Gaucci - Radiofrequência-1-30
Gaucci - Radiofrequência-1-30
Gaucci - Radiofrequência-1-30
A PRACTICAL MANUAL OF
RADIOFREQUENCY PROCEDURES
IN CHRONIC PAIN MANAGEMENT
3rd Edition
by
U.K.
Graphics by
Basia Jankowiak
Co MEDICAL
Radiofrequency Pain Management
© 2011 CoMedical , Ridderkerk, the Netherlands
INTRODUCTION
MISCELLANEOUS PROCEDURES
1. Trigeminal ganglion radiofreguency 188
2. Intervertebral Disc needling & disc biaculoplasty 197
3. Pulsed radiofreguency of peripheral targets 205
• Occipital nerve 205
• Suprascapular nerve 207
• Other targets 209
};> Upper limb
Gleno-humeral joint 211
Rotator Cuff 211
Humeral epicondyles 211
Elbow joint 212
Wrist joint 212
};> Lower Limb
Hip Joint 212
Trochanteric bursa 212
Kneejoint 213
Ankle Joint 213
Cluneal nerve 213
Lateral femoral cutaneous nerve 214
Coccygeal nerve 215
4 . Percutaneous cervical RF Cordotomy 216
5 . Atlanta-Occipital & Lateral Atlantoaxial joints,
including the modified technique described by Dr. 0. Rohof 223
6. Glossopharyngeal nerve 229
7. Phrenic nerve 231
8 . Pudendal nerve 232
INTRODUCTION
I said in my introduction to the 2nd . Edition of this book that the first edition of
Manual of RF Techniques, which was printed in 2004, was a worldwide
success and was also produced in Korean and Spanish editions.
I was then asked to write a 2nd. Edition, which I did in 2008 .
Both editions have sold out, which is why I have been asked to produce this
3rd. Edition .
Radiofrequency and Pulsed radiofrequency are modalities which are used all
over the world by interventional pain physicians; the techniques in use are
constantly being refined and modified as more targets are located; in my
writing, I always ensure that the Manual keeps up to date with recent
developments.
I have added quite a lot of material to this edition, viz . alternative ways of
targeting the lumbar facet joints, as well as the sacroiliac joint (the latter
includes use of the Cosman TM Bipolar Palisade technique and of the
Neurotherm TM Simplicity probe) .
I have added alternative ways of targeting the thoracic facet joints (using cool
RF) and the thoracic dorsal root ganglia, alternative ways of targeting the
cervical facet joints and the lateral atlanto-axial joint. I have also included
pulsed radiofrequency of the pudendal , phrenic and coccygeal nerves.
In addition the physics section has been rewritten and expanded .
I am very grateful for the contributions of Prof. Alex Cahana & his team , Prof.
Eric R. Cosman Sr. , Dr. Eric R. Cosman Jr. , Prof. Phil Finch, Dr. Olav Rohof
and Prof. Miles Day; these are all big names in interventional pain as well as
being good drinking colleagues at WIP meetings!
Basia Jankowiak, my graphic designer has, yet again , provided her great skills
to make this book what it is .
Once again , I hope that interventional pain physicians across the world will
continue to find this Manual of RF Techniques, useful to them in their daily
practise of their chosen field.
Charles A. Gauci
London, UK
August 2011
LIST OF CONTRIBUTORS TO THIS BOOK
(in alphabetical order)
It is now ten years since publication of my first book on pain relief therapy
'A handbook of clinical techniques in the management of chronic pain' which
I co-authored with my colleague and friend Dr. John Wedley. This book was
a great success and is still being used by many pain relief specialists. Since its
publication, more techniques have been added to our armamentarium and old
techniques have been modified in the light of further detailed anatomical
studies coupled with clinical observations .
Over the past eight years, I have acquired considerable experience in teaching
radiofrequency lesioning techniques at cadaver workshops, worldwide . I have
always found this form of teaching very useful as nothing beats seeing the
procedures in question being demonstrated by an experienced practitioner.
Indeed, I am indebted to many a colleague for instructing me in techniques
I had never carried out before when attending these workshops as a faculty
member. Not only do I teach , I learn!
Following each teaching session, it has always been my practise to jot down
points, which were raised by the participants . I have used these points to
develop my own mode of instruction, which I freely admit is strongly didactic
- probably the result of the fact that I served for so many years in the British
Army! Many participants at my cadaver workshop sessions have repeatedly
requested me to come up with a simple and straight forward 'how to do it'
radiofrequency textbook which they could take with them into the operating
theatre when carrying out procedures; a book which th ey could use to help
them get through the FIPP examination , since this is now fast becoming the
gold standard for interventional pain practice .
I have written an easy to follow instruction manual, which I trust, will be of use
to relatively inexperienced colleagues until such a time as they feel confident
enough to do without it. It is not a detailed, exhaustive textbook covering all
the aspects of radiofrequency. Dr. Menno Sluijter's two volumes on the subject
remain the bible as far as I am concerned .
The format used is one of spring bound laminated pages which allows the
reader to add his/her own notes and comments enabling the manual to
become a trusted friend in times of need! In this book, I have attempted to get
straight down to the object of the exercise i.e. 'how to do it'. I have not gone
into the indications for each technique and I have not carried out a detailed
review of evidence.
Repetition is kept to a bare minimum. Thus, for example, I assume that the
reader is aware that intravenous access should be established before starting
the procedure, that meticulous attention should be paid to sterility and that the
patient should not be on anticoagulant or on antiplatelet medication. The
information on after-care covers the most important and reasonably common
possible complications.
The emphasis on the book is pictorial with text reduced to a bare (heavily
didactic) minimum; this should make it very easy to use .
I am also grateful to my pain fellow, Dr. Serge Nikolic who helped me with
the proof-reading of my draft manuscript.
Charles A. Gauci
London, UK
March 2004
INTRODUCTION TO 2N°. EDITION (2008)
In view of its popularity, it was also published in Korean and Spanish Editions.
My good friend Professor Eric Cosman together with his son, Dr. Eric Cosman
jnr, both world-renowned scientists, experts on the physics of radiofrequency
and designers of the Cosman ® RF Lesion Generator, have very kindly added
to the chapter on the physics of pulsed RF.
I have also added some information on the physics of Cooled RF, developed
by the Baylis Medical Company Inc®.
The pictures of the main Radiofrequency machines in the Physics section have
been upgraded .
I have added sections on L5 Dorsal Root Ganglion PRF and on Sacral Nerve
PRF.
In view of the fact that pulsed radiofrequency is now also being used to treat
many different targets, including peripheral ones, I have included additional
material on 'target' location in both the upper and lower limbs . I have also
included sections on the Atlanto-Occipital and Lateral Atlantoaxial joints and
on the Glossopharyngeal Nerve.
I trust that this second edition will be as popular as the original version and
will be of use to interventional pain physicians around the world .
Charles A. Gauci
London, UK
June 2008
A
THE PHYSICS OF RADIOFREQUENCY
& PULSED RADIOFREQUENCY
• Electrode Polarity:
o Monopolar RF: Current passes between a needle electrode and a large-
area reference ground pad. RF current intensities are highest near
the needle electrode's uninsulated tip. In Monopolar Thermal RF, an
ellipsoidal heat lesion is generated (fig. 1). With proper full adhesion of
the ground pad to the skin, current densities are low over the pad's large
area, and thus nearby tissue is not typically elevated to lesion levels.
o Bipolar RF: Current passes between two needle-electrode tips and the
current density is high at both locations. Thus, in Bipolar Thermal RF, a
heat lesion is generated near both tips . When parallel tips are brought
close together, the electric field is focused between the tips and a large
"strip" lesion is formed (fig. 6a) .
MANUAL OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 17
& PULSED RADIOFREQUENCY
SECTION 1
In one author's clinical experience (CAG), there are some basic rules which
should be followed in RF lesioning. Thermal RF should be used only for
treatment of nociceptive pain. RF should not be used in patients with marked
psychological overlay and/ or drug dependency. RF should not be used in
patients with total body pain. You should ensure that the patient has realistic
expectations since the total abolition of pain may not be possible . You should
exhaust all other non-destructive forms of treatment first and achieve unequivocal
benefit from preliminary prognostic blocks.
MANUAL OF RF TECHNIQUES
18 THE PHYSICS OF RADIOFREQUENCY
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MONOPOLAR THERMAL RF
Using standard equipment, the steps for monopolar RF lesioning in the spine
typically include the following steps :
1. Place the Ground Pad on the skin near the treatment site .
2. Place the RF Cannula percutaneously near the target nerve.
3 . Stimulate: The RF Electrode delivers sensory and motor nerve stimulation
to ensure that the cannula's tip is near the target nerve and distant from
non-target nerves .
4 . Inject anesthetic through the cannula to prevent pain during lesioning.
5 . Lesion : The electrode delivers RF current to the cannula's tip and the nearby
nerve(s) are lesioned with temperature control.
The RF cannula is typically a hollow 22G, 21 G, 20G, 18G, or 16G needle that
is fully insulated except at the tip. The cannula 's hollow interior accepts either
(a) a stilette to make the cannula solid for insertion, (b) injected fluid anesthetics
and steroids, or (c) a 28G thermocouple (TC) electrode for tip temperature
measurement and delivery of stimulation and RF currents . In some applications,
such as cordotomy, DREZ, brain , and even spinal lesioning, the electrode and
cannulae are integrated into a single device . X-ray guidance is typically used
to position the cannula nearby the target nerve by reference to bony landmarks .
Once positioned , the cannula 's stilette is removed and is replaced by the
electrode . The operator then seeks the nerve by sensory stimulation, which are
low-voltage electrical pulses delivered at 50 Hz (pulses per second) . A stronger
sensory response at a lower voltage indicates the cannula's tip is closer to the
nerve . In the clinical experience of one author (CAG), the cannula needs to
be within 3 mm of the nerve in order to create an adequate heat lesion and a
stimulation level of at most 0.6 V is indicative of this .
The operator should always ensure that the cannula/ electrode is not
dangerously close to any motor nerve in the vicinity of the sensory nerve he/she
is trying to lesion. To accomplish this, low-frequency motor stimulation pulses
are delivered at 2 Hz. In the clinical experience of one author (CAG), if no
muscle twitch in the territory of the nerve is noted at twice the voltage strength
necessary to ach ieve sensory stimulation, it can be safely assumed that there
are no motor paths within 3 mm of the needle, and that consequently, there
MANUAL OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 19
& PULSED RADIOFREQUENCY
SECTION 1
When the operator is satisfied that the needle is safely in position, RF current
is delivered to the electrode and cannula. Frictional heating occurs near the
cannula's uninsulated tip due to tissue electrolytes being pulled to and fro by
the RF current alternating at approximately 500 kHz (500,000 cycles per
second) . While heating occurs only in the tissue and not within the electrode,
within a few seconds of sustained RF heating, the temperature measured in
the electrode/cannula's tip registers the maximum tissue temperature (Cosman
and Cosman, 2003; Cosman, 2010; fig. 1) . This occurs due to coherent
heat diffusion into the electrode tip from all sides . This maximum temperature
can be directly controlled by the operator. It must be cautioned that for cooled
RF, where the electrode is cooled by internally circulating water, the electrode
does not measure the maximum tissue temperature; rather, the maximum tissue
temperature occurs at a variable location remote of the electrode and can
far exceed the temperature measured within or nearby the electrode (Wright,
2007). As the current is applied at the destructive levels typical of Thermal RF,
a well-circumscribed heat lesion appears . It will grow until a steady-state is
reached; at this point, the passage of current only maintains the temperature .
Little further spread takes place at the edge of the lesion, since (a) the electric
field and rate of heating decreases with distance from the electrode, and (b) the
rate of RF heating within the lesion volume is roughly balanced by the rate of
heat diffusion into the surrounding tissue, heat diffusion into the electrode shaft,
and blood-flow cooling.
The heat lesion is shaped like a match head (fig. 1) and is commonly defined
as the tissue regions for which the temperature exceeds 45-50 oc for at
least 20 seconds (Brodkey, 1964; Dieckmann, 1965; Smith, 1981; Cosman
and Cosman, 1974 and 1984) . Though permanent neurological damage
occurs when tissue is exposed to temperatures exceeding 42 oc over longer
durations (Cosman, Cosman, Bove, 2009), for practical purposes, when we
talk about lesion size, we mean the volume of tissue within the 45 °C isotherm
(fig. 2). According to Abou-Sherif et al. (2003), thermal RF produces the
following effects in the rat sciatic nerve at 6-8 weeks: Wallerian degeneration
in all nerve fibres, physical disruption of the basal laminae, focal disruption
of the perineurium, degranulation of mast cells, recruitment of exogenous
MANUAL OF RF TECHNIQUES
20 THE PHYSICS OF RADIOFREQUENCY
& PULSED RADIOFREQUENCY
SECTION 1
Fig. 2 Monopolar Thermal RF lesion Zone Fig. 2a Post-mortem monopolar thermal RF lesion
and the 45 °C isotherm . Adapted from width around the electrode shaft for different
Cosman and Cosman ( 1984) electrode diameters/gauges and tip temperatures .
Adapted from Cosman et al. (1988)
The heat lesion extends maximally around the shaft of the cannula, with a
diameter that ranges from 2-1 0 mm depending on the cannula's diameter/
gauge, the tip temperature, and lesion time (fig. 2a). The lesion extends
1-2 mm both ahead of the tip and up the shaft, yielding a total length 2-3
mm longer than the tip length (Cosman and Cosman, 1984). Because of this
geometry, many physicians prefer 'para llel' /'side on' cannula placement for
monopolar thermal RF lesioning, so that the nerve is positioned at the side
of the cannula tip where the lesion extends maximally. In the alternative
'perpendicular'/'point-on' approach, the nerve is placed directly ahead of
the cannula tip, thus exposing a smaller volume of the nerve to neurolytic
temperatures.
MANUAL OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 21
& PULSED RADIOFREQUENCY
SECTION 1
T1
Permanent
00 T2
-.a...
Q)
45.0
Lesion
{E. 37.0
c. ---------+~---r-:--------------- ~~~~erature
j::
Small Lesion (T2) ,
Large Lesion (T1) Distance from Electrode Tip
(arbitrary units)
Fig. 4 Effect of tip temperature on RF lesion size . Adapted from Cosman and Cosman (1974)
MANUAL OF RF TECHNIQUES
22 THE PHYSICS OF RADIOFREQUENCY
& PULSED RADIOFREQUENCY
SECTION 1
tip temperature and electrode/cannula diameter (fig. 2a) . All other things
being equal, a larger heat lesion will be produced by a larger electrode tip
and a higher tip temperature (assuming that boiling does not shut down RF
current flow). Additionally, several factors can affect lesion size and dynamics,
including variations in tissue densities, proximity to bone, proximity to CSF
(especially in Trigeminal lesions), blood vessels, etc.
It is advisable to keep the tissue temperature below boiling ( 100 oq. Boiling
can lead to uncontrolled gas discharges, burning steam that travels up the
electrode's shaft to the skin, irregular lesion geometry, and charring at the
electrode tip.
In one author's clinical practice (CAG), the lesion temperature is held below 85
0
( to give a broad temperature margin relative to 100°C.
The resistance to the flow of electrical current from the tip of the cannula, the
impedance, can be measured and should be observed by the operator. A very
high impedance, or open circuit, can indicate that the electrode or g round pad
is not in proper contact with the patient, or that the cables are disconnected .
A rising, high impedance can also indicate tissue is boiling at the cannula 's
tip, since electrical current cannot easily traverse boiling gas bubble; this is an
important safety check in case the temperature sensor is broken or misplaced
outside the cannula's tip (Cosman, 201 0) . A very low impedance, or short
circuit, can indicate a failure of the RF equipment, or direct contact between
the electrode and the ground pad or contact with a large metallic implant.
Impedance can also be of use in certain procedures since it can indicate the
tissue type in which the cannula's tip is positioned . For example, during a
percutaneous cordotomy, the impedance will be 400 Q when the tip is in the
extradural tissues, fall to 200 Q as the needle tip enters the CSF, and then rise
to over 800 Q as the needle tip enters the spinal cord. When working in the
intervertebral disc, the impedance is usually very high in the outer annulus,
falling to less than 200 Q in the nucleus pulposus .
For facet denervations, some physicians use "pole needles". These are non-
temperature-monitoring, tissue-piercing electrodes with integrated, flexible, fluid
injection lines. They are used when it is felt that the electrode position must not
be perturbed through stimulation, injection, and lesioning. Typically, 20 Volts
is applied with the expectation of producing an 80 oc heat lesion . However,
in vivo clinical experiment shows that the tip temperature is not consistently
MANUAl OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 23
& PULSED RADIOFREQUENCY
SECTION 1
(c) Kimberly Clark Pain Management System (d) DIROS OWL URF-3AP Multi-Lesion
Fig. 5 RF Generators
MANUAL OF RF TECHNIQUES
24 THE PHYSICS OF RADIOFREQUENCY
& PULSED RADIOFREQUENCY
SECTION 1
BIPOLAR THERMAL RF
• Large: Bipolar RF lesions are larger than cooled RF lesions as used in pain
management (fig. 6b; fig. 6c, left) . The size of one bipolar RF lesion is
roughly that of three conventional monopolar RF lesions placed side by side
(fig. 6c, right).
• Conformal: Bipolar RF applied to closely-spaced electrode tips produces
heat lesions shaped like a rounded brick, also known as a "strip lesion".
To conform to anatomical constraints, the width and length of the strip can
be adjusted nearly independently of each other and the lesion depth (fig.
6a). As such, a large lesion can be produced without unnecessary damage
to healthy tissue and with reduced risk to sensitive structures . This is not
~~.i. I . 1- •
: ,, ••. ;.'~ •
. . . .. . · ..
.
. .
I . .
Fig. 6a Bipolar Lesion Size for 20 gauge, 10 mm tip length , 90 °C, 3 minutes and increasing
spacing: Strip 12 x 15 x 8 mm 3 (left), Strip 10 x 17 x 5 mm 3 (middle) , Two Ellipsoids 12 x 7 x 7
mm 3 (right)
MANUAL OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 25
& PULSED RADIOFREQUENCY
SECTION 1
Cooled Monopolar (18 ga, 4 mm tip) Bipolar (20 ga, 10 mm tip) Monopolar (20 ga, 10 mm tip)
E
E
~
Sacral
Blopolar
Surface
Omm
Spacing
Fig. 6c Comparison of bipolar RF lesion size with that of cooled and conventional monopolar RF
MANUAL OF RF TECHNIQUES
26 THE PHYSICS OF RADIOFREQUENCY
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Bipolar RF lesions of the sizes shown in (fig. 6a) have been used successfully
in pain management (Ferrante et al., 2001; Burnham et al., 2007; Cosman
and Gonzalez, 2011). Ex vivo experiments by Cosman and Gonzalez (2011)
document further flexibility in the size and shape of bipolar lesions. Indeed,
bipolar lesions with dimensions exceeding 2 em can be readily created with
standard RF equipment (fig. 6b) . As for all RF lesioning, before the clinical use
of novel bipolar configurations, a physician must consult lesion-size studies to
determine whether that configuration is appropriate for the target anatomy. The
proximity of target nerves to non-target nerves, blood vessels, skin surface, and
other sensitive structures imposes an upper bound on the safe size of any heat
lesion, especially in the spine.
MANUAL OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 27
& PULSED RADIOFREQUENCY
SECTION 1
MONOPOLAR PULSED RF
8
-10- ~ TIME (seconds)
that the E-field per se has little or no
~E~~5~
clinical effect in Thermal RF.
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Burst of RF RFOff
MANUAL OF RF TECHNIQUES
28 THE PHYSICS OF RADIOFREQUENCY
& PULSED RADIOFREQUENCY
SECTION 1
level assumed not to produce gross neurodestructive effects (fig. 7b). Cosman
and Cosman (2005) have shown that tissue around the electrode shaft is
broadly exposed to high-intensity E-fields without substantial heating . They also
showed that the very intense electric fields at electrode's pointed tip cause "hot
flashes" during each RF burst. The full details of this physical geometry is given
later on in this book, but some salient points are :
• Ahead of the tip: Within =0.2mm of the electrode point, temperature spikes
into the neurolytic range and above the measured tip temperature during
each burst of RF (fig. 7d). At larger distances and between RF bursts, the
temperature does not substantially exceed that of the electrode tip. While
the electric field is maximal within =0.2mm of the electrode point, it falls
off very quickly with distance ahead of the tip, so that beyond =0.2mm, its
magnitude is smaller ahead of the tip than it is lateral to the shaft (fig 7c).
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MANUAL OF RF TECHNIQUES
THE PHYSICS OF RADIOFREQUENCY 29
& PULSED RADIOFREQUENCY
SECTION 1
MANUAL OF RF TECHNIQUES