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A young patient walks in with ordinary back pain and leaves on a path that can quietly weaken the muscle holding the spine together. Francisco M. Torres is an interventional physiatrist who noticed these patients coming back to him sooner, and traced it to radiofrequency ablation denervating the multifidus, the back's most important stabilizer, until the muscle atrophies and fills with fat. This episode is based on his article "Radiofrequency ablation and the young back pain patient," published on KevinMD. You will hear why insurers began steering these patients toward the procedure, why most of the evidence comes from older patients with degeneration rather than people in their twenties, and why he believes the muscle damage should be spelled out in the consent form. He explains why generic core exercises fall short, how facet injections and targeted rehabilitation offer a lower-risk path, and the exact questions to ask before you agree. Press play to hear the questions worth asking before you let anyone burn a nerve in your back.
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A spine doctor started telling his patients one more thing before they signed for a common back procedure. A lot of them stopped signing.
The one more thing is that the procedure works by burning a nerve, and that nerve is also the supply line for the muscle your lower back depends on.
Francisco M. Torres is an interventional physiatrist who spent most of his career treating young adults whose back pain doesn't radiate anywhere and whose imaging shows almost nothing.
For years his plan was simple. Calm the joint down with an injection and get them into real physical therapy. He wouldn't hear from those patients again for years.
Then the rules changed. Insurers began requiring a diagnostic nerve block before they'd approve the joint injection. Torres doesn't perform that block, so those patients went to the physicians who do. And once a patient is sitting in front of a physician who does nerve blocks, the next thing on the menu is radiofrequency ablation, which pays well and which cauterizes the nerve instead of quieting the joint.
His patients started coming back sooner.
What patients aren't told, he says, is what else that nerve is doing. It's the medial branch of the dorsal ramus, and it also supplies the multifidus, which Torres calls the most powerful stabilizer of the back. Take out the nerve and you take out the pain signal, and the muscle loses its supply along with it.
He is careful about the evidence, and that carefulness is the whole reason to listen to him. A 2009 study found atrophy and fatty replacement of the multifidus two years after a one-sided ablation, and it could not tie those changes to pain or disability. Nobody has run the long-term study that would settle it either way. And what we do know about ablation comes mostly from patients over 50 whose spines are already degenerating, not from a 20-year-old who still has 40 years to go on that spine.
Torres says the procedure has a role and he isn't out to badmouth it. What he wants is one line on the consent form, so a patient knows a muscle is being denervated and gets to decide whether that trade is worth it. When he says it out loud in his own exam room, a fair number of people tell him no.
If someone you love is being offered this in their twenties, he wants them asking four things. Is anyone measuring the size and quality of my multifidus before we do this? Can I have a baseline? Will we repeat the imaging after I train? And will physical therapy actually measure whether the muscle is firing, instead of just telling me to do core?
Torres put it this way:
"We are destroying something here. It is not a benign procedure. You are actually changing the anatomy."
Listen to the full conversation on The Podcast by KevinMD. Link in the comments.
#BackPain #InformedConsent #ThePodcastbyKevinMD
