Radiofrequency Ablation for Low Back Pain

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The #1 MISTAKE Back Pain Sufferers Make

By Dan Lieberman, MD In medicine the right treatment depends on understanding exactly what is wrong. The challenging thing about the lower back is that there are so many different problems, and even more treatments. In addition, the stakes are high. It is NOT just about relieving your pain; the wrong treatment is risky, sucks [...]

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Why you may have severe back and leg pain after RFA (and why not to panic!)

Radiofrequency ablation (RFA) is a common procedure for the treatment of low back pain due arthritic facet joints. Prior to RFA a pain management doctor typically performs a medial branch block to make sure your pain originates in a painful joint. Medial branch blocks are done with a needle. Radiofrequency ablation is done through a [...]

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Lower Back Vs. Hip Pain

I first realized how much low back pain can feel like hip pain while placing a needle in a guy’s low back. I was using x-ray to guide a needle to inject a facet joint ---his was in the bad old days before we knew facet injection damaged the joint and made the pain we [...]

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FAQ: Why does radiofrequency ablation (RFA) sometimes fail to relieve back pain even after a successful medial branch block?

To qualify for an RFA in the first place, you should have reported greater than 80% pain relief during the treatment window after Medial Branch Block (MBB). For example, if the MBB brought your pain from a 9 out of 10 to a 2 or below, you qualify for the RFA procedure.

Some doctors even repeat the MBB a second time to minimize the chance of a false positive result. The medial branch block only relieves pain coming from the facet joint. So, the degree of pain relief you get after RFA is the percentage of your pain coming from the blocked facet. Pain left over during the active treatment window of a medial branch block may be coming from a non-facet pain generator, typically a torn disc or inflamed nerve root.

In this image of the cervical spine a needle (silver) has been placed on a facet joint capsule (light blue). The medial branch nerve fibers which go to the facet joints are shown in yellow, blue, and red. During a medial branch block procedure, a numbing agent would be injected through the needle to block the medial branch nerve fibers in the injected area. Note that facet joints receive medial branch fibers from above and below.

For the 40% who had an RFA but did not get the expected relief despite having undergone a MBB that relieves more than 80% of the pain, there many explanations:

  • The doctor did not get it all: During RFA, heat generated at the tip of the radiofrequency needle is used to ablate the medial branch nerves responsible for transmitting pain signals from the facet joints to the brain. That is why the procedure is often called “burning the nerves.” In many of the 40% who do not get relief, the ablation was not sufficient, leaving enough nerve fibers intact and still capable of transmitting pain signals.
  • The pain fibers recovered: After they are “burned” the medial branches that send pain signals from the facet joints regenerate. If they come back too fast, back pain lasts. This is why the RFA procedure only lasts an average of 10 months, after which the “burned” nerves have recovered.
  • Wrong diagnosis: A positive response to an MBB does not always guarantee that the facet joints are the sole source of pain. This is called a false positive, and it is an unpleasant fact for all medical tests. Other spinal structures —including torn discs, stained muscles, and inflamed nerve roots— can also contribute to low back pain. If these sources are not properly identified and addressed, RFA will not be effective. That is why it is vitally important to be objective during your medial branch block test. Have hope, but do not let it cloud your judgement.
  • Outliers: Although we can standardize many things in modern medicine, it’s still true that everyone is different, some of us more so than others. Individual variations in the anatomy of the facet joints and surrounding structures are super common and affect the success of RFA. In other words, the pain management doctor did their best and put the needle where the medial branch nerves are supposed to be, but your medial branch was not where it is for most people.
  • Psychological Factors: Chronic pain has a way of getting to you. Your expectations, anxiety, and mental health can make your brain feel pain, even when the physical source is gone.
  • Drugs: Narcotics alter your body’s pain transmission pathway. If you take narcotics long enough, things that should not be painful feel like they are. That is why over time those who take oxycodone, Vicodin, or tramadol are never pain free, and typically start having whole body pain. Even if the RFA succeeded in burning the medial branch nerve, the narcotics may be causing you to experience continued pain.
  • Bad Doctors: The success of RFA can also be influenced by the experience and skill of the pain management doctor provider performing the procedure. Needle misplacement, wrong levels, and wrong medications during the RFA process can result in suboptimal outcomes. Bad doctors predictably get bad results. That is why you should always use a pain management doctor who meets the criteria for certification by Best Practice Health.

No matter what the reason for the failed RFA, if you had a positive medial branch block and did not get relief after RFA then a second opinion from a new pain management doctor is your next step.