1) The document discusses various techniques for radiofrequency treatment of sacroiliac joint and discogenic pain, including cooled radiofrequency denervation of sacral lateral branches and dorsal rami, as well as intradiscal biacuplasty. 2) Studies show cooled radiofrequency denervation provides 50-79% pain relief in 57-64% of patients with sacroiliac joint pain at 3-6 month follow-up. Intradiscal biacuplasty uses internally cooled bipolar radiofrequency to heat the posterior disc annulus to 55-60°C to treat discogenic pain. 3) The techniques aim to denervate pain fibers while monitoring temperature to avoid excessive

1. Coolief: Radiofrequency treatment for sacroilitis,
Discogenic pain and thoracic facet denervation
Leonardo Kapural, MD, PhD
Carolinas Pain Institute and Center for Clinical Research
Professor of Anesthesiology, Wake Forest University School of Medicine

2. Chronic sacroiliac joint pain: The problem
• 217 pts- pain below L5
• Twice positive (>75% relief) SIJ blocks
• Prevalence of SIJ pain was 10-20%
• (Schwarzer 1995, Maigne 1996)
• 74 patients-persistent lower back pain after LS fusion, SIJ-
pain source in 32% (single SIJ injection)
• (Katz 2005, Maigne 2005)
Maigne (1996) Spine 21:1889.
Schwarzer (1995) Spine 20:31-37.
Katz (2003) J Spinal Disorders 16;96-99.
Maigne (2005) Euro Spine J 14;654-658

3. Functional impairment
• Comparable to patients with chronic radiculopathy:
• Retrospective
• SF-36 scores- SIJ pain vs lumbar radiculopathy
• No true difference exists
Cheng (2006) Reg Anesth Pain Med;31:422-427

4. SIJ Innervation Studies
• Ikeda (1991) 18 Japanese cadavers
• Ventral surface innervated by VR of L5-S2 or
branches from the sacral plexus.
• Dorsal surface innervated by the L5 DR and S1-4
lateral branches
• (Ikeda, J Nippon Med School, 58:587,1991)

5. SIJ Innervation Studies
• Willard (1991) 10 cadavers.
• S1 and S2 lateral branches primarily innervate the SIJ and
associated dorsal ligaments, occasional contributions from
S3 but not S4.
• (Willard. Third World Congress on Low Back and Pelvic Pain.
Vienna, Austria, November, 1998)

6. S1-4 Dorsal
Rami and
Divisions
Dr. Frank
Willard
Midline
PSIS
S1
S2
S3
S4
Left
LDSI
lig.
Interforaminal
neural arcade
Lateral
branches

7. • Joint is predominantly,
innervated by posterior primary
rami1,3,4
• Nerve location is variable: 2,5
– Person to Person
– Side to Side
– Level to Level
• Nerves may run along bone, or
up to 8 mm superficial from the
sacrum 5
SI Joint Innervation
Yin W, Willard F, Carreiro J, Dreyfuss P (2003)
Spine 28:2419-2425. Images reprinted with
permission of Lippincott Williams, 2007.
• 1
Cohen S. Anesth Analg. 2005: 101: 1440-1453;
• 2
Yin W. et al. Spine. 2003; 28(20):2419-2425
• 3
Grob K. et al. Z Rheumatol. 1995;27:117-122;
• 4
Fortin J. et al. Spine. 1994;19(13):1475-1482

8. SI Joint Innervation
Yin W, Willard F, Carreiro J, Dreyfuss P (2003) Spine 28:2419-2425.
Images reprinted with permission of Lippincott Williams, 2007.
S
1
S
3
S
2

9. Present Standard for SIJ Diagnosis:
• Require dual positive (>80% relief) SIJ
injections (+/- steroid)
• Strongly consider excluding other anatomic
structures as pain generators (e.g. MBBs +/-
discography if MRI abnormal) before SIJ RFN

10. “Leapfrog” Technique for SIJ RF
• Retrospective study on 30 patients who
underwent 50 RF denervations of the joint
• Lesions made in the postero-inferior
aspect of joint by ‘leapfrogging’ RF probe
at < 1cm intervals
• 12 of 33 patients (36.4%) obtained > 50%
pain for at least 6 months (mean duration
of pain relief 12+/- 1.2 months)
• Ferrante et al. Reg Anesth Pain Med
2001

11. Sensory Stimulation-Guided SI Joint Radiofrequency Neurotomy
• Retrospective study in 14 patients who
obtained > 70% relief following 2 SIJ deep
interosseous ligamentous injections
• All pts had L5 dorsal ramus and S1 lateral
branch lesioned. 11 pts had S2 and 6 S3
lateral branch lesioned
• 64% of pts obtained > 50% pain relief @ 6
months, with 36% achieving complete relief
• Yin et al. Spine 2003

12. Bipolar “Strip” Lesion
• 9 pts with a “bipolar strip”
lesion at lateral dorsal foramina
+ conventional monopolar
lesion of L5 dorsal ramus
• 33% with >50% pain relief
and decreased analgesic
requirements for 12-month
follow up
Burnham RS and Yasui Y. Reg Anesth
Pain Med 2007; 32:12-19
08/19/15 28

13. Bipolar disadvantage?
• Tissue along the sacrum is inhomogeneous- dense fibrous
tissue, (ligament, fascia), muscle, fat etc.
• Different tissues respond differently to RF energy.
• One type of tissue may heat up quickly, while another will
require more power to reach temperature
• Can cooled RF be better, because generator controls the
rate of cooling to each probe, thereby regulating
temperature independent of energy delivered.

14. Physics of Cooled RF
Modified from 8. Goldberg SN, Gazelle GS, Mueller PR.. AJR Am J Roentgenol 2000;174:323-31.

15. Physics of Cooled RF

16. Physics of Cooled RF
Modified from 8. Goldberg SN, Gazelle GS, Mueller PR.. AJR Am J Roentgenol 2000;174:323-31.

17. Physics of Cooled RF
• Internal cooling and a small
active tip size act to project
the lesion distally in a
controlled manner
• Uniform lesions can be
produced in non-
homogeneous tissue (e.g. into
grooves, ligaments, fascia)
Standard 18G cannula
18 g cooled probe

18. Sacroiliac RF Lesion Requirements
• Level L5
– Lesion the primary dorsal
ramus at sacral ala
• Level S1, S2, S3
– Lesion all lateral branches as
they exit foramen

19. Procedure
•C-arm to visualize AP Sacrum
(adequate cranial tilt to open
L5S1)
•Local/IV sedation. No GA.
Optional Bowel prep

21. 2:30
lesion

22. 2:30
lesion

23. 4:00
lesion

24. 5:30
lesion

25. Repeat
2:30, 4 and
5:30 lesions
At S2
2:30 and
4:00 lesions
At S3

27. Procedure
•Place RF probe through
introducer (extends 4 mm
beyond tip of introducer = 2 mm
off bone)
•Lateral fluoroscopy to assure
not in canal
•Verify impedance 100 - 500
ohms

29. Sinergy Clinical Outcome Data
• Report of preliminary trial – Kapural (Pain Practice
2008)
• RCT Cohen (Anesthesiology 2008)
• RCT Patel & Gross (Pain Medicine 2012)
• Clinical case series – Stelzer (ESRA 2011)
• Kapural L., Nageeb F., Kapural M., Cata J., Narouze S., Mekhail N., Cooled Radiofrequency System
for the Treatment of Chronic Pain from Sacroiliitis. Pain Practice (2008) 8;5:348-354.
• Cohen SP, Dragovich A, Hurley RW, Buckenmaier CC, Morlando B, Kurihara C. Randomized
Placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint
pain. Anesthesiology 2008; 109(2): 279–88.
• Patel N, Gross J, Brown L, Gehkt G. A double blind, randomized, placebo-controlled trial of lateral
branch denervation as a treatment for sacroiliac joint pain using Sinergy system. Pain Medicine
2012 (online preview).
• Stelzer W., Wagner H, Aiglesberger M, Stelzer D, Stelzer V. Use of Cooled Radiofrequency Lateral
Branch Neurotomy for the treatment of Sacroiliac Joint Mediated Low Back Pain: A Large Case
Series. ESRA. September 2011 (Dresden, Germany).

30. Our data (Kapural et al., 2008)

31. Cohen Results
Percentage of Patients with Positive Outcomes: Reduction in
Pain Severity, Pain Related Disabiltiy and Opiod Use
0 %0 %
14 %
57 %
64 %
79 %
0
10
20
30
40
50
60
70
80
90
100
1 month 3 month 6 month
Post Procedure Follow-up
%Patients
Sham
Cooled-RF
• 79%, 64%, and 57% of treated patients experienced statistically significant positive outcomes at
1, 3 and 6 month post procedure, respectively.

32. Cohen Results
Mean Pain Severity: Visual Analogue Scale (VAS)
*
0
1
2
3
4
5
6
7
8
9
10
baseline 1 month 3 months 6 months
Post Procedure Follow-up
VAS
Sham
Cooled-RF
• Mean pain severity as measured by the VAS showed a clinically meaningful improvement‡
at 6
months follow-up (6 to 2.6 points) for the Cooled-RF group
• The sham group did not show an improvement from baseline in VAS at 3 month follow-up (6.4
to 6 points)

33. Lateral Branch Denervation vs. Sham
• Patients randomized
2:1 to treatment and
sham groups*
• Patient and assessors
blinded
– Equipment sounds, procedure
duration and visual indications
identical in both groups
• Study outcomes:
NRS, ODI, SF-36,
GPE
• Treatment Success:
– ≥50% decrease is VAS
corroborated by one of: i) 10-point
improvement in ODI, or ii) 10-
point improvement in SF-36BP
Treatment Group
(n=34)
Sham Group
(n=17)
Cross-Over Group
Unblinding
*12 month data currently being

34. Treatment Success
Time-Point Group
Treatment
(n=30)
Sham
(n=12)
p-value
3-Months 50% (31-69%) 8% (0-38%) .012
6-Months 40% (23-59%) ---
9-Months 60% (41-77%) ---
- A significantly greater proportion of subjects in the treatment group (50%;
95%CI 31-69%) as compared to the sham group (8%; 95%CI 0-38%) had a
successful treatment outcome at 3-months (p=0.012)*
- Treatment success rate was durable at 6-months and 9-months
Treatment Success defined as:
≥50% decrease is VAS corroborated by one of: i) 10-point improvement in ODI, or
ii) 10-point improvement in SF-36BP
•Patel N, Gross J, Brown L, Gehkt G. A double blind, randomized, placebo-controlled trial of lateral
branch denervation as a treatment for sacroiliac joint pain using Sinergy system. Pain Medicine 2012
(online preview).

35. SF-36PF
Outcome Measure Mean SD Mean SD p Value*
SF-36 Physical Functioning (0-
100)
Treatment
(n=27)
Sham
(n=11)
3-months change 17 19 2 11 .020
6-months change 16 21 --- --- ---
9-months change 21 20 --- --- ---
- A significantly greater improvement in SF-36PF seen in treatment group
(17±19) compared to sham (2±11) at 3-months follow-up (p = 0.020)
-Mean treatment SF-36PF score was durable at 6-months and 9-months
•Patel N, Gross J, Brown L, Gehkt G. A double blind, randomized, placebo-controlled trial of lateral
branch denervation as a treatment for sacroiliac joint pain using Sinergy system. Pain Medicine 2012
(online preview).

36. ODI
Outcome Measure Mean SD Mean SD p Value*
Oswestry Disability Scale
(0-100)
Treatment
(n=27)
Sham
(n=10)
3-months change -12 18 0 7 .034
6-months change -14 17 --- --- ---
9-months change -16 18 --- --- ---
- A significantly greater improvement in ODI seen in treatment group (-12±18) as
compared to the sham group (0±7) at 3-months follow-up (p = 0.034)
-Mean treatment ODI score was durable at 6-months and 9-months
•Patel N, Gross J, Brown L, Gehkt G. A double blind, randomized, placebo-controlled trial of lateral
branch denervation as a treatment for sacroiliac joint pain using Sinergy system. Pain Medicine 2012
(online preview).

37. Stelzer Clinical Series
• Retrospective chart review
• n=126
• Inclusion criteria
• Outcome measures: VAS, QOL, medication usage

38. Steltzer: Sinergy Clinical Series

39. Steltzer: Sinergy Clinical Series

40. DR L5; Kapural et al; Pain Medicine 2010
Kapural L, Sessler DI, Stojanovic PM, Bensitel T, Zovkic P. Cooled Radiofrequency (RF) of L5 dorsal
ramus for RF denervation of the sacroiliac joint: technical report. Pain Medicine 2010;11(1):53-57.

42. Max. Insertion depth
L5/S1 z-joint space

43. Probe is 2mm off bone for distal
lesion projection

44. DR L5
• Kapural et al, Pain Medicine, 2010

45. Summary
• SIJ Radiofrequency provides for anatomic RF lesioning of the
dorsal innervation of the SIJ
• No significant complications from various approaches reported
to date
• Efficacy and duration of Synergy effect demonstrated in two
RCT’s.

46. Intradiscal Biacuplasty-Technique and Data
Leonardo Kapural, MD, PhD
Carolinas Pain Institute and Center for Clinical Research
Professor of Anesthesiology, Wake Forest University School of Medicine

48. Possible Scenario
Loss of Nuclear
Hydrostatic Pressure
Delamination Fissuring
Microfracutures
of collagen fibrils
Sensitization of Nonciceptors
PLA2, NO, IL1
Repetitive stimulation
of DRG
Saal and Saal,2002; Ozaktay et al., 1998; Schwartzer et al., 1995

49. Possible algorithm (Kapural and Deer, 2011)
Kapural L, Deer T. Radiofrequency and other heat applications for the treatment of discogenic pain.
Eds. Kapural L, Kim P. Diagnosis, Management and Treatment of Discogenic Pain. Interventional and
Neuromodulatory Techniques for Pain Management Series Vol3. Elsevier, Philadelphia, PA 2011, pp
80-87

50. Provocative discography
• To date, provocation discography is the only available method
of linking the morphologic abnormalities seen on MRI with
clinically observed pain…..
• Kapural L. Lumbosacral internal disc disruption syndrome: Therapeutic intradiscal
procedures. Interventional Spine Care, ed. Brian De Palma, 2010

51. • Radiofrequency current is concentrated
between electrodes on two straight probes.
• The electrodes are internally cooled allowing
deep, even heating and eliminating tissue
adherence.
• Temperature sensors allow monitoring at
the electrode tips and disc periphery.
• The ideal temperature profile is 55-60°C in
the inner posterior disc decreasing to 45°C
in the peripheral edge of the posterior disc.
Biacuplasty

52. Temperatures monitoring at designated safety zones outside the disc
demonstrated maintenance of near-physiologic conditions while
temperature across the posterior annuls reached 65°C
Petersohn J et al. 2008 Pain Medicine (9): 26-32
In vivo Testing in Porcine Model

53. Biacuplasty study
using explanted
human lumbar
spines.
Cadaver Study
Kapural et al. 2008 Pain Medicine (9): 68-75

54. Cadaver Study
Kapural et al. 2008 Pain Medicine (9): 68-75

55. Kapural et al. 2008 Pain Medicine (9): 60-67
TransDiscal System During Procedure

58. Acceptable angle
• Approach Angle is adjusted to
45° from the median
• Increased approach angle
brings probes close enough to
create a confluent lesion
• Set temperature is adjusted to
50 °C
• Following the bipolar lesion,
monopolar lesions are created
around each electrode to
lesion the posterior-lateral
aspect of each disc.
75
• 45° approach angle
45°
<3cm

63. Statistics
Median [Quartiles]
Outcome Baseline 12 Month Difference† % Difference†
P-
Value*
SF-36 Bodily Pain 35 [33, 45] 58 [45, 78] 10 [13, 35] 37 [15, 78] 0.016
SF-36 Physical
Functioning 55 [40, 60] 75 [50, 95] 10 [-5, 35] 17 [-6, 73] 0.09
Oswestry Score 25 [17, 29] 17 [10, 24] -4 [-9, 1] -13 [-64, 6] 0.07
VAS Pain Score 7 [ 6, 8] 4 [ 1, 6] -4 [-5, -1] -44 [-86, -14] 0.003
Opioid Use 40 [40, 120] 0 [ 0, 20] -40 [-50, -20] -100 [-100, -62] < 0.001
† Differences from baseline to 12 months.
* Wilcoxon signed rank test of percent difference equal to 0.
Kapural L. Intervertebral Disc Cooled Bipolar Radiofrequency (Intradiscal Biacuplasty) for the Treatment of Lumbar
Discogenic Pain: a 12 month follow-up of the pilot study. Pain Medicine 2008;8(4):464.

64. Randomized Control Trial (Kapural et al, 2013)
1830 Excluded
1771 Did not meet clinical inclusion criteria
36 Skipped enrollment appointment
23 Declined to be randomized or comply with protocol
Treatment Group Sham Group
Unblinding 6 month follow-up (n=28)
64 Enrolled
1 month follow-up (n=27)
3 month follow-up (n=27)
6 month follow-up (n=27)
3 subjects chose not to
receive active treatment
3 month follow-up (n=30)
1 month follow-up (n=30)
2 subjects censored from analysis:
1 early drop out (no follow-up data
obtained)
1 breach of eligibility criteria
2 dropped-out (included
in analysis)
30 received sham treatment29 received IDB
25 subjects received active
treatment
32 Allocated to receive IDB 32 Allocated to receive sham
2 Excluded before treatment:
2 breached eligibility criteria
1894 Inquiries
3 Excluded before treatment:
1 declined to undergo procedure
2 breached eligibility criteria
Kapural, L., Vrooman, B., Sarwar, S., Krizanac-Bengez, L., Rauck, R., Gilmore, C., North, J., Girgis, G. and
Mekhail, N. (2012), A Randomized, Placebo-Controlled Trial of Transdiscal Radiofrequency, Biacuplasty for
Treatment of Discogenic Lower Back Pain. Pain Medicine. doi: 10.1111/pme.12023

65. IDB Sham
Outcome Measure Mean SD Mean SD p Value
SF-36 Physical Functioning (0-100) n=27 n=30
Baseline 47.04 20.30 46.03 19.30 .849
1-month 50.68 20.03 46.61 20.60 .458
3-months 57.17 20.32 48.00 22.95 .118
6-months 62.04 21.89 48.67 22.97 .029
NRS for pain (0-10) n=27 n=29
Baseline 7.13 1.61 7.18 1.98 .912
1-month 5.31 2.04 5.72 2.29 .486
3-months 4.94 2.05 5.98 2.36 .083
6-months 4.94 2.15 6.58 2.11 .006
Oswestry Disability Scale (0-100) n=27 n=30
Baseline 40.37 12.30 40.93 13.56 .871
1-month 40.85 13.36 39.85 17.03 .807
3-months 37.43 16.65 40.44 16.21 .493
6-months 32.94 16.14 41.17 13.94 .037

66. 1 level (n=16) 2 levels (n=11)
Outcome Measure Mean SD Mean SD p Value
SF-36 Physical Functioning (0-100)
Baseline 48.75 17.08 44.55 24.95 0.607
6-months 66.88 18.34 55.00 25.50 0.171
6-months change 18.13 15.37 10.45 18.23 0.248
NRS for pain (0-10)
Baseline 7.47 1.45 6.64 1.76 0.191
6-months 4.69 2.38 5.32 1.81 0.465
6-months change -2.78 2.59 -1.32 1.95 0.126
Oswestry Disability Scale (0-100)
Baseline 38.88 8.48 42.55 16.64 0.457
6-months 28.88 13.04 38.85 18.90 0.116
6-months change -10.00 8.91 -3.70 10.99 0.113
Kapural, L., Vrooman, B., Sarwar, S., Krizanac-Bengez, L., Rauck, R., Gilmore, C., North, J., Girgis, G. and Mekhail, N. (2012),
A Randomized, Placebo-Controlled Trial of Transdiscal Radiofrequency, Biacuplasty for Treatment of Discogenic Lower Back
Pain. Pain Medicine. doi: 10.1111/pme.12023

67. Treatment patients
SF (PF) and NRS at all time points (Kapural et al, in preparation)
Per protocol Mean PF ∆ PF
Mean SD ∆ SD
Baseline (n=27) 47.04 20.30
1 month (n=26) 50.68 20.03 2.99 21.43
3 month (n=26) 58.27 19.90 11.57 15.35
6 month (n=27) 62.04 21.89 15.00 16.70
9 month (n=22) 64.55 23.45 17.27 18.43
12 month (n=22) 68.86 19.33 21.59 20.26
Per protocol Mean NRS ∆ NRS
Mean SD ∆ SD
Baseline (n=27) 7.13 1.61
1 month (n=26) 5.31 2.04 -1.79 2.44
3 month (n=24) 5.06 2.01 -1.98 2.16
6 month (n=25) 4.90 2.23 -2.18 2.47
9 month (n=22) 4.59 2.28 -2.70 2.49
12 month (n=22) 4.40 2.56 -2.90 2.56

68. Treatment patients
ODI and Opioids at all time points (Kapural et al, in preparation)
Per protocol Mean ODI ∆ ODI
Mean SD ∆ SD
Baseline (n=27) 40.37 12.30
1 month (n=27) 40.85 13.36 0.48 10.19
3 month (n=26) 36.41 16.10 -3.74 10.89
6 month (n=27) 32.94 16.14 -7.43 10.11
9 month (n=22) 31.81 15.66 -7.65 9.93
12 month (n=22) 32.44 16.13 -7.01 10.92
Per protocol Mean Opioids ∆ Opioids
Mean SD ∆ SD
Baseline (n=27) 52.47 49.58
1 month (n=27) 47.94 46.86 -4.54 32.14
3 month (n=27) 44.65 47.21 -7.82 34.05
6 month (n=27) 36.87 40.56 -15.60 46.75
9 month (n=20) 26.80 35.28 -20.10 47.06
12 month (n=17) 34.07 47.44 -15.37 54.46

70. Summary
•Biacuplasty is an effective minimally invasive alternative for
treatment of lumbar discogenic back pain
•Strict selection criteria improves results of biacuplasty
•Postprocedurally an optimal rehabilitation step-by-step
program is required to ascertain a good outcome
•Patients with increased body mass index, a smoking habit,
and multilevel degenerative disk disease have less chance to
improve long term
•Based on currently available data, such minimally invasive
approach more efficacious than any surgery

71. Thank youThank you
lkapural@ccrpain.comlkapural@ccrpain.com

72. Treatment of Chronic Thoracic Facet Pain

73. Prevalence
• The z-joint may be a source of pain in 34-48% of
patients with chronic thoracic pain
• “Pain in the thoracic region is a common
complaint which can be as disabling as cervical
or lumbar pain.” (Edmondson and Singer, 1997)
Manchikanti et al. Pain Physician 2002;5:354-359
Manchikanti et al. BMC Musculoskelet Disord 2004;5:15
Manchukonda et al. J Spinal Disord Tech 2007; 20:539-545
Edmondson SJ, Singer KP. Man Ther 1997; 2:132-143.

74. Dorsal Rami in Transverse Space
• Initially, each dorsal
ramus passes through an
osseofibrous canal, and
dorsally to enter the
transverse space.
• Within intertransverse
space, dorsal ramus
travels 1-2 mm before
dividing into lateral and
medial branches. Posterior right
Transverse Process
Medial Branch
Thoracic
Dorsal
Ramus Lateral Branch
Transverse Process
Adapted from Fig 2.8 of Chua Thesis 1994

75. Medial Branches of Dorsal Rami
• The medial branch innervates:
-Z-joint joint
-Multifidus
-Spinalis thoracis, splenius cervicis, rhomboids
and trapezius (upper levels only)
• The medial branch follows a general path which
displays certain level of variability between
individuals, and between different levels in the
same individual

76. Variations in MB Path
• There are many variations of the general
path for the thoracic medial branch.
- Variations observed in individuals between
different levels, and sides.
- Variations also observed between
individuals.
- Regions display a distinct MB innervation
pattern:
• T1-T4, T9-T10 • T5 -T8
• T11
Fig 2.18 of Chua Thesis 1994

77. 
Significant overlap exists between thoracic segmental pain referral patternsSignificant overlap exists between thoracic segmental pain referral patterns
Adapted from Dreyfuss et al., Spine 1994;19(7):807-11 (Fig.3) and Fukui et al., Reg Anesth 1997;22(4):332-6 (Fig.1,2).
Thoracic Zygapophysial Pain Pattern

78. Study Method Patients Result
Tzaan and
Tasker
Can. J. Neuro. Sci.
2000, 27(2): 125-30
Retrospective: 1983-
1994
Medial branch RF
neurotomy,
including thoracic
118 procedures; 90
patients
Diagnosis: local
anesthetic block
(>50% pain reduction)
40% had >50%
pain relief
Mean follow-up
5.6 months
Stolker et al.
Acta Neurochir
(Wien) 1993, 122:
82-90
Retrospective
Thoracic RF
neurotomy
40 patients
Diagnosis: medial
branch block (>50%
pain reduction)
83% had >50%
pain relief
36 month follow-
up
Treatment with Conventional RF

79. • Level of evidence supporting thoracic RF neurotomy is
inconclusive
- Conventional RF lesion size is not adequate to encompass the
variability of the thoracic medial branch nerve path
• Local anesthetic injections provided to patients in absence of
a more effective option
- Medial branch blocks with long acting local anesthetic effective for
15-17 weeks (Manchikanti et al. Pain Physician. 2008;11(4):491-
504)
Current Treatment

80. Step 1: Position C-arm in AP; locate treatment level
AP View

81. Costotranverse joint
lucency to the right
of the needle
Oblique View
Step 2: Rotate C-arm ipsilateral oblique until the
costotransverse joint lucency comes into view

82. Skin
insertion
point
Oblique View
Step 3: Insert Introducer at inferolateral aspect of
costotransverse joint lucency level

83. Land on bone at
superomedial
aspect of joint
lucency
target
insertion
Oblique View
Step 4: Advance Introducer to superomedial aspect of
costotransverse joint lucency

84. Oblique View
Step 5: Position C-arm in AP and walk stylet up to superior
margin of transverse process

85. Ensure radiopaque
marker is at
superior margin of
transverse process
Oblique View
Step 6: Replace stylet with probe

86. Lateral View
Step 7: Confirm depth on lateral

87. Step 9: Create Cooled RF lesion
AP View
Set Temp = 60°C
Duration = 2:30 min
Ramp = 80°C/min

88. • Lateral to medial approach directs introducer tip towards
vertebral body
• Ipsilateral oblique placement constrains lesion to
superolateral aspect of transverse process
• Straightforward imaging aids in identifying transverse
process
• Large, spherical lesion targets variability of nerve path
• One introducer insertion reduces iatrogenic injury to the
patient
Procedure Summary

89. Study of temperature distribution of a novel mono-polar cooled-
radiofrequency heating system in human cadaver applied to the
thoracic medial branches of a human cadaver
N. Mekhail, M.D. Ph. D.; J. Cheng, M.D. Ph. D.
Pending Publication

90. 0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7
Radial Distance from Electrode (mm)
AverageMaximumTemperature(°C)
Neuroablative temperatures measured at 5 mm radius.
Cadaveric Temperature Study - Results

91. Description of a novel device, novel technique, in vivo
temperature study, and 8 patient 6-month outcomes
R. E. Wright, S. Brandt, K. Allen, J. Wolfson. Pending
Publication

92. Temperature in vivo
Distance from
Electrode (mm)
Temperature (°C)
3 71
4 57
5 55
6 47
8 39
23 37
• Neuroablative temperatures
are reached in the
intertransverse space 6 mm
from electrode (Smith, 1981)
• The zone of ablation measured
spans 58% of the
intertransverse space
• This zone encompasses the
volume of tissue through
which the medial branch is
known to travel
Smith HP et al. J Neurosurg. 1981;55(2):246-53

93. Six-Month Average VAS Pain Score
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
0 1 2 3 4 5 6
Months following treatment
AverageVASPainScore

94. • 7/8 (88%) >50% pain relief
• 4/8 (50%) >10 pt or >50% drop in ODI
• 8/8 (100%) >10 pt improvement in SF-36 BP
• 6/8 (75%) >10 pt drop in SF-36 PF
• 3/8 (38%) Meds reduced
• 8/8 (100%) Satisfied (positive GPE)
Prospective Trial: 6-month outcomes

95. Safety
•Survey of anatomy shows no
sensitive structures within target
area.
•Advancing introducer towards
Thoracic Safe Zone mitigates risk
of pleural puncture.
•Obtaining both AP and lateral
views confirms location of the
introducer tip.
Efficacy
• Large, spherical, Cooled-RF
lesion increases probability of
successful medial branch
ablation even with variability in
nerve path.
• Placement on bony landmark
(transverse process) provides
repeatability for procedure.
ThoraCool Advantage

96. New and upcoming Coolief Treatments
• Hip denervaton
• Knee denervation

97. Application to Hip Pain
Frequent causes of hip
pain:
•DJD
•AVN
•Labral tears
•FAI
•Tumor

98. Innervation of the hip joint is regionally specific:
• Anteromedial innervation supplied by the articular branches of the
obturator nerve or accessory obturator nerve
• Anterior hip joint capsule innervated by sensory articular branches of the
femoral nerve
• Posterior innervation supplied by articular branches derived from the
sciatic nerve
–Posteromedial hip joint capsule innervated by articular branches
from the nerves to the quadratus femoris muscle
–Posterolateral hip joint capsule innervated by articular branches from
the superior gluteal nerve.
Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of
the hip joint – An anatomical study. Surg Radiol Anat (1997)19; 371-375.

99. Neuroanatomy of the anterior hip joint
YESLocher, S et. Al. Radiologic anatomy of the obturator nerve
and its articular branches: Basis to develop a method of
radiofrequency denervation for hip joint pain. Pain Med 9(3)
Does RF lesioning of
articular branches succeed
in relieving hip pain?

100. New 2014 data on anatomic variants
• Dissected 7 cadaveric
hip joints
• Accessory obturator
nerve variant (blue)
• Obturator articular
branch variant (red) as
seen by Locher.
Franco CD, RD Menzies, JD Petersohn, A

101. Femoral articular branch innervation
• Innervation to the
anterosuperior aspect of the
hip is relatively constant
across the 11:30-12:30 clock
position.
• Two femoral articular
branches shown derived from
nerve to iliacus mm.
• Hypothetical RF lesions made
with Coolief™ RF probe at 12
o’clock position shown in gold.

102. Variation of obturator nerve innervation pattern
• The paths of the obturator
articular branch(es) vary across the
ischium – Two vertically adjacent
lesions are made with Coolief™ RF
probe over the ischium for reliable
denervation.
• An additional RF lesion shown
may be required to address
documented anatomic variation
(noted during diagnostic block)
where additional innervation to
anterior hip is provided by an
accessory obturator nerve.

103. Peripheral RF for Knee Pain
The knee joint is innervated by the articular branches of various nerves, including
the femoral, common peroneal, saphenous, tibial and obturator nerves.
Hirasawa Y, et al. Nerve Distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop
2000; 24:1-4.
The cutaneous and articular sensory innervation of the knee region is complex
and displays considerable variation.
Lund J, et al. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery:
preliminary results. Acta Anaesthesiol Scand 2011; 55: 14-19

104. 25 ga stainless steel wires
outline course of geniculate
nerves
Franco CD, RD Menzies, JD Petersohn, A Buvanendran,
LP Menzies – Manuscript in preparation 2014

105. • Supine position with ipsilateral knee elevated using
towels. Sterile prep and drape with strict aseptic
technique.
• True AP image of distal femur. Identify 2 target sites:
• Superior lateral geniculate nerve where the lateral
femoral shaft meets the epicondyle
• Superior medial geniculate nerve where the medial
femoral shaft meets the epicondyle
• Anesthetize skin and soft tissues with 1% Lidocaine.
At each target, advance 25 gauge needle using
“tunnel technique” until bony contact is made.
• Repeat using true AP image for proximal tibia.
Identify target for inferior medial geniculate nerve
where the medial tibial shaft meets the epicondyle
using technique above.
Geniculate Branch Diagnostic Block Technique

106. Optional lesion for the nerve from the rectus
intermedius supplying the subpatellar plexus.
• DO NOT block the inferior lateral geniculate
nerve! Lesioning this nerve will injure the
adjacent common peroneal nerve.
• Adjust c-arm fluoroscopy for lateral image
• Adjust needle tip to be half-way across diaphysis
before injecting 0.5-1.0 ml local anesthetic at
each site. Target is Midline femur about 2 cm
cephalad of the upper patellar border
Geniculate Branch Diagnostic Block Technique

107. Final probe positioning for RF
geniculate neurotomy

108. Coolief™ RF treatment for post-prosthetic knee pain

109. Thank youThank you
lkapural@ccrpain.comlkapural@ccrpain.com