Radiofrequency Ablation (RFA) for Facet and Sacroiliac Joint Pain

Radiofrequency ablation (RFA), or radiofrequency neurotomy, is a type of injection procedure that is used to treat several conditions including chronic neck and/or back pain. In the neck and back, pain stemming from the vertebral facet joints or the hip’s sacroiliac joints or the posterior pelvis may be treated using RFA.

RFA involves heating a part of the pain-transmitting nerve with a radiofrequency needle to create a heat lesion. This resulting lesion prevents the nerve from sending pain signals to the brain.

Goals of Radiofrequency Ablation

The goals of treating facet and sacroiliac joints with RFA are to:

• Reduce neck or back pain for longer periods of time, typically for more than 6 months.¹Senthelal S, Mesfin FB. Ablative Nerve Block. [Updated 2018 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499975/^,2McCormick ZL, Marshall B, Walker J, McCarthy R, Walega DR. Long-Term Function, Pain and Medication Use Outcomes of Radiofrequency Ablation for Lumbar Facet Syndrome. Int J Anesth Anesth. 2015;2(2):028.
• Improve neck and back function for more range of motion, which may allow the patient to continue with a physical therapy program.
• Reduce the intake of pain medications, which tend to have serious side effects or risks when used long term.
• Avoid or delay surgery, which could carry additional risks and a long recovery period.

Even if the pain is not completely eliminated, RFA may provide moderate pain-relief and restoration of function for daily movements.

Types of Radiofrequency Ablation

Three types or variations of RFA may be used to produce heat lesions on tissues and are discussed below.

• Conventional continuous radiofrequency (CRF) ablation uses a needle that delivers continuous high-voltage current to produce a heat lesion. The tip of the needle is heated between 140 to 176 degrees Fahrenheit.³Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep. 2008;12(1):37-41.
• Pulsed radiofrequency (PRF) ablation uses a needle that delivers short bursts of high-voltage current with silent phases in between when no current is passed. The needle is heated to approximately 107 degrees Fahrenheit in PRF.³Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep. 2008;12(1):37-41.
• Water-cooled radiofrequency (WCRF) ablation uses a specialized needle that is heated up to 140 degrees Fahrenheit but also cooled by a continuous flow of water. The water allows a regulated flow of current and also prevents the needle tip from being over-heated.⁴Malik K, Benzon HT, Walega D. Water-cooled radiofrequency: a neuroablative or a neuromodulatory modality with broader applications?. Case Rep Anesthesiol. 2011;2011:263101.

See Radiofrequency Ablation (RFA)

CRF and PRF produce well defined small lesions, while WCRF produces larger lesions involving larger tissue areas. All three types of RFA are used to treat facet and sacroiliac joint pain. The magnitudes of the heat lesions depend on the temperature and size of the needle, as well as the duration of the procedure.

When Radiofrequency Ablation Is Considered

Typically, RFA is performed after steroid, epidural, or other injection treatments are tried in the sacroiliac or facet joint’s nerves for treating pain symptoms. Medial branch RFA targets the facet joint nerves and lateral branch RFA targets the sacroiliac joint nerves in the posterior pelvis.

See Injections for Neck and Back Pain Relief

Medial and lateral branch RFA may be used to treat the following conditions:

• Neck and/or back pain caused due to vertebral or spinal conditions, such as spondylosis
• Cervicogenic headache
• Occipital neuralgia
• Sacroiliac joint or posterior pelvic pain

See Sacroiliac Joint Dysfunction (SI Joint Pain)

Before the RFA procedure, one or two lateral branch or medial branch diagnostic nerve blocks are performed to locate the target nerve. RFA is then performed on the confirmed nerve that responds to the diagnostic nerve block.

When Radiofrequency Ablation May Not be Performed

RFA is not done in the following conditions:

• Infection at the injection site
• Increased intracranial pressure (pressure within the head)¹Senthelal S, Mesfin FB. Ablative Nerve Block. [Updated 2018 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499975/^,5Wray JK, Walls AL. Radiofrequency Ablation. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482387/

Additionally, RFA may not be performed in patients who are allergic to local anesthetics.

Radiofrequency Ablation Success Rates

The success of RFA treatment has provided conflicting results. Success usually depends on the accuracy of diagnosis, variations in the anatomy of the nerve, and the type of technique used.⁶Anjana Reddy VS, Sharma C, Chang KY, Mehta V. 'Simplicity' radiofrequency neurotomy of sacroiliac joint: a real life 1-year follow-up UK data. Br J Pain. 2016;10(2):90-9. Some patients have reported up to 100% reduction in pain from RFA. Research suggests:

• RFA performed for the facet joint may provide pain relief in 45% to 60% of patients.²McCormick ZL, Marshall B, Walker J, McCarthy R, Walega DR. Long-Term Function, Pain and Medication Use Outcomes of Radiofrequency Ablation for Lumbar Facet Syndrome. Int J Anesth Anesth. 2015;2(2):028.^,7Perolat R, Kastler A, Nicot B, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018;9(5):773-789.
• RFA performed for the sacroiliac joint may provide pain relief in 75% to 86% of patients.⁶Anjana Reddy VS, Sharma C, Chang KY, Mehta V. 'Simplicity' radiofrequency neurotomy of sacroiliac joint: a real life 1-year follow-up UK data. Br J Pain. 2016;10(2):90-9.^,8Choi W-S, Kim J-S, Ryu K-S, Hur J-W, Seong J-H, Cho H-J. Endoscopic Radiofrequency Ablation of the Sacroiliac Joint Complex in the Treatment of Chronic Low Back Pain: A Preliminary Study of Feasibility and Efficacy of a Novel Technique. BioMed Research International. 2016;2016:1-8. doi:10.1155/2016/2834259

Typically, if effective, RFA may provide pain relief lasting 6 months up to 2 years. However, some studies have shown patients experiencing pain relief up to 3 years.¹Senthelal S, Mesfin FB. Ablative Nerve Block. [Updated 2018 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499975/^,2McCormick ZL, Marshall B, Walker J, McCarthy R, Walega DR. Long-Term Function, Pain and Medication Use Outcomes of Radiofrequency Ablation for Lumbar Facet Syndrome. Int J Anesth Anesth. 2015;2(2):028. During or after this period of time, however, the nerve usually regenerates, and the pain may or may not return. The pain relief from this treatment is usually more significant when performed on the facet joints as compared to the sacroiliac joints. Some patients may not experience any relief from pain after this procedure.

Repeated RFA may provide longer relief

If pain relief is achieved with initial treatment, repeated RFA may be performed when the symptoms return. Studies show repeated RFA may provide pain relief in 85% of patients up to 10 months.⁹Son JH, Kim SD, Kim SH, Lim DJ, Park JY. The efficacy of repeated radiofrequency medial branch neurotomy for lumbar facet syndrome. J Korean Neurosurg Soc. 2010;48(3):240-3.