Application of Radiofrequency

Treatment in Practical
Pain Management:
State of the Art

J. Van Zundert, MD*; P. Raj, MD†; S. Erdine, MD‡; M. van Kleef, MD, PhD§
*Ziekenhuis Oost-Limburg, Campus Andre Dumont, Multidisciplinary Pain Unit,
Genk, Belgium; †Department of Anesthesiology, Texas Tech University Health Services Center,
Lubbock, Texas, USA; ‡Department of Algology, Istanbul Medical Faculty, Istanbul, Turkey;
§
Department of Anesthesiology and Pain Management, University Hospital Maastricht,
Maastricht, The Netherlands

 Abstract: Many therapeutic interventions for chronic pain
are available, and decisions about optimal management are
not easy to make. Radiofrequency (RF) treatment is classified
as a percutaneous minimal invasive procedure for patients
who do not respond to appropriate medical and physical
therapy. Although RF treatment is widely used differences in
current practice exist due to ongoing controversies. 
• Complex Regional pain syndrome
• Viseral pain
• Pain originating from the peripheral nerves
• Intractable cancer pain
• Spasticity
The available evidence varies in quality and level from
one indication to another. There is a vast body of evi-
dence on the RF treatment of trigeminal neuralgia, but

K ey opinion leaders expressed their point of view in

their specific area of expertise; to agree on a cer-
tain degree of standardization. Most of the common
clinical pain syndromes are covered.
• Cranio facial pain
• Chronic cervical pain
• Pain originating from the thoracic spine
• Low back pain
• Pain originating from the intervertebral disc
• Pain in the sacral and pelvic area
Address correspondence and reprint requests to: Jan Van Zundert,
Ziekenhuis Oost-Limburg – Campus Andre Dumont, Multidisciplinary Pain
Unit, Stalenstraat 2, 3600 Genk, Belgium.
© 2002 World Institute of Pain, 1530-7085/02/$15.00
Pain Practice, Volume 2, Number 3, 2002 269–278
randomized controlled trials are lacking, which can be
attributed to several practical reasons.
In general, conducting randomized controlled trials
for invasive treatment options is complicated by the pa-
tient selection criteria, the required sample size, and eth-
ical reasons. Moreover the differences in study method-
ology don’t allow meta analysis. Though policy makers
demand clinicians to use the evidence based medicine
(EBM) and use this type of information for decision mak-
ing regarding treatment approval and financing, careful
interpretation is warranted. EBM should be a tool but
may not be considered as a rule replacing the clinical
judgment. This becomes clear with the expert’s opinion
as published in the previous sections of this issue.
All efforts should be made to narrow the gap between
the EBM data and clinical practice, using standardized
protocols for patient selection and treatment. In-line
with the experience of conducting clinical trials with
270 • van zundert et al.
pharmacotherapy multi center–multicountry approach us-
ing international accepted protocols may be considered.
Awaiting those results and the ensuing “International
Guidelines” the information gathered in this issue indi-
cates that RF treatment is a useful tool. It has a low in-
vasive character, a target selective approach and can be
performed as outpatient treatment. Following condi-
tions should be fulfilled: patients are carefully selected
with attention to both somatic and psychosocial factors,
the technique is performed by an experienced clinician
in the optimal environment.
The current evolution of RF from the intial neuro ab-
lative thermocoagulation towards the non-neurode-
structive pulsed RF seem to enlarge its therapeutic value
in the management of chronic pain.
INTRODUCTION
The management of patients suffering from chronic
pain, intractable to pharmacotherapy has proven to be a
process of trial and error. The multifactorial aspect of
chronic pain has even led to redefining acute versus
chronic pain whereby the chronicity is not a factor of
duration of pain but seems to be persistence of pain be-
yond expected recovery times, or the inability of the
body to restore its physiological functions to normal ho-
meostatic levels.1 Recognition of the multifactorial as-
pect of pain highlights the need for a multidisciplinary
approach this approach has allowed the establishment
of multidisciplinary pain clinics (MPC) which are con-
sidered to be third-line referral centers where health care
professionals with multiple specialties work together for
establishing a diagnosis and a consensus based treat-
ment scheme. MPC’s are equally considered to be cen-
ters of excellence where more invasive treatment op-
tions, requiring specific equipment and technical skills,
are frequently used thus enhancing the quality of care.2
RF treatment is classified as a minimal invasive pro-
cedure that can be considered for some patients. RF
treatment is currently used in most countries of the
world, though not equally to the same extent. Differ-
ences can mainly be attributed to a lack of accepted
guidelines, accurate training programs and financial sup-
port from health authorities and insurers.
Eligibility criteria for RF-treatment will depend on
the pain location and the identified source as described
in previous chapters of this issue. Psychological factors
should also be considered for eligibility or exclusion. A
thorough psychosocial evaluation is required in candi-
dates for RF therapy prior to treatment. Similarly, social
and psychological support should be provided during
treatment as well as during follow-up.
Psychological evaluation of the candidate for RF
treatment has 2 important objectives:
• To determine the presence of psychological and
social characteristics that could increase the proba-
bility of benefit.
• To help the physician identify the patients in whom
this treatment would result in failure, or medico –
legal consequences.
At present, however, there are no known psychological
factors that by themselves can be predictive of successful
outcomes, even when RF has been used appropriately.
In contrast, psychological-based exclusion criteria have
been identified.3
CLINICAL USE OF RF TREATMENT
RF treatment has been used since the beginning of the
twentieth-century in a variety of indications with vari-
able degree of success. The most frequently described in-
dication for RF treatment is trigeminal neuralgia, an in-
dication for which there is extensive experience. The
first report dates back to the early 1930s; later Sweet and
Wepsic developed percutaneous thermal retrogasserian
rhizotomy.4,5
A review of 25-years of experience with 1600 patients
receiving percutaneous RF trigeminal rhizotomy for
idiopathic neuralgia indicates acute pain relief in 97.6%
of the patients and continued complete pain relief at
5 years follow-up in 57.7%.6 Complications in this se-
ries were diminished corneal reflex, masseter weakness
and paralysis, dysesthesia, anesthesia dolorosa, kerati-
tis, and transient paralysis of cranial nerves II and VI.
Other studies evaluating the efficacy of RF treatment of
the gasserian ganglion in essential or idiopathic trigemi-
nus neuralgia show similar results.
Comparisons with other techniques are mainly based
on retrospective evaluations.7-15 Setting up randomized
controlled trials in this painful syndrome with patients;
refractory to other treatment options is not possible.
The benefit of RF treatment of aspecific trigeminal neu-
ralgia is still a point of discussion. Limited experience
with pulsed RF treatment of idiopathic neuralgia has re-
cently been published.16,17 Efficacy of pulsed RF at this
stage cannot be evaluated.
Cluster headache as a syndrome is well described. Re-
ports of open trials using RF treatment of the sphenopa-
latine ganglion indicate good results, though these find-
ings need to be confirmed by controlled trials.18

Chronic Cervical Pain can arise from several struc-
tures in the cervical region including zygapophyseal
joints, discs, nerve roots, ligaments and myofascial
structures.19 The prevalence of cervical pain is judged to
be as frequent as low back pain. The cervical pain syn-
dromes, which are accessible, for invasive RF treatment
are: cervical pain, cervicobrachialgia, and cervicogenic
headache. Each pain syndrome may have more than one
nociceptive source. As a consequence more than one RF
treatment modality may be needed in relieving patients’
pain.
Chronic cervical spinal pain can be defined as me-
chanical neck pain originating from the facet joints or
from the intervertebral discs.19
Cervicobrachialgia is described as pain originating
from the cervical spine radiating from the neck beyond
the gleno-humeral joint into the upper limb with referral
to a particular spinal segment.20 Cervicogenic headache
could originate from structures in the neck. The cardi-
nal feature delineating cervicogenic headache from the
other headache syndromes is the concept that the pain
originates from a structural abnormality in the cervical
spine.21 Various structures in the cervical spine, such as
the facet joints, segmental nerves, intervertebral discs,
muscles and ligaments are capable of causing neck pain
and headache. The success of RF treatment of cervical
syndromes will depend on the definition of the causative
structure using diagnostic test blocks with a local anes-
thetic.
The management of cervical pain and cervicobrachi-
algia with RF treatment was described in open; retro-
spective and 3 randomized controlled studies.22-24 One
of the RCT’s compared RF treatment at 67C with RF
treatment at 40C.22 The clinical efficacy varies from
one trial to another and in a recent review Geurts et al
concluded that there is limited evidence for RF-facet
denervation in chronic cervical pain after whiplash.
There is limited evidence that radiofrequency lesioning
adjacent to dorsal root ganglion (RF-DRG) is more ef-
fective than placebo in chronic cervicobrachialgia.25
The first publications on the use of RF treatment for
neck pain and headache suggested some chance of bene-
fit.26,27 But due to the absence of a consensus about the
diagnostic classification of cervicogenic headache and
the uncontrolled study set-up, those results are not com-
pelling. A recent open prospective study showed a sig-
nificant improvement in patients selected based on the
diagnostic criteria described by Sjaastad et al.18,21 There
are no reports in the literature on complications after
RF percutaneous facet denervation (RF-PFD) at cervical
RF: State of the Art • 271
level when the procedure is technically performed as de-
scribed.27 Postoperative burning pain is mentioned by
10% to 20% of the patients, but this disappears sponta-
neously after some weeks. After RF-DRG 40% to 60% of
the patients report a mild burning sensation in the treated
dermatome that subsides spontaneously after a short
period of time. There may also be a slight hypesthesia,
which mostly disappears after several months.20,24 Ex-
ceptionally a Horner’s syndrome may occur after RF le-
sioning of the stellate ganglion.27,28
Pain syndromes originating from the thoracic spine
occur in 5% to 7% of the patients seen in a pain clinic.
In this type of patients diagnostic evaluations should ex-
clude underlying pathology such as herniations, aneu-
rysms, tumors, old fractures or infections. One should
distinguish thoracic pain, which can be described as
pain originating from the zygapophyseal joints and/or
thoracic disc and thoracic segmental pain with referral
into 1 or more particular spinal segments due to involve-
ment of the segmental nerve in the pain syndrome, re-
lated to vertebral collapse, 12th rib syndrome, and seg-
mental peripheral neuralgia.29,30
Documentation on the use of RF treatment in the
thoracic region is relatively scarce and restricted to open
studies. After thoracic facet denervation  80% of the
patients experienced good pain reduction for at least 2
months.30,31
RF treatment adjacent to the thoracic dorsal root
ganglion is a difficult technique due to the need of drill-
ing through bone.32 Potential complications are seg-
mental nerve injury, spinal cord injury, pneumothorax,
and thoracic neuritis. Two open studies using RF-DRG
at thoracic level report good short-term and long-term
results.33,34
RF treatment of low back pain is most frequently
used and most often described. This phenomenon is
partly due to the fact that incapacitating chronic low
back pain develops in more than 14% of the patients.
The vast majority of those patients suffer nonspecific
low back pain that may be of discogenic origin, from the
facet (or zygapophyseal) joints or from the sacroiliac joint.
Lumbar pain is frequently divided into 2 compo-
nents: neurogenic pain and mechanical low back pain.35
RF-DRG is developed as an alternative to the surgical
rhizotomy, use is based on the principle that nociceptive
input at the level of the primary sensory neuron might
be reduced by coagulation of a small part of the DRG
without causing sensory deficit.36
One prospective and 6 retrospective studies have re-
ported beneficial effects of lumbosacral RF-DRG.20,36-40
272 • van zundert et al.
One randomized controlled study failed to show advan-
tage over sham treatment with local anesthetic.41
Lumbar facet denervation by means of RF treatment
is based on the premise that neurolysing the medial
branches of the distal portions of the spinal posterior
rami nerves that supply painful lumbar facet joints, will
result in alleviation of back pain and a return of func-
tion. Technically there are 2 prerequisites for success of
RF-PFD the identification of the painful joint using di-
agnostic blocks and the precise localization of the nerve
supply to the targeted joints.42
The clinical outcome of this technique has been de-
scribed in 18 retrospective, 7 prospective studies and 4
randomized clinical trials.25 The results of the RCT’s
are somewhat contradictory though comparing them is
not possible because of differences in patient selection
criteria, use of diagnostic blocks and efficacy parameters
followed by each study.26,37,42,43 The negative outcome
from the study of Leclaire et al. partly can be attributed
to the patient selection, relying on the results of diagnos-
tic injection done by the referring physician, which may
result in greater heterogeneity of the study sample than
in earlier studies, with inclusion of some patients whose
pain was not truly of facet origin.42,44
RF treatment of the intervertebral disc is a novel ap-
plication relying on indirect heating of the annulus. The
initial positive findings of a retrospective study could
not be substantiated in an RCT.45,46 Subsequently alter-
native methods of producing thermal lesion in the lum-
bar intervertebral disc have been described using flexible
catheters allowing heating of the nuclear/annular inter-
face. It is too early to evaluate its results.
The RF procedures in the sacral and pelvic area are:
lumbar and sacral DRG, sacroiliac joint denervation, RF
treatment of the innervation of the pelvic viscera such as
presacral nerve, superior hypogastric plexus and gan-
glion impar. In selected cases RF of the somatic nerves
could be considered. The simplicity of the technique and
the possibility to use it on an outpatient basis will in-
crease the interest in this treatment option. The duration
of pain relief could be limited in cases were an anatomi-
cal disturbance is unrelated to the pain. The best results
are achieved with a multidisciplinary approach.
Interruption of the sympathetic chain has been used
for a long time to treat intractable pain in the sacral-
pelvic region, for the management of visceral pain and
CRPS. The application of RF in this indication differs
from its use for other targets such as sensory nerve tissue
because no sensory threshold can be achieved in the
sympathetic nerves. The use of RF treatment has the ad-
vantage over surgical resection, phenol or alcohol neu-
rolysis because it being more selective and thus causing
fewer complications.47,48
RF treatment of CRPS was compared with phenol
neurolysis. The efficacy of RF treatment seems to be
comparable to phenol neurolysis but the incidence of
complications was lower. One should be aware of the
potential injury of the genitofemoral nerve, especially if
multiple RF lesions are performed.
The management of CRPS at the thoracic level seems
to have similar advantages over the chemo neurolytic
techniques. In this region one should be aware of the
risk of inducing pneumothorax. Up until now no ran-
domized controlled trials (RCTs) comparing RF treat-
ment with another therapeutic approach are available.
See Article lumbar and thoracic sympathetic RF lesion-
ing in complex regional pain syndrome—G. Racz and
M. Stanton-Hicks—in this issue of Pain Practice.
Visceral pain due to chronic pancreatitis, pancreatic
cancer, liver cancer or postabdominal surgery pain that
is not or no longer responding to pharmacological treat-
ment can be managed by RF lesioning of the splanchnic
nerves. From the available experience, retrospectively
analyzed we can deduct that this technique is more se-
lective and causes fewer complications. (See Pain Prac-
tice—RF lesioning of splanchnic nerves P. P. Raj et al.)
The management of pain originating in the periph-
eral nerves could only be developed when a non-neuro-
destructive RF technique became available. There are
currently several case reports on the PRF treatment of
peripheral nerves. In a small series of patients suffering
chronic shoulder pain a good pain relief was noted for a
relatively long period with a small number of interven-
tions.49 We have case reports on the treatment of su-
praorbital nerve, intra patellar nerve, tibial posterior
nerve, lateral epicondylitis, intra digital nerve (hand/
foot) and neuromata. The patients selected for this treat-
ment option all had a long history of pain and trial and
error of different treatment modalities. We noted at
least a transient improvement of the pain, but the data
are too scarce to draw any conclusions.
Neuroablative procedures have been used frequently
for the management of intractable cancer pain. Amongst
the available techniques RF treatment has proven to be
the most selective. It needs to be said that the recent phar-
macological developments have resulted in increasing
degree of pain relief thus restricting the number of pa-
tients, as candidate for RF treatment. Considering the
potential complications of neurolysis, RF should only be
used for unilateral pain when the estimated survival

time is about 6 months. The percutaneous cervical cordo-
tomy is an example. The technique requires an experi-
enced clinician and an appropriate patient selection. It is
an irreversible procedure with a low but risk of high
mortality and morbidity.
Spasticity is defined as sensorimotor disorder with a
velocity dependent increase in tonic reflexes and exag-
gerated tendon reflexes as a result of hyperexcitability of
the stretch reflex.50 The management of spasticity in
children with cerebral palsy remains to be complex, al-
though several new treatments have been developed in
recent years. Because spasticity goes beyond the scope of
1 specific discipline, careful evaluation of the patient by
a multi-disciplinary team is required. An emphasis on
functional improvement an/or facilitating rehabilitation
after treatment should be made. The management of
spasticity with the aid of physical therapy in order to im-
prove functionality and avoid painful contractures has
been the only treatment option for years. Besides physi-
cal therapy, roughly 3 treatment options are available
nowadays, oral pharmacotherapy, chemical denerva-
tion, and surgery.51 In the 1980s several authors re-
ported on the beneficial effects of percutaneous RF
lesion adjacent to the dorsal root ganglion on adult pa-
tients with intractable spasticity.52,53 A recent pilot
study investigated the effects of RF-DRG on spasticity
and pain of the lower extremities in children with cere-
bral palsy.54 The study group was small but beneficial
effect was found on both muscle tone and care giving.
Furthermore, RF-DRG improved pain associated with
the spasticity. No adverse effects or treatment complica-
tions were reported. All treatments were performed on
an outpatient basis under general anesthesia. This indi-
cation is relatively new for RF treatment and further
work is required.
VALUE OF THE EVIDENCE OF RF TREATMENT IN
THE CLINICAL DECISION-MAKING
Decision-making in pain therapy is not easy. Chronic pain
is not only a physical problem; its multidimensional as-
pect has been described earlier. Treatment outcome can
be influenced by other factors such as patients’ attitudes,
beliefs, psychological distress, and illness behavior.
The constant search for the best choice in treatment
options together with the request from policy makers to
provide proof of efficacy and safety as well as economic
advantage have stimulated the search for the “best evi-
dence” allowing clinicians to select the most appropriate
treatment option.
RF: State of the Art • 273
The practice of EBM consists of integrating the per-
sonal clinical expertise and the best available external
clinical evidence from systematic research.55 The princi-
ples of Evidence Based Medicine attribute the highest
value to systematic reviews, at A1 level, one considers
evidence generated by RCTs with good design and on a
sufficiently large number of patients at level A2, smaller
RCT’s or trials with weaknesses in the design, are
judged at level B; non-comparative studies provide evi-
dence at level C, findings from clinical trials can be com-
plemented by expert’s opinion.
In a recently published systematic review on RF treat-
ment of spinal pain, Geurts et al found moderate evi-
dence that RF lumbar facet denervation is more effective
for chronic low back pain than placebo, limited evi-
dence for the efficacy of RF-PFD in chronic cervical zyg-
apophyseal joint pain after whiplash, limited evidence
for RF-DRG to be more effective than placebo in
chronic cervicobrachialgia.25 An update on the RF pro-
cedures at the lumbar level is published in this issue.
These findings from the systematic review seem logi-
cal considering the contradictory results found in the
different RCTs. The differences may be attributed to dif-
ferences in patient selection criteria, use and interpreta-
tion of diagnostic procedures and variability in outcome
measurements. Criticisms on the studied sample size
have been formulated. As opposed to the wide accep-
tance of RCTs for pharmacotherapeutic options, where
the new treatment can be compared with the “available
golden standard,” conducting well-designed RCTs on
the efficacy and safety of invasive pain treatment is com-
plicated by:
• The need for a sham intervention as comparator, and
the obligation to obtain patient’s informed consent
which may result in refusal to participate in the trial.
• Ethical considerations of withholding an active treat-
ment from patients whom suffer intractable pain (eg,
cancer pain and trigeminal neuralgia).
Differences in study design, patient selection criteria and
outcome measurements make meta-analysis difficult.
The data results in the critical reviews mainly focusing
on the quality of the trial scored by independent review-
ers. Critical reviews offer an inventory of the available
data but do not provide meta-analytic judgments.56
Applying the methods of EBM to pain management
would demonstrate the value of interventions objec-
tively and ineffective techniques could be identified and
abandoned. Yet if current enthusiasm for EBM were to
result in no clinical intervention being offered (or reim-
274 • van zundert et al.
bursed) until and unless it has a strong evidentiary basis
this would imply that patients are withheld treatment op-
tions that might provide a considerable pain relief and im-
provement of the quality of life. As stated by McQuay and
Moore, Wiffen, Jadad in the evidence based pain medicine
movement: it should offer “tools not rules.”56-59
A more complementary approach, considering the
best evidence that gives the most valid and objective an-
swer to the different types of questions arising both in
clinical practice and in heath care resource management,
and coming from the synthesis and integration of the re-
sults of scientific studies from different knowledge fields
aside from health sciences—such as social, economic, and
political sciences.60 In one author’s recent work [thesis—J.
Van Zundert—Treatment of (chronic) low back pain in a
multidisciplinary pain center: effects and costs] he found
that the standard use of RF techniques in a multidisci-
plinary setting for the management of low back pain results
in less frequent application of more invasive and expensive
treatment options (eg, surgery and neuromodulation).
Though it is hard to accept that after 25 years of clin-
ical use of RF procedures one still lacks evidence of effi-
cacy and safety. Many patients seem to have pain relief
and there is a vast amount of documentation on out-
come. However, the difference in study design doesn’t
allow meta-analysis and thus preventing drawing objec-
tive conclusions. The reason for the limited amount of
high quality clinical randomized studies lies in the fact
that the procedure was only applied in few countries
such as the Netherlands, Belgium, Australia, and En-
gland. Only after 1996 the RF procedures became popu-
lar in United States. (See the article in Pain Practice.)
RF procedures presently have first prospective ran-
domized studies on the efficacy of RF-procedures, which
are small in number, have a short follow-up of out-
come.43 They are of limited value because of variable
patient selection.22,44,61
The experts’ opinion, as published in this issue, mention
the use of RF treatment in a large spectrum of indications,
illustrating a gap between results obtained in research set-
tings and daily practice. Clear and standardized documen-
tation of procedures and outcome in daily practice may
contribute to elucidating the differences observed in out-
come in RCTs (efficacy), which rely on experimental con-
ditions, and in everyday clinical practice (effectiveness).
The use of sham interventions is questionable.62
Can this gap between scientific data and clinical prac-
tice be narrowed?
In order to avoid RF treatment to be used “as a gen-
eral solution” and to shorten the learning curve about
the best technical approach, centers should have stan-
dardized protocols for patient selection and treatment.
Outcome should be accurately documented, allowing
retrospective evaluation. The findings of such clinical
audits should then lead to the set-up of an RCT.
In-line with the experience of conducting clinical trials
with pharmacotherapy, statistical significance of RCT’s can
be achieved by conducting multi center—multicountry
studies using international accepted protocols.
Attention should be paid to identifying diagnostic
sub-populations, describing the clinical characteristics
of those populations and validating the clinical diagno-
sis. The outcome measurements should be standardized
and validated. The studies should answer the questions:
Which type of RF treatment is suitable for this popula-
tion and is this treatment efficacious?
For the RF-procedures, it will be years before we will
be able to present “International guidelines on adequate
and validate RF techniques.”
How can we handle this situation in the mean time?
The available documentation on the RF treatment in
different pain syndromes published elsewhere in this
journal indicates that this option will only be considered
when conservative causative and symptomatic treat-
ment has been used to its full extent and fails to provide
satisfactory pain relief. For the well-documented indica-
tions, authors mention patient selection criteria, consist-
ing of clinical signs, medical imaging, and identification
of the causative nerve structure—if possible by means of
diagnostic blocks—and psychological assessment. The
success rate will depend on the accuracy of the diagnosis
and the identification of the causal nerve structure, the
experience of the physician using the technique and the
patient’s expectations. The optimal environment for ap-
plying RF treatment is a multidisciplinary setting facili-
tating diagnosis, treatment and guidance in terms of ex-
pectations and coping with the rest pain.
In general, we can say that the application of RF in
the management of chronic pain is a useful tool, because
of its low invasive character, the target selective ap-
proach, the possibility of outpatient treatment, and its
safety (if it’s done by a well-trained pain physician in the
right setting). In-line with the WHO treatment ladder
for the management of chronic cancer pain, the treat-
ment algorithm for chronic nonmalignant pain could be
represented as illustrated in Figure 1.
MINIMAL STANDARDS AND RECOMMENDATIONS
Among the invasive pain management options, RF treat-
ment is probably the most described. It is documented in

a wide variety of painful conditions, refractory to con-
ventional treatment. Accurate use of RF treatment as
part of a multimodal and multidisciplinary approach,
may avoid the use of more invasive and often more ex-
pensive treatment options. Moreover, most of the RF
procedures are done on an ambulatory basis in outpa-
tient clinics.
We recommend:
• Multidisciplinary patient selection, using validated
selection criteria
• An informed consent from the patient can be consid-
ered.
• Where indicated, use of diagnostic blocks
• Use of fluoroscopy
• Standardized report on the intervention including:
impedance, volt, temperature, time and radiographic
photos
• Standardized patient follow-up with validated out-
come evaluation tools
• Physicians should receive an accurate training includ-
ing the anatomy, technical aspects, practical treatment
and radiation protection.
FUTURE EVOLUTIONS OF RF TREATMENT
RF treatment may be a valuable treatment option for
patients suffering from refractory pain resistant to con-
ventional treatment. Its use is still somewhat restricted
due to the remaining controversies in accurate patient se-
lection; the available level of evidence and the risk for
Figure 1. Schematic representation of the step-wise approach of chronic pain.
RF: State of the Art • 275
neurological complications due to heat induced nerve
damage.
The current evolution of RF from the initial neuro ab-
lative thermocoagulation towards the non-neurodestruc-
tive pulsed RF seems to enlarge its therapeutic value in the
management of chronic pain.
RF treatment has been used empirically for the man-
agement of different chronic pain syndromes based on
the assumption that thermocoagulation of the nerve fi-
bers will interrupt the pain conduction. The success of
this treatment option is mainly attributed to the experi-
ence that pain may be alleviated without causing clinical
signs of nerve damage.23 Letcher and Goldring sug-
gested that small myelinated fibers might be more sensi-
tive to heat.63 However, histological studies reveal in-
discriminate destruction of both small and large fibers
following RF-treatment.64,65 These findings were con-
firmed in the animal study on the morphological effects
of RF lesion on the DRG.66 The authors found destruc-
tion of the small and large nerve fibers when the elec-
trode was placed inside the DRG, when the needle was
placed adjacent to the DRG no damage was seen under
light microscopy but there was a significant increase in
monoclonal antibodies against recombinant parts of the
Ki-67 antigen (MIB-1) activity. Immunohistologically this
indicates proliferation of satellite cells and regeneration
of the damaged nerve fibers. These findings are in line
with the clinical results observed by Slappendel et al sug-
gesting absence of any relationship between the temper-
276 • van zundert et al.
ature used for thermal lesioning and the desired clinical
effect.22 They compared clinical outcome after RF-DRG
at 40C with RF-DRG at 67C and found no differences.
In 1998 Sluijter et al compared the effects of continu-
ous RF current at 42C with pulsed RF with a maximum
of 42C and found better results with the pulsed RF
treatment.67 It is a non-destructive alternative to the RF
thermocoagulation, whereby the tip temperature of the
electrode doesn’t exceed 42C while maintaining a high
output. This is achieved by exposing the nerve to a high-
frequency electric field of 45 V during only 20 msec per
500 msec, allowing the 480-msec pause to eliminate the
heat generated during the active cycle. During applica-
tion of RF treatment the generation of heat is not the
only event that occurs; the tissue is also exposed to the
RF field. Such electric fields are known to have a biolog-
ical effect, which may explain the mode of action of RF
although the mechanism is still ill understood.68
The alternative isothermal Pulsed RF (PRF) treat-
ment, described by Sluijter et al has recently been com-
pared in animal experiments with continuous treatment
at 42C. In PRF applied to the dorsal root ganglion of
the rat, c-fos, a marker of neuronal activation, was ex-
pressed in the laminae I and II of the corresponding part
of the dorsal horn, which was observed after continuous
treatment at 42C.69 This implies that in PRF adjacent
to the DRG the effects of exposure to electric fields are
transmitted to more central neurons.
In organotypic nervous tissue cultures, PRF at 38C
and 40C but not continuous RF at 42C transiently
modulates excitatory synaptic transmission, measured
by neuro electrophysiological records.70
Mungliani described his case reports with PRF indi-
cating that this treatment option might be safer than the
continuous RF-treatment.71 More recently promising
results have been reported in the cervicobrachialgia and
frozen shoulder syndrome, and 2 contradictory results
on the use of PRF in the management of idiopathic
trigeminal neuralgia.16,17,49,72
Finally, even though (P)RF treatments are used in many
countries and clinical use is increasing well-designed trials
should be conducted to establish the real value of this
treatment option.
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