“They’re going to burn out the nerves in my neck.” Sounds pretty permanent, but fortunately, not accurate.
Radiofrequency ablation or neurotomy, aka RFA, is a procedure done in a pain management or anesthesiologist’s office. RFA is the next step after a series of epidural steroid spinal injections have failed to provide lasting relief. Usually, a nerve block procedure is done first as a test to see if burning out the nerve is going to be done on the correct level or area.
As I mentioned, this does not “burn out” the nerve. Rather, it is a procedure that uses a high frequency electrical current at a very specific temperature to destroy the myelin sheath that surrounds the nerve, while not damaging the nerve itself. For low back pain (not sacroiliac pain) caused by the facet joints, the nerve that is cauterised is the medial branch nerve that provides feedback between the joint and the brain. If there is a problem with this facet that is creating inflammation, it is likely that there is a constant message up to the brain that you perceive as pain. Burning off the myelin sheath cuts off communication between that facet and the pain centers in the brain.
Sounds like a great idea and sometimes, it is one of the few options left to patients. While I don’t have any numbers to back me up, I would not be surprised if a large chunk of patients referred for RFA have never seen a chiropractor.
So what’s the problem if it works? Even if it is just temporary (the myelin sheath ultimately grows back and the communication between the facet and brain is restored, usually taking anywhere from 3-12 months)? The problem, like all medical procedures, is that there are dangerous side effects. But before we get into the gist of this blog post, I need to highlight some problems that occur when the nervous system is cut off from a joint.
Charcot joint (aka neuropathic arthropathy) occurs when damage is done to the nerves feeding a joint. This can be from diabetes, leprosy, syphilis or any other disease process that destroys the nerves. Ultimately, the joint breaks down and severe joint damage occurs. While the exact mechanism is still not understood, part of this process is believed to occur by dysregulation of the autonomic nervous system that leads to an increased blood flow to the denervated joint. This increased blood flow results in weakening of the bones surrounding the joint and breakdown of the joint.
In addition, it is possible that the lack of feedback from the joint due to the nerve damage leads to further damage and destruction of the joint.
Back to this particular study. In it, researchers looked at the long-term effects of radiofrequency ablation on the disc, joints and muscles surrounding the joint (specifically the multifidus). Here’s the details:
- 27 patients were identified that had before and after MRIs done.
- Spinal levels not treated with RFA were used for comparison.
- The disc in the area of the radiofrequency ablation had 342% more degeneration (14.9% versus 4.6%).
- Luckily, there was no difference in the multifidus cross-sectional area or rates of deterioration in the facet joints.
The greatly increased disc breakdown is not a good thing. There is a chance that all of the damage was not caused by the RFA since we already know that epidural steroid spinal injections also increase the degeneration that occurs within the disc and it is highly likely that patients had epidurals before they got to the point of needing a RFA.
Either way, this information once again supports the idea that chiropractic care should, unequivocally be at the front end of care for musculoskeletal complaints and especially spinal complaints. This does not ensure that epidurals and radiofrequency ablations will not happen, but it darn well makes sure it’s only used as a last resort. And a last resort is where it should sit.