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15 Articles in Volume 19, Issue #3
Analgesics of the Future: The Potential of the Endocannabinoid System
Buprenorphine: A Promising Yet Overlooked Tool
Chronic Pain and the Psychological Stages of Grief
Could a Personalized Approach to Therapy End the War on Pain?
Finally, A Systematic Classification of Pain (the ICD-11)
Hormone Therapy for Chronic Pain
How to Communicate with a Medical Marijuana Dispensary
Letters: Opioid Conversions; Scrambler Therapy for CRPS
MSK Pain: Time for an Enhanced Assessment Model
National Drug Use & Abuse Trends: Prescribed and Illicit
Neuroplasticity and the Potential to Change Pain Response
Should Emergency Naloxone Be in Schools?
Talking to Patients about Medical Cannabis
Utility of Pulsed Radiofrequency Ablation in Xiphodynia
When Opioid Prescriptions Are Denied

Utility of Pulsed Radiofrequency Ablation in Xiphodynia

A first-look case report demonstrates that RFA may relieve long-term pain for patients with xiphodynia compared to standard approaches.
Pages 70-72

Xiphodynia is a potentially debilitating syndrome characterized by marked xyphisternal pain replicated by palpation. Historically, standard treatment has involved a combination of steroid and/or anesthetic injections, although long-term efficacy has been debated.1 In this paper, we review a case of xiphodynia, and discuss the utilization of pulsed radiofrequency ablation (RFA) as a novel potential treatment approach for the condition, aimed at providing longer-term relief compared to conventional treatment options.

About Xiphodynia

Xiphodynia is a hypersensitivity pain syndrome thought to be caused by an irritated or inflamed xiphoid process. It is characterized by marked xyphisternal pain that is replicated with moderate palpation, with possible referral to the chest, abdomen, throat, arms, or head.2 The first case discussed in the literature was documented in 1712, as reported by Lipkin, et al.3 Unfortunately, the true incidence of this condition since then has not been made clear. Some believe it to be a rare condition,4-6 while Lipkin et al., estimated it to be present in about 2% of the general world population.3

It is generally agreed upon that xiphodynia can be a potentially debilitating condition that severely impacts function. The syndrome has remained a diagnosis of exclusion, as it may mimic the pain of acute coronary syndrome (ACS),1,2,5,6 and may be comorbid with a number of other conditions, including arthritis, gastroesophageal reflux disease, cholecystitis, and peptic ulcer disease.3,6 Trauma is thought to be a contributing factor in the development of xiphodynia,2,7 including acceleration/deceleration injuries, blunt trauma,2 unaccustomed heavy lifting,4 and occupational injury.7

The duration of pain attacks is usually minutes to several hours, with multiple daily recurrences. Left untreated, the syndrome may last weeks or months and rarely lasts for years, although it is generally expected to spontaneously disappear.3 The treatment for refractory cases has largely involved a combination of local anesthetic and/or steroids.2-4 Other treatments with varied success in the literature include NSAIDs,7 low-level laser therapy,2 and in certain cases, xiphoidectomy.1,3

RFA, a procedure gaining increased popularity within the medical literature, involves the use of alternating electromagnetic waves to modulate the transmission of pain signals without causing neurolysis.8 While the exact mechanism of action for pulsed RFA has not been demonstrated, a highly debated theory involves the modulation of gene expression through a marker of neuroactivity, c-Fos.8,9 Potential advantages of this modality include decreased likelihood of tissue degeneration and neuritis associated with conventional RFA.10 Pulsed RFA has been studied most commonly as a treatment option for axial, facial, and radicular pain.8,9

Could radiofrequency ablation (RFA) provide better long-term pain relief? (Source: 123RF)

Patient Case

A male in his 40s with a history of post-traumatic stress disorder (PTSD), anxiety, chronic obstructive pulmonary disease (COPD), and alcohol dependence complained of having sternal pain for approximately 20 years. He has not had direct trauma to the xyphisternal region, but has had blast exposure during his time in the military. Prior workup for the etiology of the pain included ruling out ACS, which revealed a normal cardiac stress test, and negative imaging of the chest for any significant pathology.

The patient shared that, in the past, alcohol consumption helped with his chronic pain. He had undergone multiple xiphoid injections with lidocaine and methylprednisolone which provided about 100% pain relief for two to three months each. In the pain clinic, his exam was remarkable for tenderness along the inferior sternum, and a diagnosis of xiphodynia was made. Given this response and the positive benefits from his injections, he underwent pulsed RFA at the xiphoid. At the patient’s two-month follow-up, he continued to have 100% sustained pain relief, which he credited with aiding in his recovery from alcohol dependence.

Approximately 10 months post-procedure, the pain began to return, and the patient received another xiphoid injection with lidocaine and methylprednisolone. About one year after the initial procedure, the patient underwent a second pulsed RFA to the xiphoid process and has since (more than 12 months to date) remained free of xyphisternal pain (see Figure 1).

Discussion

Among the musculoskeletal etiologies of chest pain, xiphodynia may be considered in patients who are refractory to other treatments. As noted, diagnosis of xiphodynia may be made based on physical exam showing marked tenderness to palpation of the xiphoid process, with potential referral of pain to the chest, abdomen, throat, arms, or head.2

For the patient herein, injection was transiently therapeutic and, after exclusion of other pathology, a diagnosis of xiphodynia was made when taking into account the findings of tenderness to palpation in the region. The onset of this pain may be associated with a previous trauma to, or near, the xyphisternal region.

Yapici Ugurlar, et al, posited that repeated microtrauma may result in stress fractures, further bone formations, and xiphoid protrusion and pain.7 It is possible that such restructuring can explain the characteristically reproducible pain at the xiphoid process. While the mechanism of action is not fully understood, it is thought that pulsed RFA may exert its analgesic effects through a temperature-independent pathway involving a rapidly alternating electrical field.8

Based on a review of the literature, this case appears to be the first of its kind to report on the use of pulsed RFA for xiphodynia. The approach may induce a more effective and long-term relief of pain than conventional methods of treatment for xiphodynia. For this reason, we believe medical providers should consider pulsed radiofrequency ablation for those presenting with xiphodynia when other treatments are found to be ineffective.

Last updated on: May 3, 2019
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The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain
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