basics of radio frequency techniques in pain management jadon.a
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Basics of radio-frequency ablation techniquesTRANSCRIPT
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Basics of Basics of Radio Frequency Radio Frequency
techniques in Pain techniques in Pain ManagementManagement
Dr. Ashok Jadon, MD DNBDr. Ashok Jadon, MD DNB
Sr. Consultant & HOD Sr. Consultant & HOD AnaesthesiaAnaesthesia
Tata Motors Hospital, Tata Motors Hospital, JamshedpurJamshedpur
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Principle of RF lesion Principle of RF lesion
• RF lessoning involves passage of a RF lessoning involves passage of a very high frequency current (at 300 very high frequency current (at 300 kHz) through a 27 G thermocouple kHz) through a 27 G thermocouple probe.probe.
• When a high frequency alternating When a high frequency alternating current is passed current is passed – To & fro movements of the charged ions To & fro movements of the charged ions – Generation of heat due to this electro-
mechanical friction.
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stylet
Exposed tip = 5 mm
RF electrode
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Principle of RF (contd.)Principle of RF (contd.)• The electrical field The electrical field
generation and generation and movement of movement of charged particle is charged particle is maximum at its tip maximum at its tip and minimum and minimum around the shaft. around the shaft.
• Therefore the heat Therefore the heat lesion is maximum lesion is maximum around the shaft and around the shaft and minimum at its tip.minimum at its tip.
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Conventional vs. Pulsed Conventional vs. Pulsed RFRF
• Heat producing Heat producing lesion. lesion.
• Temp can go up-Temp can go up-to 85 degree C.to 85 degree C.
• In the pulsed RF In the pulsed RF electrical field is electrical field is producing the lesion. producing the lesion.
• Temp. is not raised Temp. is not raised beyond 42 degree Cbeyond 42 degree C
In pulsed RF. Electrical field produces In pulsed RF. Electrical field produces some punch in the capacitor of small some punch in the capacitor of small diameter nociceptive fibers. Thereby diameter nociceptive fibers. Thereby signal transmission is stopped.signal transmission is stopped.
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Conventional vs. Pulsed Conventional vs. Pulsed RFRF
• In the conventional In the conventional type the nerves are type the nerves are regenerated in regenerated in future.future.
• Average pain-free Average pain-free period varies for period varies for type of nerve. (3-4) type of nerve. (3-4) years.years.
• In the pulsed RF In the pulsed RF the nerve is the nerve is repaired. repaired.
• Average pain free Average pain free period is 4-24 period is 4-24 months.months.
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Lesion characteristicsLesion characteristics
• Temperature Temperature
• Rate of thermal Rate of thermal equilibriumequilibrium
• Local Tissue Local Tissue characteristics-characteristics-ImpedanceImpedance
• Radius of Electrode tip Radius of Electrode tip and Configurationand Configuration
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ImpedanceImpedance
• Proximity of electrode Proximity of electrode to the CSF can present to the CSF can present low impedance pathwaylow impedance pathway
• Proximity of large blood Proximity of large blood vessel to electrode can vessel to electrode can deviate the energydeviate the energy
• Proximity to bone can Proximity to bone can cause discontinuity of cause discontinuity of heat due to lower heat due to lower conductivityconductivity
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Lesion size versus Lesion Lesion size versus Lesion Time CW: 20V, t= 0 secTime CW: 20V, t= 0 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=10 secCW: 20V, t=10 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=20 secCW: 20V, t=20 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=30 secCW: 20V, t=30 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=40 secCW: 20V, t=40 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=50 secCW: 20V, t=50 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=60 secCW: 20V, t=60 sec
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C
COSMAN, MIT
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CW: 20V, t=60 secCW: 20V, t=60 sec 50˚C Isotherm
37˚C
40˚C
45˚C
60˚C
55˚C
50˚C
67˚C |E|=2,750 V/m
|E|=17,000 V/m
COSMAN, MIT
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Choice Between Choice Between Conventional RF & Pulsed Conventional RF & Pulsed
RFRF
• Special IndicationSpecial Indication• Proximity to Vital StructuresProximity to Vital Structures• Newer ResearchNewer Research
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Localization of the Localization of the Target nerveTarget nerve
• Fluoroscopic guidance is mandatoryFluoroscopic guidance is mandatory• Check impedance for the integrity of Check impedance for the integrity of
the circuit (between 200 to 700 the circuit (between 200 to 700 ))• Sensory-Motor DissociationSensory-Motor Dissociation
– Sensory stimulation at X Sensory stimulation at X – No motor stimulation at 2XNo motor stimulation at 2X
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Conventional RFConventional RF
• Sensory testing: 0.4-0.6 V at 50 HzSensory testing: 0.4-0.6 V at 50 Hz• Motor testing: 1V at 2HzMotor testing: 1V at 2Hz• Lesion is carried at 80 -85 degree C Lesion is carried at 80 -85 degree C
for for
60 – 90 sec.60 – 90 sec.
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ClinicalClinical Indications of Indications of Conventional RFConventional RF
• Gasserian ganglion Gasserian ganglion Trigeminal Trigeminal NeuralgiaNeuralgia
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Indications of Conventional Indications of Conventional RF Contd…RF Contd…
Cervical facet joint Cervical facet joint denervationdenervation
Sacro -iliac Joint denervationSacro -iliac Joint denervation
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Conventional RF Contd..Conventional RF Contd..
Lumber facet joint Lumber facet joint denervationdenervation
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Indication of Pulse RFIndication of Pulse RF
• Stellate Ganglion Stellate Ganglion • Other GanglionOther Ganglion• Brachial Brachial
PlexopathyPlexopathy• SuprascapularSuprascapular• AS ROMANS’ DO• Knee Neuropathic Knee Neuropathic
PainPain
Stellate Ganglion RF
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Cervical DRG lesioningCervical DRG lesioning
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Lumber DRG lesioningLumber DRG lesioning
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Lumber DRG lesioningLumber DRG lesioning
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Lumber sympathetic Lumber sympathetic blockblock
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ComplicationsComplications• Dysesthesia-5-25%Dysesthesia-5-25%• Anesthesia Anesthesia
dolorosadolorosa• Masticator muscle Masticator muscle
weakness -4%weakness -4%• Facial numbnessFacial numbness• Corneal analgesia-Corneal analgesia-
15%15%• KeratitisKeratitis
• Chemical meningitisChemical meningitis• Carotid-cavernous Carotid-cavernous
fistulafistula• Haematoma –Cheek, Haematoma –Cheek,
RetrobulbarRetrobulbar• Cerebrospinal fluid Cerebrospinal fluid
leakleak• Cranial nerve Cranial nerve
paralysisparalysis
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ConclusionConclusion• Radiofrequency AblationRadiofrequency Ablation is a is a
useful minimally invasive useful minimally invasive option for offering option for offering long-termlong-term pain relief, improving quality of pain relief, improving quality of life in a significant proportion life in a significant proportion of chronic pain patients.of chronic pain patients.
• Careful patient selection & Careful patient selection & thorough knowledge about the thorough knowledge about the proposed procedure are proposed procedure are mandatorymandatory
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My Sincere My Sincere Thanks to Thanks to
•Dr Gautam DasDr Gautam Das•Dr Krishna PoddarDr Krishna Poddar
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Thank YouThank You