Lewis Joshua B, Wahezi Sayed E, Yener Ugur, Kaye Alan D, Lawandy Marco, Palee Suwannika, Fortin Joseph D
Montefiore Medical Center/Albert Einstein College of Medicine, Department of Physical Medicine and Rehabilitation, Bronx, NY.
Montefiore Medical Center/Albert Einstein College of Medicine, Department of Physical Medicine and Rehabilitation, Bronx, NY; Montefiore Medical Center/Albert Einstein College of Medicine, Department of Anesthesiology, Bronx, NY.
Pain Physician. 2025 Jan;28(1):E23-E29.
Chronic low back pain is a global health burden with significant health care costs. Accurate diagnosis and treatment are often complicated due to its multifactorial nature. The sacroiliac joint has been identified as a major source of lower back pain, especially among the elderly and individuals with a history of lumbar fusion surgery. Conservative treatments frequently fall short in providing relief, leading to the exploration of alternative interventions such as sacroiliac joint radiofrequency ablation (RFA).
We aimed to demonstrate a novel approach for sacroiliac joint RFA based on new ex vivo evidence.
Development of a novel methodology integrating ex vivo evidence and clinical approach.
Academic health care institution.
Current radiofrequency methods, such as conventional RFA, water-cooled RFA, and cryoneurolysis, involve 2 main needle placement strategies: the palisading and the strip lesioning techniques. Additionally, the periforaminal/intraforaminal lesion technique, performed with fluoroscopy, visualizes the dorsal sacral foramina by adjusting the beam according to sacral tilt while the patient is prone. Targeting the lateral borders of the S1-S3 foramina, the technique aims to reach described lateral branch neural locations. Needle placement focuses on the lateral borders of the posterior sacral foramina, spaced one mm to 10 mm from the foraminal border, often following a clock face analogy. Protruding electrode RFA needles are recommended because of their demonstrated larger lesion width. After directing the needles to the lateral border of the S1-S3 posterior sacral foramina and then medially into the foramen, a lateral projection confirms proper needle placement beyond the posterior sacral ridge. Sensory-motor testing follows, with 0.5 mL of iohexol 180 administered to assess vascular flow and minimize contrast medium migration. Subsequently, 0.5 mL of lidocaine 2% is given for ablation anesthesia.
This technique achieves an estimated 95% needle approximation of the lateral branches, enhancing neural ablation efficacy by optimizing needle tip positioning.
Our technique faces challenges as lesion success rates decrease with distance from the foramen.
Adipose interference is minimized when a protruding electrode RFA needle is used within a posterior sacral foramen; neural approximation may be enhanced by giving 2% lidocaine prior to ablation. Considerable gaps in knowledge still exist despite advances in our understanding of the effect of tissue on RFA. Thorough research aimed at refining RFA procedures is essential to ensuring the best feasible patient care and sustainable pain relief. For sacroiliac joint RFA, perineural lateral branch ablation is a viable option that needs further clinical research.
慢性下腰痛是一项全球性的健康负担，医疗成本高昂。由于其多因素性质，准确的诊断和治疗往往很复杂。骶髂关节已被确定为下腰痛的主要来源，尤其是在老年人和有腰椎融合手术史的个体中。保守治疗常常无法缓解疼痛，这促使人们探索诸如骶髂关节射频消融术（RFA）等替代干预措施。
我们旨在基于新的体外证据展示一种骶髂关节RFA的新方法。
开发一种整合体外证据和临床方法的新方法。
学术性医疗保健机构。
当前的射频方法，如传统RFA、水冷RFA和冷冻神经lysis，涉及两种主要的针放置策略：栅栏状和条状损伤技术。此外，透视下进行的椎间孔周围/椎间孔内损伤技术，在患者俯卧时根据骶骨倾斜度调整光束来观察骶骨背侧孔。该技术以S1 - S3孔的外侧边界为靶点，旨在到达所述的外侧支神经位置。针的放置集中在骶骨后孔的外侧边界，距离孔边界1毫米至10毫米，通常采用时钟面类比法。由于已证明其损伤宽度更大，推荐使用突出电极RFA针。将针指向S1 - S3骶骨后孔的外侧边界，然后向内侧进入孔内后，侧位投影确认针在骶骨后嵴之外的正确放置。接着进行感觉 - 运动测试，注射0.5毫升180的碘海醇以评估血流并尽量减少造影剂迁移。随后，给予0.5毫升2%的利多卡因用于消融麻醉。
该技术实现了估计95%的针接近外侧支，通过优化针尖定位提高了神经消融效果。
随着与孔的距离增加，损伤成功率降低，我们的技术面临挑战。
在骶骨后孔内使用突出电极RFA针时，脂肪干扰最小化；在消融前给予2%的利多卡因可能会增强神经接近度。尽管我们对组织对RFA的影响的理解有所进展，但知识上仍存在相当大的差距。旨在完善RFA程序的深入研究对于确保最佳可行的患者护理和可持续的疼痛缓解至关重要。对于骶髂关节RFA，神经周围外侧支消融是一个可行的选择，需要进一步的临床研究。
