When Radiofrequency Ablation (RFA) became popular in the late 90s, it seemed like a miracle for many patients with chronic neck pain. At the same time, while this therapy seemed to work reliably to provide pain relief in the neck, it was always hit or miss as a treatment for low back pain. Perhaps that’s because the nerves treated with this procedure are also the ones that stabilize the spine. The procedure uses heat to destroy nerves, therefore a “Burn Nerves in Low Back” treatment is a more accurate name for the procedure. Now new research hopefully puts the proverbial final nail in the coffin for using RFA to treat back pain.
While the term “radiofrequency ablation” (aka radiofrequency denervation) sounds like some fancy new high-tech procedure, it has actually been around and used to manage pain for many decades. I’ve mentioned before how innocuous and elegant the phraseology—radiofrequency ablation—sounds, but the truth is, this procedure is more medieval than it is modern. Let’s break it down a bit.
At the basic level, RFA uses radiofrequency, converting electromagnetic signals into heat energy. The heat energy travels into the tissue being treated via a tool such as a probe or needle. “Ablation” means to melt, vaporize, and remove or destroy using a very high temperature or chemicals. What exactly are we “nuking” during an RFA for back pain? Nerves and surrounding tissue—remember an RFA can also be called radiofrequency denervation (de- meaning “to remove,” and nervation meaning “nerves”). Chances are, it would be very difficult to have patients buy into radiofrequency nerve “vaporization” or “melting” or “destruction,” or burn nerves in low back, so the more obtuse “radiofrequency ablation” is used.
It did seem, before our more modern regenerative-medicine options came along, that RFA might have been a great technology for its time. Despite the negative long-term effects of the tissue destruction, a treatment for low back pain having longer periods of short-term pain relief seemed preferable to dangerous painkillers and back fusions for example. However, the results of the new study certainly brings to question whether an RFA was ever a good option for chronic back pain. Let’s review the study.
The new study set out to determine how well radiofrequency for chronic low back pain worked when compared with standard exercise. The three-month study consisted of 681 subjects in three randomized control trials. Subjects were randomized into either a test group (RFA plus exercise) or a control group (exercise only) with 521 completing a one-year follow-up. Subjects had chronic low back pain due to problems in the facet joints, the sacroiliac joints, the discs, or a combination of these and had not responded to other treatments.
The researchers concluded that when compared to the exercise-only control group, the RFA-with-exercise group experienced no clinically significant improvements. So RFA with exercise was no better than exercise alone.
I’ve shared before that in the long run, destroying nerves in low back discs via RFA for back pain treatment is a really bad idea. Our nerves serve a purpose. In the discs, for example, they help take forces off the disc so it can heal. Destroying the nerves not only disrupts that process but also, based on what we’ve observed in patients, degenerates the disc over time.
The nerves also transmit pain signals from the joint and other tissues. Frying the nerves may mask the pain, but the pain is there for a reason, and if the root cause isn’t addressed (e.g., arthritis in the joint), more damage is likely to be done, especially since the ability to transmit the pain signal has been stifled. In other words, in the case of arthritis, your joint still hurts because the forces on your joint (as these haven’t changed) continue to advance your arthritis. However, since your nerves have been burned away, your body can’t tell you your joint hurts and, therefore, that your arthritis is getting worse.
Additional side effects we see with radiofrequency ablation for chronic low back pain include killing off the multifidus muscle which can cause instability in the low back. This extra movement due to dead multifidus muscles means more wear and tear on the low back discs, joints, and ligaments. In fact, you can tell the level of success of a low back RFA (i.e. did you really kill all of the nnerves by sticking an EMG electrode into the multifidus to make sure it’s dead.
We see the same problem with radiofrequency ablation procedures in the upper back, the neck area. With the advent of interventional orthopedics in recent years, there’s no reason to ablate these nerves when we now have regenerative-medicine options to address the real problem along with the pain.
The upshot? RIP low back RFA. Good-bye to the Burn Nerves in Low Back procedure. Not sure how we ever thought that killing the nerve that goes to the muscle that stabilizes the spine was a good idea as a treatment for low back pain? With newer regenerative medicine techniques, it’s time to hold a big wake and get those RFA probes six feet under, where they belong!
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About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…