. I'm Raveena, your host, guiding you through the often overwhelming world of pain management. In today's episode, Dr. Karmy shares his knowledge on radiofrequency ablation, a treatment that is being used to target mechanical lower back pain. With back pain being the most common form of chronic pain and affecting nearly 8 percent of the population, finding effective long term solutions is critical. Dr. Karmy breaks down the science behind radiofrequency ablation, examines its pros and cons, and the clear indications if this is the right treatment for you. As always, we're privileged to have Dr. Karmy with us, a veteran in the field with over two decades of experience to provide his expert insights. Let's dive in.

Dr Karmy: 1:17

Hi, this is Dr. Karmy for Chronic Pain Chronicles, and today I wanted to discuss treatment called radiofrequency ablation. So you go to a pain clinic and you try nerve blocks and you try cortisone injections, but neither one seems to be helping, or if it's helpful it only helps for a day or two. Let's suppose you looked into platelet rich plasma injections for your pain and you can't afford them. What are your other options? Well, one option is a treatment called radiofrequency ablation. Radiofrequency ablation is a procedure that's offered in some but not all pain clinics in Ontario. Instead of reducing inflammation around the nerves, go to the painful areas, or trying to desensitize the nerves that go to the painful areas, or trying to reduce muscle spasm in the painful area. With radiofrequency ablation, what you are simply doing is destroying the nerves that go to painful joint. The idea, of course, is if you have no pain signals from, a damaged or painful joint, you will not realize you are in pain and so hopefully you can go on with your normal life. So what are the pros and cons of radiofrequency ablation? In terms of pros, the big one is that it is an OHIP covered service. So, generally speaking, there is no charge to the patients. It is also a treatment that can help for a long time. After radiofrequency ablation, pain reduction can last anywhere from two months to a year. On average, physicians talk about improvement for eight to nine months. The other advantage of this treatment is that it has been extensively studied. This approach originated from academic institutions in the U. S. There's a number of companies that manufacture equipment for radiofrequency ablation. Therefore, there are was both expertise from academic institutions and money from, manufacturers of some of that equipment to do a lot of studies. And the results of these studies are a little bit of a mixed bag. Invariably when you see reviews done by associations of physicians who do these procedures for a living or published in journals whose editors are financially benefiting by providing these procedures in their own practices. These reviews will often state that evidence supporting the use of radiofrequency ablation is fairly good. On the other hand, when you look at reviews of that same evidence, but done by disinterested party, be it a biostatisticians or physicians who do not do these procedures, the level of evidence is low. Having said all of that, the number of publications and radiofrequency ablation in terms of pure quantity, and I'm not talking quality, I'm talking quantity, is fairly high. So it is one of the most researched approaches to pain management. So what are the cons of this procedure? First of all, it is obviously a lot more aggressive than an injection. It is sort of like a mini surgical procedure. You're actually destroying tissue. So if you happen to burn the wrong nerve, the complications can be paralysis. Now to put it in perspective, if physicians are good at what they do, chances of these very serious complications are very, very low. A more common complication is post procedure nerve pain. When you destroy a nerve, often it becomes a bit inflamed and causes a burning type sensation, which can take, two to four weeks to subside. There's the goal of radiofrequency ablation, as I mentioned earlier, is to destroy the nerves that go to joints of the back, called facet joints. However, it is difficult to destroy that nerve without destroying a few fine fibers nearby that go to the muscles of the neck and back. When these nerves are destroyed, the muscles can atrophy. So there is a concern about muscle atrophy after repeated radiofrequency ablations. especially in the neck, where muscles are smaller to begin with. There have been some cases of patients whose neck muscles became so weak that they couldn't straighten out the neck. Again, these complications are extremely rare. Having said all of that, a lot of physicians will state that one shouldn't do radiofrequency ablation on both sides of the neck for that reason. There is, of course, repeated radiation exposure with radiofrequency ablation. It is incredibly important to place the needle in the right place to avoid complications and therefore x rays have to be used to see the needle. The other issue with radiofrequency ablation procedure is that it does become less effective over time in many patients. What do I mean by that? Well, initially when you burn a nerve, let's suppose you are somebody who responded, your pain went away for a year. After that, the nerves typically grow back in and the pain comes back. So then you repeat radiofrequency ablation again, and let's say this time the pain goes away for only nine months. And then, after the nerves grow back again, you do the procedure. a third time and this time it only helps for six months and after that three months and after that two so in other words often it is a law of diminishing returns. Not everybody has that kind of experience. Some patients continue to get long term benefit with each procedure. However, this sort of experience is fairly common. So why is it that radiofrequency ablation becomes less effective over time? Well, it has to do with nerves growing back. Typically, when you do the first procedure, the nerves take a well established path to the joint and you catch the nerve before it reaches the joint. However, after the nerve is destroyed, when it starts to grow back to the joint again the second time around, it may not take the same path as the first time. Keep in mind that when we do x ray guided injections, we cannot actually see the nerve. We can only see the bones next to which the nerve classically or traditionally passes. So if the nerve takes a different path, or the nerve fibers are not as close together to each other as they grow out, then the next treatment may not be as effective because maybe the tip isn't as close to the nerve. Maybe it's only able to burn some of the fibers, but not all of the fibers. So, besides this sort of a law of diminishing returns, there's just the issue of overall effectiveness of this treatment. There is a fundamental difference between something that has been very well researched and something that's very effective. Radiofrequency ablation in the back is primarily used to treat the pain coming from joints called facet joints. It is estimated that anywhere from 15 to 40% of back pain involves these joints. There's a number of other potential sources of pain in the back or neck, including discs, muscles, ligaments, compressed nerves, and so on. Even when facet joints are involved, as, uh, a source of the pain, often it is not exclusively the only source of the pain. So treatment of just facet joints without treating the other sources often does not provide adequate pain relief. There is a way to try to get at this concept of what percent of the pain is coming from facet joints by doing a nerve block under x ray guidance and bringing the patient back on a different visit to decide whether to do radiofrequency ablation or not. So, if you block the nerves that go to the facet joint and the pain becomes less severe by 60 to 80 percent, often it is an indication to go ahead with the radiofrequency ablation procedure. If, on the other hand, the reduction in pain is less than 50%? Then typically, this treatment is not used. Again, try to think about what it means if the pain is 50 percent less severe. What it means is that at most 50 percent of the pain is attributable to facet joint. And the rest of the pain is caused by other painful sources in the back or neck. So at the very most, your pain will be reduced by 50%. Even that test is not foolproof, as only about 60 percent of people who have facet joint pain based on nerve blocks respond to radiofrequency ablation. So, putting it all together if you have a patient walking through the door with back pain without knowing anything else about them, chances are that patient responding to radiofrequency ablation is about 1 in 10. So, in other words, it is a well researched treatment, but it helps a relatively small proportion of patients with chronic back pain. There's a couple of other variations on radiofrequency ablation that you should be aware of. One is called pulsed radiofrequency, where instead of destroying the nerve with heat, it is just irritated. The advantage of this approach is there's less post procedure pain. It is also safer. It can also be used on wider range of nerves. For example, radiofrequency ablation can only be used on sensory nerves that provide sensation. Because if you use it on a mixed nerve, which both provides sensation and controls muscles, you could end up with paralysis. Well, these kinds of nerves could be treated with pulsed radiofrequency. There is also another type of radiofrequency ablation called cooled radiofrequency ablation. Just like the regular type, the nerves are burned, but with cooled radiofrequency ablation. The size of the burns is greater, which is sometimes advantageous, specifically, when one is trying to destroy many nerves, because the joint is so big, such as, sacroiliac joint, perhaps cooled radiofrequency is superior. What are my other thoughts on radiofrequency ablation? Well, my other thoughts don't have much to do directly with the procedure itself, but have to do more with politics. And the politics are that a lot of physicians who practice radiofrequency ablation make it sound that it is the only treatment that should be offered to patients with chronic mechanical back pain because it has the most research to back up its use compared to other approaches. Well, there's a fundamental difference between number of studies to look at a specific treatment and effectiveness of a specific treatment. As mentioned, the early radiofrequency ablation, unfortunately, only helps a small percentage of patients with mechanical back pain, and to use it exclusively to other approaches would mean that vast majority of patients would not be able to access treatment. These particular physicians will often try to create an impression with politicians and with Ministry of Health that radiofrequency ablation is the only procedure that should be covered for mechanical back pain. And my concern is if they succeed, I think the field would be worse for it. My final thoughts on this treatment as a whole are this. If someone tried nerve blocks, and tried cortisone injections, and they're not finding that these approaches provide them with lasting improvement in their pain, perhaps radiofrequency ablation is worth a try. It is fully covered by OHIP. When it works, it can work for a long period of time. And vast majority of patients who use it do not get the side effects. Thank you.

Raveena: 18:36

Thank you for listening to the seventh episode of Chronic Pain Chronicles with Dr. Karmy, where we explore chronic pain from a physician's point of view. In our upcoming episodes, we'll continue to delve into some of the most effective and widely used approaches to managing chronic pain. We'll also investigate the causes of chronic pain and where the field is heading in the future. I'm Raveena Aujla. Until next time, take care. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care