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8 Articles in Volume 5, Issue #2
Considerations in Treating Intractable Pain
Hospice Care Evolution
Myofascial Elements of Low Back Pain
Radiofrequency Neuroablation in Chronic Low Back Pain
State Pain Laws: A Case for Intractable Pain Centers Part III
Temporomandibular Joint Referred Pain
The ABC’s of Pain
Therapies for Chronic Pain and Fibromyalgia

Radiofrequency Neuroablation in Chronic Low Back Pain

This retrospective study of pain outcomes for radiofrequency neuroablation patients confirms the viability of this modality where conservative, traditional treatments for chronic low back pain have failed.

Clinicians and health care administrators are all acutely familiar with the impact that low back (LBP) has on quality of life, worker productivity and the workers’ compensation system. Numerous studies report the economic impact of LBP to be in the excess of $100 billion dollars. Additional studies suggest that LBP will effect nearly 80% of the population at some point in life.

Pain that persists despite routine medical management poses a difficult problem for patients and their treating physicians. When pain continues despite medical care, there is an increasing probability of physical disability, psychosocial dysfunction, drug dependence, and development of chronic pain.

Recent advances in technology, along with new understanding of the anatomy and Physiology of pain, make it possible to accurately diagnose and effectively treat pain previously thought untreatable. In the area of spinal pain for instance, spinal patho-physiology has allowed for a variety of new diagnostic and therapeutic interventions into low back pain, radiculopathy, neck pain and cervicogenic headache.

Etiology of Low Back Pain

Typically back pain may be precipitated by any of the following seven pain generators:

  1. Skin (e.g., shingles)
  2. Pathology of muscle and soft tissue with the possibility of myofacial pains, muscle ligament pains with strains
  3. Posterior complex pain emanating from the facet joint arthropatheis or spondylolisthesis with pars defects
  4. Medial complex or neuro origin pain from radiculopathy caused by either foraminal narrowing or neural encroachment from the herniated disc with radiculitis or a chemical radiculitis caused by a leakage of the nucleus pulposous
  5. Annulus tear and anterior complex pain emanating from possible degenerative or internally deranged disc disease
  6. Sacroiliac joint disease
  7. Back pain not specifically involving the spine may be related to some retro peritoneal masses or aortic aneurysm or sometimes renal mass or renal problems, thus intra-abdominal pathology needs to be ruled out

Radiofrequency Lesioning

Radiofrequency neuroablation, or lesioning, has recently been used successfully as a treatment for chronic, refractory neck pain from whiplash injury, a condition in which recent scientific research has identified spinal facet joints as commonly responsible for persistent pain. Facet joints may also be the source for pain in certain types of cervicogenic headache and in non-radicular low back pain. Facet pain can be identified by its characteristic pattern of radiation, and the diagnosis is confirmed when pain is relieved transiently with precise fluoroscopic nerve block of the facet joint nerves. Radiofrequency denervation is gaining acceptance as an effective treatment option with minimal risk and low morbidity when more conservative approaches fail to relieve symptomatic relief. It is also successfully used for neuro-ablation of the ganglia in sympathetically maintained pain syndromes.

This article reports on the outcomes of a group of patients with chronic low back pain who have undergone radiofrequency neuroblation in an urban hospital setting. One male patient underwent the procedure for chronic neck pain he experienced for at least one year.

Pain Relief Yes No
Number 30 9
Table 2. Pain relief reported following radiofrequency procedure.

Of the 77% of patients who reported pain relief following their radiofrequency procedure; 69% indicated that they were somewhat satisfied to very satisfied with the procedure, while 23% had no relief, and 31% were not satisfied. Following the procedure, 13% of patients reported that there were able to sit pain free for 10 minutes or less; 18% were able to sit up to 30 minutes; 67% were able to sit for one hour or more (one participant did not answer this portion of the questionnaire).

Gross evaluation in functional status following the radiofrequency procedure showed improvement in 59% of patients in terms of sitting, 62% in terms of standing, and 67% in terms of walking.


Lumbar spine pathology is certainly a common and sometimes difficult problem to treat. Low back disorders are the most common site of problems along the entire spinal axis. In understanding the proper use of radiofrequency lesions and the treatment of chronic pain emanating from the lumbar spine, it is important to understand the correct anatomy and pathoanatomy of the lumbar spine itself.2

Spinal Anatomy

From an anatomical viewpoint, the lumbar spine has several sources that are potential generators. There are specific areas that have been identified thru neuroanatomical dissections as containing pain fibers. The areas in the lumbar spine that can generate pain include the annulus of the disc, the posterior longitudinal ligament, portions of the dural lining, the facet joints and capsules, the spinal nerve roots and ganglion, and the associated paravertebral musculature.3-5 Specific radiofrequency techniques have been devised for the treatment of pain emanating from the facet joints, nerve roots, and annulus fibrosis. No specific techniques have yet been devised for the treatment of pain emanating from the dura or posterior longitudinal ligament and the use of radiofrequency techniques for the treatment of muscular (myofascial) pain is certainly not appropriate.

The lumbar facet joints receive innervation from multiple levels of the lumbar spine.3,4,6 However, there is no clear-cut, one-to-one innervation pattern of joint to nerve root level.

Hence, to properly deinnervate a lumbar facet joint (even in a partial fashion) multiple levels need to be lesioned. The lumbar facet joints derive their innervation from the medial branches of the posterior primary ramus.4 From the levels of L1 through L4 the medial branches of dorsal rami run across the top of the transverse process at their own level and go through the intertransverse ligament at the base of the transverse process. Each medial branch then runs across the periosteum at the junction of the base of the transverse process. The nerve then wraps around the medial aspect of the base of the superior articular process and at that point is covered by a relatively dense connective tissue called the mamilloaccessory ligament.4 Finally, the nerves cross the lamina and divide into several branches that supply the paraverebral musculature, interspinas muscles and ligaments, and two separate facet joints. For all practical purposes, each medial branch actually innervates the facet joint above and below its anatomical course.

Also, according to Bogduk and Twomey,4 the facet joint receives additional innervation ventrally from the dorsal ramus in front of the joint. Therefore, it is obvious that each facet joint receives multiple sources of innervation and therefore multiple sites of radiofrequency lesions need to be performed to partially deinnervate the facet joint itself. Understandably, the facet joints are richly endowed with adequate nerve fibers to provide proprioceptive and nociceptive information.


This study was designed to retrospectively determine the long-term outcome in a group of patients with functionally limiting chronic low back pain and who failed to respond to various conservative treatments. The patients in this study suffered from severe pain an average of three months to four years. Following the procedure, a significant portion of these patients achieved clinical, meaningful, and statistically significant improvement in pain and functional level. No clinical complications were observed among the 39 patients who responded to the survey.

Duration < 3 Months 3-6 Months 7 Mos. - 1 Year 1-2 Years
Number 7 4 3 15
Intensity (1-10) 1-3 4-6 7-10
Number 9 7 3
Table 3. Duration of pain relief for those reporting pain relief. Notes: One participant did not indicate the duration of pain relief. Eleven participants did not indicate the intensity of pain.
  Sitting Standing Walking
Pre Post Pre Post Pre Post
10 or less 33% (13) 13% (5) 64% (25) 46% (18) 64% (25) 38% (15)
Up to 30 26% (10) 18% (7) 28% (11) 13% (5) 23% (9) 15% (6)
1+ hours 36% (14) 67% (26) 5% (2) 33% (13) 8% (3) 41% (16)
No response 1 1 1 1 1 1
Table 3. Functional status pre- and post-procedure.

Based on the results of the present study, it is concluded that radiofrequency neuroablation is a safe and effective procedure for some patients suffering from chronic, functionally-limiting low back pain where conservative, traditional treatments have failed. Patient satisfaction is high (69%) and functional status improved among those patients who responded to the study. We believe these patients to be more motivated with respect to sampling bias and patient response. Whereas 30% of study participants did not respond to treatment, such factors as (a) total time to lesion, and (b) sensory stimulation level appear to have vital significance. The author posits that (a) time to temperature of


This retrospective study was compiled by Roger Williams II and Sophia Fernandez.

Last updated on: December 27, 2011
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