Sacroiliac Joint Radiofrequency Neurotomy
Radiofrequency (RF) neurotomy is a therapeutic procedure designed to decrease pain by destroying the nerves that innervate a joint. This intervention uses RF-generated localized heat to ablate the nerves, and thereby interrupt the nervous pathway that transmits pain sensation from the spine to the brain.
Facet and sacroiliac joint pain are often treated with neurotomy, and though neurotomy has proven efficacy for facet joint pain, the evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited.3
More recently, two randomized, placebo-controlled trials have been published.
The first compared the efficacy of lateral branch neurotomy using cooled RF to a sham intervention for sacroiliac joint pain. At 3 months, 47% of treated subjects showed significant improvements in global perceived effect (GPE) and quality of life as compared with 8% of the sham group. After the 3 month follow-up, unblinding occurred and the sham group subjects were offered RF lateral branch neurotomy; those who opted to receive treatment (“crossover” group) were followed up to 6 months post-RF ablation, with 47% of the subjects reporting a positive GPE at 6 months, though these results were not compared to the treatment group.4
The other trial compared RF denervation of the L4-5 primary dorsal rami and S1-3 lateral branch to placebo-controlled trial of injection-diagnosed sacroiliac joint pain patients. Of the 14 patients in the RF group, 11 (79%), 9 (64%) and 8 (57%) experienced ≥50% pain relief and significant functional improvement at 1, 3, and 6 months post-procedure, respectively, vs the placebo denervation control group, in which only 2 patients (14%) experienced improvement at 1 month post-procedure, and none reported relief exceeding 3 months.5
The American Association of Pain Management & Rehabilitation society, or AAPM&R, states there is limited evidence supporting the efficacy of RF ablation for sacroiliac joint pain due to the lack of studies, and proposes these guidelines for managing the patient through different stages of the disease:6
- New onset/acute: Initial treatment emphasizes education and local pain control with nonsteroidal anti-inflammatory drugs (NSAIDs), topical creams, ice, and electrical stimulation. Patient education includes postural awareness, proper pelvic and spinal body mechanics, and activity modification. SI joint belts or kinesiotaping can be helpful.
- Subacute (Recovery phase): The main focus of this phase is to increase mobility, flexibility, and stability and to restore healthy gait. Manual medicine techniques include muscle energy, sacroiliac joint mobilization, and manipulation. Rehabilitation exercises include pelvic and spine stabilization, core strengthening, and postural re-education. This should be followed by a maintenance exercise program. If residual pain limits function, a sacroiliac joint injection should be considered.
- Chronic/stable (Maintenance phase): The focus is to restore muscle balance, strengthen appropriate muscles, and initiate functional exercises (standing in multiple planes) with transition to a home program. If pain persists and there have been positive responses to diagnostic and therapeutic sacroiliac joint injections on 2 occasions (75%-90% relief), then RF ablation is indicated.7 Judicious use of medications, such as NSAIDs and opioids, on selected patients can be used to maintain function and quality of life. If pain persists over 6 months and is unresponsive to conservative treatment, surgical consultation should be considered.
A 2009 systematic review of sacroiliac joint interventions by the American Society of Interventional Pain Physicians (ASIPP) also found limited evidence for the efficacy of thermal and pulsed radiofrequency neurotomy in managing sacroiliac joint pain.8 Additionally, ventral sacroiliac joint innervation cannot be targeted by lateral branch neurotomy,4 which limits its application.
Besides the limited clinical evidence, another drawback with both therapeutic injections and RF denervation is, though they may provide symptomatic relief, they do not address the fundamental, underlying problems of sacroiliac joint instability or degeneration, if present.
Next page: Sacroiliac Joint Prolotherapy
Sacroiliac Joint Anatomy
Sacroiliac Joint Treatment Options
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- Muhlner SB. Review article: radiofrequency neurotomy for the treatment of sacroiliac joint syndrome Curr Rev Musculoskelet Med 2009;2:10–14.
- Patel N et al. A Randomized, Placebo-Controlled Study to Assess the Efficacy of Lateral Branch Neurotomy for Chronic Sacroiliac Joint Pain. Pain Med. 2012 Feb 2. doi: 10.1111/j.1526-4637.2012.01328.x.
- Cohen SP et al. Randomized Placebo-Controlled Study Evaluating Later Branch Radiofrequency Denervation for Sacroiliac Joint Pain. Anesthesiology 2008 August;109(2):279–288.
- Nieves R. SI Joint Pain. http://now.aapmr.org/pain-neuro/pain-medicine/Pages/SI-Joint-Pain.aspx December 2011.
- Vallejo R et al. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain Med. 2006:7:429-434.
- Rupert MP et al. Evaluation of Sacroiliac Joint Interventions: A Systematic Appraisal of the Literature. Pain Physician 2009;12:399-418.