Radiofrequency techniques in pain management

Radiofrequency techniques are minimally invasive procedures used to provide prolonged pain relief compared to local anaesthetic blocks and forms part of a multidisciplinary approach in managing chronic pain. A generator produces a high-frequency current that passes from an electrode to an earthing plate. The electromagnetic field created around the tip of the electrode then has an effect on the surrounding nervous tissue resulting in pain relief.     

Radiofrequency techniques in pain management

Radiofrequency techniques are commonly used in management of persistent pain. It involves application of high-frequency alternating current to the neuronal pathways. It is employed for both neuromodulation and neuroablative type procedures in interventional pain management. Technological advances have widened the scope of their use within clinical practice. The evidence base for both conventional and new technologies is accumulating. A clear understanding of the principles and technologies will enable the clinician to use it safely and effectively.     

Radiofrequency procedures in chronic pain

Radiofrequency current is simply a tool used for creating discrete thermal lesions in neural pathways in order to interrupt transmission. In pain medicine, radiofrequency lesions have been used to interrupt nociceptive pathways at various sites. This is a palliative treatment not without complications, so its use should be limited to those patients with cancer pain or chronic non-cancer pain for whom conservative non-surgical therapies have been ineffective or intolerable. With the development of alternatives such as intrathecal opioid infusion and neuromodulation technologies, the number of patients considered for neuroablative therapy may dwindle. Nevertheless, there is evidence that radiofrequency neurotomy has an important role in the management of trigeminal neuralgia, nerve root avulsion and spinal pain. In this chapter the evidence for efficacy and safety is reviewed and interrogated with special emphasis on the available randomized controlled trails and systematic review.     

射频热凝纤维环成形术治疗椎间盘源性腰痛

目的 观察射频热凝纤维环成形术治疗椎间盘源性腰痛的临床疗效。方法 2010-10-2012-10共采用射频热凝纤维环成形术治疗椎间盘源性腰痛患者65例。结果 术后VAS评分较术前有明显降低,差异有统计学意义（P〈0.01）,术后6个月和12个月评分较术后7 d无明显反弹（P〉0.05）。按照Mac Nab评分标准,12个月随访时优29例,良31例,可5例,总有效率100%,优良率92%。结论 射频热凝纤维环成形术是治疗椎间盘源性腰痛的有效、微创的方法。     

Radiofrequency lesioning techniques in the management of chronic pain

Radiofrequency lesioning is used in pain management as a means of denervating a painful structure by generating a thermal lesion within a sensory nerve or sensory pathway of the CNS. Radiofrequency lesioning apparatus uses a radiofrequency source to apply a current to an insulated needle with an exposed tip. A radiofrequency current applied to the needle causes a zone of heating around the uninsulated part of the needle. The tissue is heated not the needle, therefore the needle has to be placed adjacent and parallel to a nerve rather than perpendicular to it. Data from randomized trials or large open series support the use of radiofrequency lesioning in lumbar facet arthropathy, cervical facet arthropathy, trigeminal neuralgia, unilateral cancer pain (e.g. mesothelioma), segmental cancer pain, discogenic low back pain, and sympathetically mediated pain. The safety of percutaneous radiofrequency lesioning compares favourably with many of the techniques it has supplanted. However possible complications include unintentional nerve injury and peripheral and central neuropathic pain.     

Radiofrequency lesioning techniques in the management of chronic pain

Radiofrequency lesioning of nerves is a procedure that may be used to reduce certain kinds of chronic pain by preventing transmission of pain signals. It is a procedure in which a portion of nerve tissue is either heated by the application of current via an electrode to a temperature not exceeding 85°C alongside the nerve (this procedure is sometimes called radiofrequency ablation) or by using a pulsed current flow, the effect of which is thought to be due to an electrical field causing a change in cellular behaviour distal to the electrode (pulsed radiofrequency) as temperatures are controlled by a thermocouple to not exceed 45°C. These interventions cause a long-lasting interruption in that sensory nerve or pathway and potentially reduce pain in that area. Application of these techniques has been studied and shown to be of use in several areas. These include the zygapophysial (facet) joint, dorsal root ganglion, sacro-iliac joint, sympathetic nervous system and trigeminal ganglion. The most recent use of radiofrequency is ‘percutaneous nucleoplasty’ or Coblation™. This is an effective treatment for symptomatic intervertebral disc prolapse. Radiofrequency has many advantages, including a lesion size that can be accurately controlled and a recovery which is rapid and usually uneventful. This then allows the procedures to be performed as a day case. Patients need to be aware that this is not a curative procedure and it is of little use in those patients who have multiple pain sites. When used appropriately and after the patient has been shown to respond adequately to diagnostic blocks, radiofrequency and pulsed radiofrequency have been shown to be effective and worthwhile treatments.     

Economic implications of pain management

BACKGROUND: Economic issues in pain management affect the patient, the provider and society. This paper will review some of the data on the costs to society of chronic pain and its associated disability. It will also look at the costs to patient and provider of alternative economic models. Conceptual issues that underlie health care delivery and the attendant costs must be addressed if society is to gain control over runaway health care costs and reduce the economic burden of chronic pain and disability for the patient as well as the provider. METHODS: Literature review and synthesis. RESULTS: Chronic pain is the primary cause of health care consumption and disability in the working years. Multidisciplinary pain clinics have proven utility. Data on efficacy of most other kinds of care is lacking. Disability costs are related to conceptual inadequacies and the medicalization of post-industrial societies. CONCLUSION: To control inappropriate care and escalating costs, we must change concepts of pain and disability and the methods of funding both of these in relation to chronic pain. The outcome of the continuing struggle between the profession of medicine, the state and capitalists will determine how and whether pain management is a part of medical care.     

长期接受慢性疼痛治疗患者的围术期疼痛管理进展

背景 慢性疼痛患者往往长期接受一系列的治疗措施来控制疼痛,如因某种疾病要接受手术治疗时,这类患者的围术期疼痛管理是非常棘手的. 目的 了解不同慢性疼痛治疗措施下患者的围术期疼痛管理进展. 内容 分别阐述口服阿片药物、抗抑郁药、抗惊厥药,应用脊髓刺激器及鞘内药物输注系统等慢性疼痛治疗措施下患者的围术期疼痛管理策略.趋向 对长期接受慢性疼痛治疗患者的围术期疼痛管理的研究,将有助于提高这类患者在围术期的舒适度及安全度,加快术后康复.     

Treatment of hepatocellular carcinoma using percutaneous radiofrequency thermoablation: Results and outcomes in 56 patients

The aim of this study was to evaluate the efficacy of and tolerance for radiofrequency thermoablation (RFTA) in patients with hepatocellular carcinoma (HCC). From March 1999 to September 2001, a total of 56 patients (46 men and 10 women) whose mean age was 67.8 years (range 51 to 76 years) underwent RFTA for 71 HCCs at our institution. RFTA was carried out in 45 patients with one lesion less than 6 cm in diameter, in seven patients with two lesions less than 4 cm in diameter each, and in four patients with three lesions less than 3 cm in diameter each. The mean diameter of the lesions was 4.1 cm (range 0.8 to 6.0 cm). The etiology of the cirrhosis was alcoholism in 31 patients, post-hepatitis C in 19 patients, post-hepatitis B in four patients, and hemochromatosis in two patients. Forty-five patients were classified as Child stage A and 11 were Child stage B. No ascites, prothrombin time >60%, and platelet count <60,000/mm³ were needed. Two types of cooled needles were used depending on the size of the lesion (a needle 15 cm in length was used for 2 or 3 cm tumors, and a cluster of needles was used for tumors larger than 4 cm). Helical computed tomography was performed 8 weeks after treatment. The main criterion for a complete response was the presence of a hypodense lesion without contrast enhancement. Mean follow-up was 14 months. Complete tumor destruction was achieved in 50 (89.2%) of 56 patients after one session and in 52 (92.8%) of 56 after two sessions. Twelve months later, a complete response was confirmed in 45 patients (80.3%), four patients had a local recurrence and new liver nodules, and three patients had died (one of bone metastasis, one of acute alcoholic hepatitis, and one of bronchial carcinoma). Thirty-nine patients (69.6%) were still in complete remission 36 months later, and a new HCC had developed in six patients. At 36 months 49 of 56 patients were alive and 39 of 56 were free of disease. Patients with HCCs that developed following viral cirrhosis had a worse prognosis than those with HCCs that occurred after alcoholic cirrhosis (2-year survival, 57.7% vs. 77.7%; P = 0.0241). It was concluded that radiofrequency ablation is an effective treatment for HCC, although the prognosis is better in patients who develop HCC after alcoholic cirrhosis compared to those in whom HCC occurs after viral cirrhosis.     

Surgical techniques preventing chronic pain after Lichtenstein hernia repair: state-of-the-art vs daily practice in the Netherlands

Background Morbidity associated with open inguinal hernia repair (IH repair) mainly consists of chronic pain. The aim of this study was to identify possible disparities between state-of-the-art Lichtenstein repair, and its application in general practice. Methods A questionnaire was mailed to all surgeons and surgical residents (n = 1,374) in the Netherlands in February 2005. The objective was to determine the state of general practice with respect to technical steps during the Lichtenstein repair that are suggested to be involved in the development of chronic pain, as recently updated by Lichtenstein’s successor, Amid. Results More than half of the respondents do not act according to the Lichtenstein guidelines with respect to surgical steps that are suggested to be involved with the origin of chronic pain of somatic origin. Compliance with Amid’s guidelines with respect to the handling of the nerves is variable. Surgeons conducting high numbers of IH repair are more likely to operate according to the key principles of the state-of-the-art Lichtenstein repair. Conclusion There is a substantial disparity between the state-of-the-art Lichtenstein repair and its application in general practice with respect to steps that are suggested to play a role in the origin of chronic groin pain.     

Paediatric chronic pain

Many children and adolescents experience chronic pain at some point in their childhood. While the majority may be successfully supported by their local services, some may develop persistent pain-related functional disability that should prompt referral to a multidisciplinary paediatric pain service for assessment. These teams work with the family to provide a framework for promoting rehabilitation and restoration of function based on the biopsychosocial model. Mental health difficulties including psychological trauma are often a significant factor. Individualized therapeutic work is core to the pain management pathway. Medications and therapeutic injections are used less frequently in children compared to adult practice but may have a role in facilitating rehabilitation as part of a multidisciplinary approach.     

Application of cooled radiofrequency ablation in management of chronic joint pain

Radiofrequency ablation (RFA) is a minimally invasive neurotomy technique that can provide sensory ablation in patients with chronic pain. Cooled RFA, however, can create larger lesions compared with traditional RFA. Size of lesions plays a more important role in neurotomy of articular nerves where neural anatomy is not as predictable. We review the literature present about cooled radiofrequency neurotomy of articular branches of joints in patients with chronic pain of sacroiliac, hip, or knee joints. Sacroiliac joint pain is a significant etiology of low-back pain whereas low-back pain can be experienced by up to a third of the population. Chronic hip and knee pain can result in huge healthcare expenses as well as disability. The patients with chronic hip and knee pain might not be good candidates for arthroplasty surgeries because of their other comorbidities. Moreover, they might have persistent pain postoperatively. We also explain the technique used for neurotomy of articular branches in these joints.     

Neurosurgical techniques in the management of chronic pain

Neurosurgical treatment for pain can be classified into three categories: treatment of the cause, neuro-ablative techniques and neuromodulation. Treatment of the cause is exemplified by microvascular decompression for trigeminal neuralgia.     

Role of pain injection procedures in the management of chronic pain

The paper offers an overview of pain intervention procedures which are just one facet of a holistic approach to managing pain. They can have a therapeutic and/or diagnostic focus, at times being useful in terms of guiding the clinician to useful pointers to the source of pain, and at others allowing windows of opportunity of pain relief to allow the patient to engage with other modes of pain management such as physiotherapy or occupational therapy with a common goal of improving level of function. The paper explores the importance of managing patient expectations, providing clear patient information and acquiring appropriate patient consent. It provides a brief overview of different procedures, drugs and other modalities as well as imaging used in their delivery.     

Laparoscopy in the management of children with chronic recurrent abdominal pain.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to evaluate the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain. PATIENTS AND METHODS: Thirteen children with chronic recurrent abdominal pain were subjected to diagnostic laparoscopy. Ages varied from 10 to 17 years. There were six males and seven females. Abdominal pain was present from 3 weeks to 12 months (mean, 2 months). Extensive laboratory and imaging studies did not contribute to the diagnosis. In all patients, the pain was disabling and severe enough to warrant repeated visits to the pediatrician, emergency room visits, or hospital admissions, as well as absence from school. RESULTS: All children recovered uneventfully. Laparoscopic findings that identified the cause of abdominal pain were obtained in 12 of 13 patients. Laparoscopic appendectomy was done in all patients. There were no operative complications. One child presented three months later with incomplete small bowel obstruction, which resolved with conservative management. There were no other postoperative complications. Follow-up varied from six months to three years. Abdominal pain resolved in ten patients. One patient presented eight months later with biliary dyskinesia. She improved following laparoscopic cholecystectomy and later on sphincterotomy, but her pain has not yet completely resolved. One patient presented six months later with abdominal pain secondary to intestinal adhesions. Her pain completely resolved after laparoscopic lysis of adhesions. A third patient who developed lower abdominal pain six months after laparoscopy improved with conservative management and antibiotics for pelvic inflammatory disease. CONCLUSIONS: Diagnostic laparoscopy is a valuable procedure in the management of children with chronic recurrent abdominal pain. In the present study, laparoscopic examination revealed the cause of abdominal pain in most patients, and this pain resolved in most cases. Based on our experience, we recommend diagnostic laparoscopy early in the course of debilitating chronic recurrent abdominal pain in children. Appendectomy should be done when no other significant cause of abdominal pain has been identified, even if the appendix looks normal.     

Chronic pain in children

Chronic pain (CP) in children is a significant medical condition. The exact incidence is difficult to define but we know that historically it has been underdiagnosed and undertreated. Children can present with a variety of pain conditions (e.g. chronic headache, abdominal pain and musculoskeletal/limb pain).     

Paediatric chronic pain

Chronic pain in childhood is common and if untreated may lead to significant pain-related disability, emotional disturbance and poor school attendance. Many children and adolescents are successfully managed outside of specialist paediatric pain management clinics in a wide range of clinical settings. However, some children require the expertise of a multidisciplinary pain management team in a dedicated paediatric centre. Following multidisciplinary assessment an individualized pain management plan is agreed with the family. Treatment options can be classified into pharmacological, physical and psychological therapies. The aim of treatment is to facilitate a restoration of function for the child, working with the family as a whole.