Lumbar RFA younger patients

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paingate21

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Recently saw a patient who is fused T3-L3 in setting of adolescent scoliosis - mid 20s now with chronic low back pain. CT myelogram with facet arthropathy most pronounced L4-L5. No central stenosis - some LR narrowing. Bending forward improves symptoms - standing and extension increase.

Did intraarticular L4-L5 facet steroid injection with over 2 months of relief…would you just repeat this? Consider RFA? Or consider something different?

No conclusive evidence out there for RFA leading to multifidus atrophy but what is end game with RFA in younger patients?
 
This is different than your classic young patient with facet disease most likely secondary to an injury.

There are structural changes due to prior surgery.

In these cases, I would be more inclined to do RFA.

that would also save years of steroids.
 
post the CT.

i bet its disc.

RF wont have great results
 
I used to be concerned about RFing young patients too but they usually have robust relief from RFA’s and then no longer need to come in for regular shots. You don’t want to be going to the doctor every few months as a 20 year old.
 
I kept a younger patient away from a multilevel fusion that her spine doc wanted her to have. She has had rfs every year or two and has been fusion free for 10 years.
 
Could try facet injections with PRP. Might last longer than 2 mo.
 
RoloTomassi said:
Could try facet injections with PRP. Might last longer than 2 mo.
Click to expand...

Comparing the efficacy of intra-articular injection of Platelet Rich Plasma (PRP) with corticosteroids (CS) in patients with chronic zygapophyseal joint low back pain confirmed by double intra-articular diagnostic blocks: A triple-blinded randomized

To compare the safety and effectiveness in improving function and reducing pain of autologous PRP to corticosteroid (CS) zygapophyseal (Z-joint) intra-articular (IA) injections at six months for patients with chronic osteoarthritis Z-joint mediated ...
pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov

This weekend at IPSIS, abstracts were presented showing longer-term follow-up (12 month) for that article (which stopped at 6 months. PRP effect peaked at 9 months which is close to what you would get with an RFA, without the denervation.

Another poster presentation, again at IPSIS, showing PRF (similar to PRP but some particularities) to be superior to RFA in a small non-blinded RCT.
 
Not a lot, there was another poster on here who did a lot and saw pretty good results. My results are 50/50
 
Mid 20s, I would do facet injections with either steroid or PRP, but would do an RFA if those were not lasting very long.

Just not an ideal situation, but certainly not wrong to do it.

I am still on the fence about multifidus atrophy and whether that matters, but I am inclined to think it does.

I go out of my way not to ablate young people though...Rare event I do that but I don't see a lot of young people either.
 
without being long winded, this study is similar to the studies that drusso has already posted.

a lot of ppl recruited for the study then a lot eliminated to get a small group of 50 people.

ultimately, the study showed that CS patients were better up to 3 months and PRP was better after 3 months. so no different.

i would like to see the poster presentation, but from my experience, poster presentations are poster presentations because the evidence isnt robust enough.
 
appreciate thoughts so far - Here are some of the CT slices - 2 Sags and Ax through L4-L5.

1.PNG
3.PNG
2.PNG
 
paingate21 said:
appreciate thoughts so far - Here are some of the CT slices - 2 Sags and Ax through L4-L5.

View attachment 409565 View attachment 409566 View attachment 409567
Click to expand...
That’s a big surgery for a young kid. Probably going to have life long back pain unfortunately. If he’s only getting two months of relief with intra-articular steroids id do an RFA without question. I’ve never done PRP in the spine (it might work?) but that would be cash pay and off label.

If you cause multifidus atrophy you could always do Reactiv8 later and “rebuild the muscles” like their website says 😉.

Do an RFA and see what happens. If no benefit you could consider SCS. Tough case. Kid got dealt a bad hand.

-also, I’d probably get an MRI. Not sure if anyone else agrees, but if you are concerned about the adjacent levels you should be able to see the discs and the lower levels despite artifact. Just a thought
 
Last edited:
I told him you, it’s the l4-5 disc. You see it on the CT SCAN.

You can RF, and I wouldn’t consider it dangerous, but the facets at that level are fine. The RF wouldn’t give as good a response as the steroids bc there is a local
Anti inflammatory effect with the steroids.

The kid is not gonna get an RF every year. Maybe when he is 50 or 60 it will start working.

Time to move away from the needles here

Update us a couple months after the RF
 
I agree with SS, why not try an esi first?
 
I had a 50 year old guy who had lumbar mbb by a different group. Doc used a 22 gauge and the guy had severe pain during the procedure. Patient is an average guy, no pain meds, works as an accountant. His pain is more facetogenic, but I assumed that the other pain doc (the name of which I know) just had poor technique, so I repeated the mbb with 25 gauge needle and he had no relief. My own hubris clouded my decision making when I shouldn’t have just tried an esi. Now someone else is gonna play Monday morning qb and look like a hero while my press ganey score will suffer..
 
Dr. Ice said:
I had a 50 year old guy who had lumbar mbb by a different group. Doc used a 22 gauge and the guy had severe pain during the procedure. Patient is an average guy, no pain meds, works as an accountant. His pain is more facetogenic, but I assumed that the other pain doc (the name of which I know) just had poor technique, so I repeated the mbb with 25 gauge needle and he had no relief. My own hubris clouded my decision making when I shouldn’t have just tried an esi. Now someone else is gonna play Monday morning qb and look like a hero while my press ganey score will suffer..
Click to expand...
I’d still do the mbb first here (if has clinical features to support) before I rec an esi for axial pain where perhaps 50% chance it helps at all and will be short term
 
I would do esi first. Usually some short term benefit from either addressing disc or systemic steroid response. gets them on board for further treatment
 
Taus said:
I’d still do the mbb first here (if has clinical features to support) before I rec an esi for axial pain where perhaps 50% chance it helps at all and will be short term
Click to expand...
Mbb just bc it is axial pain?
 
SSdoc33 said:
Mbb just bc it is axial pain?
Click to expand...
The patients symptoms were actually more facet related. He had minimal disc disease at 4-5 and 5-1. Pain was worse with transitional movement, non radiating, stiffness in the morning, better with sitting, yady yada. PT for 3 months, home exercises, supposedly compliant with hep, trialed NSAID’s.
 
Agree that statistically its most likely disc, but could be a bit of both. I just edited my post after seeing the above post. MBB/RFA is a reasonable next step. If not enough relief then MRI and potentially Intracept.
 
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