Bipolar RFA for knee pain; patients with Pacemaker

Dr Ashok Jadon,MD, DNB, MNAMS, FIPP

Chief Consultant Anaesthesia In-charge Pain Relief Service

Tata Motors HospitalJamshedpur-831004

India

BackgroundChronic pain in the knees accounts for 15% of

chronic pains in the body. Degenerative cause e.g. osteoarthritis is one of the

commonest cause of knee pain

Radiofrequency ablation (RFA) is a new interventional approach being used to manage chronic knee pain*

Three genicular nerves are the targets for RFA**Choi, Woo-Jong, et. al."Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial." PAIN 2011;52: 481-487.

Genicular nerves Sensory nerves branches of the tibial, common

peroneal and obturator nerves. They supply the capsule of the knee joint as well as the

intraarticular and extraarticular ligaments.Tibial nerve: superior medial, inferior medial and

middle genicular Common peroneal nerve: superior lateral and the

lateral inferior genicular Obturator nerve: branch of the posterior division of the

obturator nerve

RFA of genicular nerves; conventional technique

SHAFT

EPICONDYLE

RFA with pace maker; concernsWith RFA a variety of changes in pacemaker are

possible during and after the treatment. EMI (Electromagnetic interference )Sensing failures in 32.0% pacing failures in 16.0% Prolonged pauses , Tachy-arrhythmias & complete pacemaker inhibition

Pfeiffer D, et al. Pacemaker function during radiofrequency ablation. Pacing Clin Electrophysiol 1995; 18: 1037-44.

RFA with pace maker; current guidelines-1ASA Practice advisory ; after report by the ASA task force on for the

perioperative management of patients with cardiac implantable pacemakers. Anesthesiology 2011; 114: 247―261.

Deactivation of implanted generators and an external pacing electrode.

Keep grounding electrode 15cm away from pacing leads

Use “00” mode

Use Magnet over Pace maker

Cardiac monitoring

Pacing system should be carefully evaluated after the procedure.

RFA with pace maker; ASA guidelines-2

Use a bipolar electro-cautery system or an ultrasonic (harmonic) scalpel if possible.

Bipolar RFA

Two patients with pacemaker64 yrs old male He has osteoarthritic

changes* in both knees but left knee was having sever

He was on Tablet Losartan, Asprin, Pregablin, Amitrptiline and Tramadol with paracetamol.

Pacemaker for syncopeRFA due to refusal for knee

implant due to poor cadiac reserve and associated high risk for surgery.

56yrs femaleRight knee osteoarthritis * She was on Tan Nifidipine

retard, pregablin, paracetamol and pentaprazol

Pacemaker for complete heart block with pain in

RFA due to side effects of analgesic drugs (gastric ulcer) and unwillingness for surgery.

*(Kellgren-Lawrence scale (K-L scale) 3-4

Methods:Medical treatment optimized

Informed consent

Physician informed and involved

With due aseptic precaution under local anaesthesia two 10cm needle with 5mm tip inserted at all three target points

Needles were inserted parallel (10mm apart)under AP view and depth was checked in lateral view (up to 2/3 distance of bone)

Bipolar RFA 80◦C for 90 sec. at each of the three target points (two cycles)

Pain was evaluated on Oxford Knee Score and VRS before procedure, and at 1wk, 1 month (in hospital) and monthly for 6 months (Telephonic)

Patient-1

Patient-2

Pain relief; Oxford score and VRS

Base line OKS (0-48) &VRS (0-10)

One week

One month

2nd Month

3rd Month

4th month

5th month

6th month

Otherremarks

Case-1

VRS

42

9/10

20

3

20

3

20

3-4

23

3-4

26

4-5

28

5-6

29

3-6

Happy on medicine

Case-2

VRS

40

9/10

22

2

20

3

20

4

20

3

24

5

30

4-6

30

3-6

TKR

Results: Oxford score & VRS

Procedure was uneventful

>70 to 80% relief for 2 and 3 months

40-50% relief at 6months

Satisfied

DiscussionRFA with bipolar electrodes is safe in patients with

pacemakers. Yuman fong. Hepatobiliary cancer.In billiary tumors.Chapter-

14;2013:pmph-usaTwo patients with pacemakers who safely underwent radiofrequency

ablation with bipolar electrodes to treat primary hepatocellular carcinoma. Sho Ijuin, et al., KANZO 2015 56(2):57-64.

Bipolar is effective RFA for knee pain 8 cases done (including leading orthopedic surgeon)Results similar to conventional may be betterLess painful, Less time taking

Conclusions

Bipolar RFA of genicular nerves was safe

and effective to manage chronic knee pain in

two patients with pace maker.

More studies with more number of cases

are required to prove the ultimate safety of

this procedure

THANK YOU

USG guided PRF Tibial, Common peronial, femoral nerve ,

Saphenous, subsartorial, peripatellar, and popliteal plexuses along with innervation of the quadriceps muscle.