Downloaded 88 times
Uploaded byProf. Dr. Mohamed Mohi Eldin
Sacroiliac Joint RF Denervation
This document discusses radiofrequency denervation of the sacroiliac joint. It begins by describing the innervation of the SIJ, noting it is innervated by the posterior primary rami of S1 and S2 as well as occasional contributions from S3. It then discusses the diagnosis of SIJ pain, treatment options, and techniques for performing RFN of the SIJ including targeting the lateral branches of S1-S3 and the L5 dorsal ramus. Finally, it compares traditional RF and cooled RF techniques, noting cooled RF allows for large, controlled lesions and reduces risks compared to traditional RF.
More Related Content
Similar to Sacroiliac Joint RF Denervation
More from Prof. Dr. Mohamed Mohi Eldin
Sacroiliac Joint RF Denervation
- 1. Radiofrequency Denervation of SacroiliacJoint Mohamed M. Mohi Eldin, Professor of Neurosurgery, Faculty of Medicine, Cairo University One-Day Spine Clinic 2nd workshop & hands-on 20-21 April 2016
- 2. SIJ Innervation Ventral surfaceby VR of L5-S2 or branches from the sacral plexus. Dorsal surface by the L5 DR and S1-4 lateral branches
- 3. SIJ Innervation Joint ispredominantly, innervated by posterior primary rami S1 and S2 lateral branches primarily innervate the SIJ and associated dorsal ligaments, occasional S3 contributions but not S4
- 4. S1-4 Dorsal Rami andDivisions Midline PSIS S1 S2 S3 S4 Left LDSI lig. Interforaminal neural arcade Lateral branches
- 5. SI Joint Innervation •Nerve location is variable: – Person to Person – Side to Side – Level to Level • Nerves may run along bone, or up to 8 mm superficial from the sacrum
- 6. SI Joint Innervation Lateralbranches of cadavers with thin wires laid over each nerve that ran into the sacroiliac joint. Fluoro images were taken to show the relationship of the nerves to landmarks such as the foramina and the joint S1 S3S2
- 7. Dorsal sacral plexus& lateral branch nerves supplying sensation to the dorsal sacral joint complex (arrows) from L5 to S3. Note the variability in lateral branch topography between right and left.
- 8. Chronic sacroiliac jointpain: The problem • Pain below L5 • Twice positive (>75% relief) SIJ blocks • Prevalence of SIJ pain 10-20% • Persistent lower back pain after LS fusion, SIJ- pain source in 32% (single SIJ injection)
- 9. RF of SIJ Amore definitive palliative therapeutic treatment
- 10. Clinical causes ofSIJ pain Primary causes 1. Fracture 2. Tumor 3. Rheumatologic disorders – ankylosing spondylitis – psoriatic arthritis 4. infection 5. mechanical – Locking – hypermobility 6. DJD/overuse 7. After L/S fusion. Secondary causes 1. discogenic pain, 2. Z-joint (facet) pain, 3. Hip disease, 4. Spinal stenosis, 5. Flail coccyx (coccygodynia), 6. S1 foraminal stenosis
- 11. How can wediagnose SI pain? • History and physical exam • Radiographic studies • Intra-articular injection • Neural blockade
- 12. Diagnosis • Referral Zones •Screening Exam: – Maximum pain below L5 coupled with pointing to the PSIS or – local tenderness just medial to the PSIS has the – Distraction Tests limited utility • Imaging: Little value • Intra articular blocks gold standard? • 37-66% False positive responses from the first injection (22% FP rate) Sacral Sulcus Tenderness Buttocks 94% Lower lumbar 72% LE 50% Groin 14%
- 13. candidate for treatment Persistentlow back pain (below L5 and buttocks pain), with a VAS score more than 5 facetogenic source ruled out, positive temporary response to SIJ injections
- 14. Present Standard forSIJ 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
- 15. Fluoroscopy AP only versusAP & lateral Confusing factor Frequent practice AP view only Sometimes a small amount of contrast give misleading “elongated form” producing “false positive” intraarticular injection if only viewed from an AP Confirm IA -lateral view
- 16. A successful outcome Reliesspecifically on a correct diagnosis Patients should have more than 80% pain relief on two consecutive fluoroscopically guided SIJ injections, a confirmed diagnosis of SI joint pain or dysfunction.
- 17. Concept of usingRF in SIJ pain Though sound but complicated because of the difficulty in locating the sacral nerves and ablating them
- 18.
- 19. TECHNIQUE 1. SIJ Lesioning •Prone position • a pillow beneath the abdomen to reduce the lumbar lordotic curvature • A dispersive plate to the posterior thigh • Sterile drape of lower lumbar region and buttocks on the operative side • Local/IV sedation. No GA. • Optional Bowel prep
- 20. C-arm to visualizeAP Sacrum (adequate cranial tilt to open L5S1) caudal/cephalad tilt of the C-arm to parallel the superior endplate of S1
- 21. Antero-posterior (AP) projection witha vertical position of the C-arm, centered on the inferior border of the ipsilateral sacrum
- 22. Identify the skinentry point at the ipsilateral, lateral, inferior border of the sacrum, 1 cm lateral of and below the S4 foramen
- 23. Spinal needle placement (fromthe sacral target point to the mid-SIJ) to anesthetize the track
- 24. • A 25-Gauge3-1/2 inch (10cm) spinal needle and 1% buffered Lidocaine can be used, to anaesthetize the aimed track • Tip: you could use a pencil point spinal needle which is easier to advance when there is bone contact.
- 25. Electrode Placement Spinal needlesare used to mark the PSFA Introducer and electrode are directed “down the beam” towards the target anatomy Electrode is positioned 7-10 mm from the PSFA for safety
- 26. Sacral target point Advancethe spinal needle to contact sacral target point lateral to the S4 foramen
- 27. Making sure That sacrumis contacted at an appropriate depth That needle has not entered either the S4 or any other sacral foramen, Or inferior to the sacral margin into pelvic cavity
- 28. Once the periosteumis contacted Advance the needle in a cephalad and slightly lateral direction, staying lateral to the sacral foramen, in contact with the sacrum, and medial to the SI joint, and advance into the ligamentous tissue between the sacrum and ilium
- 29. Tips & Tricks Useboth hands to insert and gently steer the electrode with one hand at the electrode and one hand at the handle
- 30. Tips & Tricks Placementwith tip curved down until you reach periosteum, but always try to touch it tangentially, not under a steep angle. Touch down the handle to the skin, and steer the electrode with your other hand
- 31. Tips & Tricks “wiggle”the electrode when advancing so it does not get “stuck” into periosteum; Assure bone contact, but merely touch the periosteum don’t turn the electrode more than 90° (look at the marker at the handle in case of doubt)
- 32. Beginners tip You canuse the 25-G spinal needle as a “marker” by placing it at the endpoint of the track of the electrode. It defines the steering direction. Keep one eye at this needle and one eye at the electrode during “wiggling”
- 33. Tips & Tricks Halfway in advancing the electrode, a critical point is encountered. You should make a lateral x-ray to make sure you are not advancing over the ilium, but indeed advancing into the deep interosseous ligament
- 34. Lateral view mainly tocheck if you are staying in contact with the sacral posterium
- 35. Electrode is thenadvanced Maintaining continuous contact with sacrum, on a cephalad and slightly lateral line, staying lateral to the sacral foramen, medial to the sacroiliac joint, and ventral to the ilium, until contact with the sacral ala prevents further advancement
- 36. AP view Endpoint adjacentto the S1 posterolateral branches
- 37. Anesthetize the lesiontrack (to optimize patient comfort) Once advanced along this line to a point where no further cephalad advancement can occur, remove the stylette and inject 4 cc of a 2% lidocaine solution +/- 1 cc of a non-particulate steroid as the needle is withdrawn, to anesthetize the lesion track
- 38. Procedure Place RF probethrough introducer (4 mm beyond tip of introducer = 2 mm off bone) Lateral fluoroscopy to assure not in canal Verify impedance 100 - 500 ohms
- 39. Appropriate positioning should beconfirmed by changing the caudal/cephalad tilt of the C-arm to parallel the superior endplate of S1 and verifying, once again, that the entire length of the SImplicity III electrode was advanced to the ipsilateral sacral ala and the three independent, active contacts were positioned adjacent to the S1, S2, S3, and S4 lateral branch innervation pathways
- 40. Two techniques havebeen described in the literature Yin technique Kline technique
- 41. Yin technique (Sensory Stimulation-Guided) Locaterelevant nerves using traditional sensory stimulation • If the SI pain was reproduced, ablated is done 80 C for 60 sec • If a sensory response was elicited, but did not reproduce the pain, the level was not ablated • 64% of patients had > 50% pain relief at six months
- 42. Kline technique (leap frogfashion ) Perform dual electrode lesions to create an ablation line long enough to ablate across all sacral nerves Sensory stimulation is not necessary Care must be taken to not spread the electrodes too far apart (>4 mm) or incomplete ablating between the electrodes can result Success between 40‐60 %
- 43. “Leapfrog” Technique forSIJ RF Lesions made in the postero-inferior aspect of joint by ‘leapfrogging’ RF probe at < 1cm intervals mean duration of pain relief 12+/- 1.2 months
- 44. Sacroiliac RF LesionRequirements • Level L5 – Lesion the primary dorsal ramus at sacral ala • Level S1, S2, S3 – Lesion all lateral branches as they exit foramen
- 45. Lesion Geometry Lesions 8-10mm from lateral edge of foramen Target sites should be 50° apart (1:40 on the clock) to achieve overlap
- 47.
- 48.
- 49.
- 50.
- 51. At S2 2:30, 4 and 5:30lesions At S3 2:30 and 4:00 lesions Repeat
- 53.
- 54. Technique 2. L5 PrimaryDorsal Ramus Lesioning
- 55. Tips & Tricks Firstdo the dorsal ramus L5 RF lesioning in the awake patient (as for a facet joint denervation) Then start IV sedation
- 56. A solution containinglidocaine +/‐ steroid solution is injected through the RF cannula, and radiofrequency lesioning of the L5 dorsal ramus is performed at 85 °C for up to 90 seconds
- 58. Max. Insertion depth L5/S1z-joint space
- 59. Probe is 2mmoff bone for distal lesion projection
- 60.
- 61. Cooled RF SIJNeurotomy
- 62. Cooled RF Lesions SACRALSURFACE Isotherm Map White meat tests comparing SInergy probe and Standard RF 10 mm 3.5 mm
- 63. Perpendicular & ObliquePlacement Spherical lesion shape allows for perpendicular or oblique probe placement near the treatment site.
- 64. Bipolar Cooled RF“Strip” Lesion • a “bipolar strip” lesion at lateral dorsal foramina + conventional monopolar lesion of L5 dorsal ramus • >50% pain relief and decreased analgesic requirements for 12- month follow up
- 65. Bipolar disadvantage? • Tissuealong 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.
- 66. Summary • SIJ Radiofrequencyprovides for anatomic RF lesioning of the dorsal innervation of the SIJ • Cooled RF technology allows for controlled and repeatable large volume lesions • No significant complications from various approaches reported to date
- 67.