Ankylosing Spondylitis: best literature on treatment?

[Ligament]

Hi All,

I have a very nice patient with AS with diffuse axial low back and SI pain. Responded very well to SI blocks. Have there been any studies on treatments for AS with RF, intraarticular facet blocks, or other interventional pain treatments? Your advice appreciated. Thanks.

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[Ligament]

bump. He's responding very well to multi level MBB. Anybody here do multi level rhizo (ie. the whole lumbar spine) for severe AS?

 

[CB1Antagonist]

I have done a 5 level (C3-7) bilateral RFA for an AS patient who is now 6 months pain free. No experience in the L spine though.

 

[SSdoc33]

i would be careful burning out those medial branches. its like putting a band-aid on on gaping wound. AS is systemic, so while you may provide some temporary relief you will necessarily need to to it over and over, and more likely than not, expand your coverage. the relief will become less efficacious as time goes on, and the procedures more difficult.

also, by denervating the z-joints, you might hasten then development of spondylosis and fusion.

if the patient has the means and insurance covers it, they'd be better off on a biologic, IMHO.

 

[lobelsteve]

i would be careful burning out those medial branches. its like putting a band-aid on on gaping wound. AS is systemic, so while you may provide some temporary relief you will necessarily need to to it over and over, and more likely than not, expand your coverage. the relief will become less efficacious as time goes on, and the procedures more difficult.

also, by denervating the z-joints, you might hasten then development of spondylosis and fusion.

if the patient has the means and insurance covers it, they'd be better off on a biologic, IMHO.

You are making bold claims that have no foundation in the literature.
RF does not lead to spondylosis, Charcot spine, or fusion.
Why would the relief become less? You can propose that the sprouting that occurs makes performing repeat RF in the same manner less effective, but in trained hands, parallel lesioning to capture and destroy the sprouts will be equally effective.

 

[Tenesma]

having done RF on a few AS patients i find the amount of relief shorter in duration (usually about 3-4 months) - you can blame my technique, but i blame the disease...

 

[SSdoc33]

You are making bold claims that have no foundation in the literature.
RF does not lead to spondylosis, Charcot spine, or fusion.
Why would the relief become less? You can propose that the sprouting that occurs makes performing repeat RF in the same manner less effective, but in trained hands, parallel lesioning to capture and destroy the sprouts will be equally effective.

which claim is bolder?

1. RF does not lead to spondylosis, Charcot spine, or fusion.
2. RF might hasten the development of spondylosis, Charcot spine, or fusion.


you tell me. sounds like you are being absolute here, not me. the reason i am not quoting literature is b/c i dont think there is any info on the above potential complications in the literature. if you know about some, please let me know. just because there is an absensce of complications in the literature does NOT mean that it might not occur.

and why do you think this would not happen, when it occurs in every other weight-bearing joint? do you at all give a second thought to performing an RF on a 25 year old because of potential long-term sequellae? i do.

my overall point is that AS occurs along the length of the entire spine. to me, RF sounds like a temporary solution when the pateint would be better off with a long-term solution (such as a TNF inhibitor).

 

[lobelsteve]

which claim is bolder?

1. RF does not lead to spondylosis, Charcot spine, or fusion.
2. RF might hasten the development of spondylosis, Charcot spine, or fusion.


you tell me. sounds like you are being absolute here, not me. the reason i am not quoting literature is b/c i dont think there is any info on the above potential complications in the literature. if you know about some, please let me know. just because there is an absensce of complications in the literature does NOT mean that it might not occur.

and why do you think this would not happen, when it occurs in every other weight-bearing joint? do you at all give a second thought to performing an RF on a 25 year old because of potential long-term sequellae? i do.

my overall point is that AS occurs along the length of the entire spine. to me, RF sounds like a temporary solution when the pateint would be better off with a long-term solution (such as a TNF inhibitor).

In between cigarettes, Nik told me so. And he had a good explanation at the time. That was in 2003.

As far as RHeumatology- I'll let them handle the scary stuff.
The patients need both.

 

[SSdoc33]

In between cigarettes, Nik told me so. And he had a good explanation at the time. That was in 2003.

As far as RHeumatology- I'll let them handle the scary stuff.
The patients need both.

'nuff said.

as an aside, i asked the same question at a question and answer session and he basically gutted me like a fish.

 

[Ligament]

To clarify, the patient is under care of rheumatology for meds and DMARDS and stuff.

He is in his late 30's.

His options are lifetime, presumably escalating opioids or until Rheum has a "cure" Or rhizotomy and hopefully a lesser need of opioids with repeat rhizotomies as needed. Perhaps simplistic thinking on my part. I'm open to ideas of course!

 

[Formication]

I know of no data that says RF does or does not produce more radpid spondylosis or fusion. But, in the case of AS, doesn't autofusion diminish this pain from the segment? Sure seems like it would to me.

 

[Tenesma]

what i find is that they are battling with a lot of muscular pain - constant spasms, especially when the AS contorts the spine....

 

[dc2md]

what i find is that they are battling with a lot of muscular pain - constant spasms, especially when the AS contorts the spine....

then what do you think the RFA is doing for the muscles?? you are denervating the multifidi (which i guess could lead to no spasms), but unless you also lesion the lateral branch of the DPR, you're leaving the longissimus and iliocostalis. sounds like baclofen/zanaflex/etc would be better for pain relief.

and let's not forget about physical therapy/swimming.