Radiofrequency lesioning
When is Radio Frequency Rhizotomy Used?
When the doctor wants to decrease and/or eliminate pain symptoms arising from painful nerves within the spine or periphery, he'll use this therapeutic procedure. It involves destroying the nerves that innervate the facet joints with highly localized heat generated with radiofrequency. By destroying these nerves, the body has no method of linking pain signals from the spine to the brain. A similar effect may be achievable with Pulsed radiofrequency rhizotomy. In this technique, the same type of needle and probe are placed on the affected nerve, but instead of creating a heat lesion, normothermic (or body temperature) radio frequency energy is delivered to the nerve to effectively "turn it off" for a period of time.
The Procedure:
Once Dr. Carpentier had confirmed where your pain originates, by using one of the procedures described above for nerve blocks, epidural injections, facet blocks, etc., a radiofrequency lesioning may be offered to provide sustained or long term pain relief.
During the procedure:
- A thin needle electrode is placed near the nerve determined to be the source of the pain.
- The doctor may use fluoroscopy to guide the needle. Or, an ultrasound may be employed, or the needle can be located simply by "stimulating" the nerve using the built in nerve stimulator employing very low energy electricity.
- Its position will be very carefully confirmed using sensory and motor stimulation as well as X-ray images or ultrasound if necessary.
- The doctor will then inject an anesthetic directly onto the nerve.
- A lesion will then be created on the nerve employing either thermal or non thermal radiofrequency energy. While this procedure doesn't typically "destroy" the nerve, it can eliminate its ability to transmit painful signals for a prolonged period of time lasting anywhere from 6 months to a year.
- This procedure is then repeated at each nerve as needed. It can also be repeated if the pain recurs.
After the procedure:
The nurse will review with you how you should take care of yourself. Numbness and/or relief from symptoms for 2-8 hours after the procedure is normal due to the anesthetic. It is also common for your usual symptoms to return once the local anesthetic effects have worn off. They may be more severe for up to 5-7 days after the procedure. This is called neuritis and it occurs as the nerve is in the process of "shutting down." It generally takes 2-3 weeks to reach maximum improvement.
You will be contacted by the office staff in the first couple of days following the procedure to be sure all your questions are answered and to make sure there were no problems that need to be addressed. You will be asked to keep a pain diary and record the duration of pain relief following the procedure and bring it with you to the scheduled follow up visit.
As bones of the spine age they can weaken. If it is stressed enough, the bones can form cracks or fractures. These fractures can be a significant source of pain. The pain is generally mechanical in nature, meaning that it worsens with activity and improves with rest. These fractures can be visualized on X-ray and CT and sometimes MRI. If they are acute or new, and causing pain, it is possible to stabilize them with a technique called vertebroplasty/Kyphoplasty. With this technique, the fractured areas can be stabilized using a needle to inject methylmethacrolate or other bone cement. The cement acts as glue to hold the pieces together and thus reduces the pain that occurs when the fractures shift. It is most effective with acute or fresh fractures, so additional evaluation such as a radionuclide bone scan may be warranted to be sure the fractures identified are new. The procedure is typically used for a spine fracture caused by osteoporosis, a disease that causes weakening of the bones and can lead to fractures in the vertebral bodies (those bones that make up the spinal column). An osteoporotic fracture can cause extreme back pain along with other symptoms, such as decreased height and spinal deformity or a hunchback appearance.
When is Vertebroplasty Used?
This is used to reduce pain caused by compression fracture in the spine. It is a minimally invasive procedure and patients usually go home the same day.
The Procedure:
An IV will be placed in the holding area. This will be used to administer fluids and sedation to keep you comfortable during the procedure. You will be brought to the procedure room and placed on your abdomen. Your back will be prepped in a sterile fashion just as if an open surgical procedure were to be performed. A live X-ray or fluoroscopy will be used to identify the Pedicle of the vertebral body in question. The soft tissue overlying the bone will be anesthetized locally. A specialized needle will be advanced into the vertebral body and positioned at the area of the fracture. Bone cement will then be injected into a fractured vertebra in order to stabilize it. Once the injection is completed, the needle will be removed and you will be taken to the recovery area for observation. You will generally be discharged within an hour or so.
When is Kyphoplasty used?
Kyphoplasty differs from vertebroplasty in that rather than simply injecting the bone cement, the vertebral body is first expanded using a specialized balloon in an effort to restore more normal height to the compressed and fractured vertebral body. It is often employed when the vertebral body is deformed enough that it alters the normal physics and mechanics of the spine.
From the patient standpoint, the procedure is almost identical to vertebroplasty with the preparation and recovery from the procedure being the same. It can require slightly longer surgical times to inflate the balloon to restore the height of the vertebral body and to possibly inject larger volumes of bone cement.
The risks from the two procedures are roughly the same. The recovery period and post operative courses are also similar.
You will be contacted by the office staff in the first couple of days following the procedure to be sure all your questions are answered and to make sure there were no problems that need to be addressed. You will be encouraged to rest following the procedure. A specific recovery program will be prescribed. You will begin with simple exercises and gradually increase your activities in a carefully prescribed manner. You will be asked to keep a pain diary and record the duration of pain relief following the procedure and bring it with you to the scheduled follow up visit.
Spinal Cord Stimulators were developed in the 1960's to treat neuropathic, or nerve injury pain. They have been gradually improved over the decades to their current form. They utilize pacemaker battery technology and small electrodes to effectively relieve the pain from a variety of painful conditions. They require surgical implantation and are generally performed in two stages. The first stage or trial is performed by placing a specialized needle into the epidural space in the spine and then guiding an electrode through the needle using live X-ray or fluoroscopy. The patient is awake during the procedure as precise placement requires feedback from the patient to determine optimal positioning. Once the lead is positioned in the appropriate place, the needles are removed and the patient is able to "test drive" the stimulator to determine whether or not it is effective at relieving pain. Following the trial, the leads are removed in the office and it will be determined if permanent implantation is appropriate.
Permanent implantation requires surgery to fasten the leads to the spine and to create a pocket under the skin to contain the pulse generator, or power source for the electrodes. A connection between the generator and electrodes will also be made beneath the skin so the entire system is hidden beneath the skin when the procedure is completed. Recovery from this surgical procedure generally requires about a week.
When are Spinal Cord Stimulators Used?
Spinal Cord Stimulators or Dorsal Column Stimulators are implantable medical devices used to treat chronic pain in the trunk and limbs. An electric impulse generated by the device near the dorsal surface of the spinal cord provides a "tingling" sensation that alters your perception of pain. The device can excite descending inhibitory fibers that effectively blunt the painful sensations being transmitted to the brain. The technique is most effective for treating nerve injury type pain from Failed Back Surgery Syndrome, RSD, or other peripheral nerve pains. It is less effective for treating neck and back pain, but newer technologies are allowing for pain relief in these areas as well for some patients.
There are three types of Spinal Cord Stimulators:
- A radio frequency device is simple and has an implanted receiver and a transmitter that you wear. The transmitter sends signals to the receiver which then sends stimulation to the lead. These units have traditionally been used for patients that require high-power settings that would quickly deplete a primary-cell implantable pulse generator.
- A Conventional Implantable Pulse Generator has a primary cell battery and control electronics. When the battery is depleted, it is surgically replaced for you.
- A Rechargeable Implantable Pulse Generator carries a rechargeable battery and control electronics. The battery is recharged by an external device worn every two to three weeks for a few hours. This type of device has largely replaced the Radio Frequency device and primary cell technology described above.
The Procedure:
An IV will be placed in the holding area. This will be used to administer fluids and sedation to keep you comfortable during the procedure. You will be brought to the procedure room and placed on your abdomen. Your back will be prepped in a sterile fashion just as if an open surgical procedure were to be performed. A live X-ray or fluoroscopy will be used to identify the target area in the spine for needle placement. The soft tissues will be anesthetized and a specialized epidural needle will be placed. Dr. Carpentier will then introduce the spinal cord stimulator lead into the epidural space via the needle. The lead will be positioned at the appropriate level of the spine based on the pain complaint and a trial of stimulation will commence. The lead will be adjusted using Fluoroscopy until the tingling sensation covers all painful areas. The needles will then be removed and the leads will be left in place. You will be provided with an external power supply and control device so that you may operate the stimulation at your leisure. You will be instructed in the use of the device in the recovery area and will have close contact with representatives of the device manufacturer for the duration of the trial, which usually lasts 5-7 days. You will be instructed about activities to avoid during the trial period such as bathing, bending, stooping, overhead work, etc. A complete instruction sheet will be provided. You will be given a prescription for antibiotics which you will take for the entire duration of the trial.
When the trial stimulation period is completed, the leads will be removed in the office or surgery center. The removal of trial leads is no more complicated than removing an IV from your hand. It is not painful and takes a few seconds. You will then be asked about the effectiveness of the device. If you meet criteria for permanent implantation based on pain relief and functional improvement, you will be able to undergo permanent implantation.
Permanent implantation requires one or two incisions. The procedure is carried out much in the same way as the trial, except that an incision will be made over the spine and carried down onto the spine before the needles are advanced into the epidural space. This is so that the leads can be securely anchored to the spinal column in order to reduce the risk of lead movement or migration over time. Once the leads are properly positioned as they were in the trial, they will be sewn in place. A second incision may be made in order to create a pocket under the skin to accommodate the IPG or battery, depending on where you elect to have the battery placed and other surgical considerations. A connection between the two incisions will be made in order to connect the leads to the IPG. The wounds will be closed surgically and you will be taken to the recovery room. The procedure is generally performed as an outpatient procedure and you will be discharged home after an hour or so in the recovery room. You will again be instructed on the use of the device in the recovery room. You will be given a complete instruction sheet in the recovery room. You will be given a prescription for antibiotics which you will take for a course of 7 days following the surgery
Our office will call you two days after the procedure to ask questions about how you are feeling and to ensure that you did not experience any negative side effects from the injection. You will be asked to bring your pain diary with you to review during the scheduled follow up visit in a few days.
Peripheral Nerve Stimulators are identical to the devices used in spinal cord stimulation. The electrodes are placed over nerves in the scalp, trunk, arms, abdomen, back, pelvis or legs to relieve the pain from specific nerve injury. The technique is very similar for nerve block procedures described above except that rather than injecting medications only, a stimulator electrode is placed next to the nerve using stimulation just as in the placement of spinal cord stimulators. The stimulator can disrupt the painful signals being transmitted from the nerve to the brain and significantly reduce pain. It is only effective to treat pain from injured nerves. The trial and surgical procedures are carried out in essentially the same manner as for spinal cord stimulation. Implantation of permanent stimulators is also very similar except that there is no need to anchor the device directly to the spinal column. Instead, the lead is anchored to tissues near the affected nerve to prevent migration. A similar pocket is created for the IPG.