Bipolar Radiofrequency Neurotomy of the Genicular Nerves for Chronic Pain Due to Knee Osteoarthritis.

Background: The current treatments for chronic knee osteoarthritis (OA), a disabling and costly healthcare condition in the United States, vary in their level of supporting evidence. Although total knee replacement is one of the best-supported interventions, its associated risks should not be taken lightly, especially in older patients with comorbidities. Genicular nerve block with subsequent genicular nerve radiofrequency neurotomy (GN-RFN) has emerged as a promising intervention for refractory pain in knee OA. Purposes/Questions: We sought to assess the pain and functional outcomes of genicular nerve bipolar radiofrequency neurotomy (B-RFN) for the treatment of chronic pain due to knee OA. Methods: A total of 21 patients who underwent unilateral genicular nerve B-RFN after positive diagnostic genicular nerve block (50% or greater pain relief) treated between July 2018 to December 2018 were included. Pain numeric rating scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected at baseline, 3 months, and 6 months post-B-RFN. Changes at each time point were compared to baseline scores using paired sample t tests. Results: At 3 months, 62% of patients had a greater than 50% improvement in NRS scores and 57% of patients had a greater than 50% improvement in WOMAC scores. At 6 months, 81% of patients had a greater than 50% improvement in NRS scores and 67% had a greater than 50% improvement in WOMAC scores. The absolute change in mean NRS (± standard deviation) at 6 months went from 7.5 ± 1.9 to 2.5 ± 1.2. The absolute change in mean WOMAC scores at 6 months went from 46.9 ± 8.0 to 19.0 ± 6.2. Conclusion: Of 21 patients, 14 (67%) saw greater than 50% improvements in both NRS and WOMAC scores at 6 months after genicular nerve B-RFN. Further prospective studies are needed to determine the selection criteria of patients most likely to benefit from this procedure.

A systematic review of full endoscopic versus micro-endoscopic or open discectomy for lumbar disc herniation.

Aim: Endoscopic discectomies provide several advantages over other techniques such as traditional open lumbar discectomy (OLD) including possibly decreased complications, shorter hospital stay and an earlier return to work. Methods: An electronic database search including MEDLINE/PubMed, EMBASE, Scopus, Cochrane Database of Systematic Reviews and Cochrane Controlled trials (CENTRAL) were reviewed for randomized controlled trials (RCTs) only. Results: A total of nine RCTs met inclusion criteria. Three showed benefit of endoscopic discectomy over the comparator with regards to pain relief, with the remaining six studies showing no difference in pain relief or function. Conclusion: Based on review of the nine included studies, we can conclude that endoscopic discectomy is as effective as other surgical techniques, and has additional benefits of lower complication rate and superior perioperative parameters.

Lay abstract This systematic review investigates the use of a common surgical procedure, endoscopic discectomy, for the surgical treatment of lumbar disc herniation. It is a type of minimally invasive spine surgery (MISS) procedure, which has been shown to be not only effective in outcomes, but also optimal for peri-operative parameters, such as post-operative hospital stay, time duration of surgery and blood loss during the procedure. We utilized five search databases to collect data on only randomized controlled studies that investigated endoscopic discectomy compared with another surgical technique. Our results include nine randomized controlled trials, three of which showed improvement in pain scores for endoscopic discectomies. Consequently, in combination with the optimal peri-operative measures, it is concluded that endoscopic discectomy is a reasonable procedure to treat lumbar disc herniation surgically.

Treatment of knee osteoarthritic pain with platelet-rich plasma: a systematic review of clinical studies.

Introduction: Knee osteoarthritis is a degenerative joint disease that is secondary to degradation of articular cartilage, reformation of subchondral bone through degradation and proliferation as well as presence of synovitis. Materials & methods: This systematic review was conducted and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Results: A total of 30 of the 48 comparators showed statistically significant superiority with platelet-rich plasma (PRP) compared with a control, while the other 16 comparators showed no significant difference between PRP and the comparator. Conclusion: We can only recommend PRP for patients with early-stage osteoarthritis (I or II) and who are aged below 65, based on our findings. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations, while studies reviewed were randomized controlled studies, and therefore, high grade, due to variance in imprecision, risk of bias and inconsistency among the 37 studies, it would be reasonable to rate this paper as subjectively moderate.

Two-Needle Technique for Lumbar Radiofrequency Medial Branch Denervation: A Technical Note.

BACKGROUND: Radiofrequency ablation (RFA) of the medial branches of the dorsal rami has been reported to relieve facet joint-related back pain for 6 months to 1 year in 60% of patients. Although providing benefit in a significant proportion of patients, there remains a group of patients who do not experience any pain relief from RFA or experience only benefit from the ablation for a short period. Failure of RFA has been attributed to technical failure of coagulating the nerve or coagulation of a minimal section of the nerve, allowing for early reinnervation. Increasing the success rate and duration of relief may require techniques that increase the likelihood of successful nerve ablation over a relevant distance by maximizing lesion size. OBJECTIVES: The aim of this technical note is to detail a modification to the current commonly used lumbar medial branch radiofrequency (RF) denervation approach to increase lesion size. STUDY DESIGN: This is a technical report describing a novel two-needle approach to lumbar RF medial branch denervation. SETTING: Large private interventional pain management institute. METHODS: A dual needle placement of two 10-mm active tip RF cannulas separated by 6 mm is used to optimally contact the superior articular process (SAP) from its ventral to dorsal borders, which encompasses the anticipated course of the medial branch nerves. RESULTS: The described technique creates a lesion that we estimate to be 11.0-mm wide and 11.6-mm long along the course of the medial branch adjacent to the SAP ensuring adequate coverage and treatment. LIMITATIONS: This report does not encompass a systematic evaluation of the clinical safety and efficacy of the two-needle RFA approach. Future studies will have to assess the long-term efficacy and safety of the approach. CONCLUSIONS: The detailed two-needle approach to lumbar RF medial branch denervation appears to be promising in terms of projected treatment success by coagulating a large volume of tissue, in a cost- and time-efficient manner.

Lumbar Radiofrequency Ablation Interfering With S1 Dorsal Root Ganglion Stimulation Systems: Experience From Two Cases.

BACKGROUND: Dorsal root ganglion stimulation (DRG-S) has emerged as a treatment for complex regional pain syndrome (CRPS) of the lower extremities, and recent small studies are demonstrating its potential efficacy in pain syndromes that are traditionally considered nociceptive in nature, such as axial low back pain. While improvements in neuromodulation technology have been substantial over the past decade, with DRG-S systems patients occasionally require additional interventional pain treatments for treatment of pain from other sources. Radiofrequency ablation (RFA) of medial branch nerves innervating the facet joints is an accepted therapy for pain arising from the facet joints. METHODS: We describe 2 cases from the same practice where we observed similar phenomena while performing a 2-needle monopolar lumbar RFA in patients with a DRG-S system implanted with leads positioned bilaterally at the S1 DRGs. RESULTS: Initiation of RFA resulted in motor activation and discomfort in an S1 distribution in the legs in both individual cases. CONCLUSIONS: RFA can interfere with implanted DRG-S systems, resulting in overstimulation with motor recruitment. Specific anatomical considerations and device settings that may prevent interference are discussed.

Alteration of astrocytes and Wnt/ß-catenin signaling in the frontal cortex of autistic subjects.

BACKGROUND: Autism is a neurodevelopmental disorder characterized by impairments in social interaction, verbal communication and repetitive behaviors. To date the etiology of this disorder is poorly understood. Studies suggest that astrocytes play critical roles in neural plasticity by detecting neuronal activity and modulating neuronal networks. Recently, a number of studies suggested that an abnormal function of glia/astrocytes may be involved in the development of autism. However, there is yet no direct evidence showing how astrocytes develop in the brain of autistic individuals. METHODS: Study subjects include brain tissue from autistic subjects, BTBR T + tfJ (BTBR) and Neuroligin (NL)-3 knock-down mice. Western blot analysis, Immunohistochemistry and confocal microscopy studies have be used to examine the density and morphology of astrocytes, as well as Wnt and ß-catenin protein expression. RESULTS: In this study, we demonstrate that the astrocytes in autisitcsubjects exhibit significantly reduced branching processes, total branching length and cell body sizes. We also detected an astrocytosis in the frontal cortex of autistic subjects. In addition, we found that the astrocytes in the brain of an NL3 knockdown mouse exhibited similar alterations to what we found in the autistic brain. Furthermore, we detected that both Wnt and ß-catenin proteins are decreased in the frontal cortex of autistic subjects. Wnt/ß-catenin pathway has been suggested to be involved in the regulation of astrocyte development. CONCLUSIONS: Our findings imply that defects in astrocytes could impair neuronal plasticity and partially contribute to the development of autistic-like behaviors in both humans and mice. The alteration of Wnt/ß-catenin pathway in the brain of autistic subjects may contribute to the changes of astrocytes.