What kind of surgery is this involving freezing and burning nerve endings?
February 1, 2010 11:03 PM   Subscribe

Freezing and burning nerves to help with back pain? What kind of surgery is this, exactly?

My friend with severe back pain is having surgery to freeze the nerve endings in her lower back so she doesn't feel anything, and then said a week later, the doctor will go back in and burn these nerve endings off. It sounds like both surgeries will be done as outpatient procedures... at least she hasn't mentioned being hospitalized, and she said the incisions will be the size of typical laparoscopic incisions.

She's not good with medical terminology and remembering the names of procedures and has mostly just trusted her doctor and not gone for any second opinions. Googling just gets me a lot of information about burns and frostbite.

This surgery is supposed to replace the epidurals and trigger point shots she's been getting and hopefully help her get off suboxone and Lidoderm patches.

I was wondering if anyone here could tell me more about this surgery, including possibly the name of the procedure? Also, she's nervous because the doctor will be working near her spine, and could potentially paralyze her in a worst-case scenario. Exactly how close to the spine will he be? And why must the surgery be separated into 2 procedures a week apart? If she is under general anesthesia, why must the nerves be frozen to begin with? Is it like a test run to see if the surgery will work?
posted by IndigoRain to Health & Fitness (7 answers total) 3 users marked this as a favorite
Radiofrequency rhizotomy of the facet joint nerves?
posted by mr_roboto at 11:19 PM on February 1, 2010

It sounds like she's having a neurolysis to destroy the nerves that are carrying the pain signals to her spinal cord and brain. First, she's having a cryoablation (freezing), followed by a radiofrequency (burning) procedure. These will be performed with a percutaneous technique--through a small incision in the skin that will only need a band-aid, at most maybe a couple of stitches. She will probably be able to go home the same day, but will need a helper because she will be sedated for the procedure.

Without asking her doctor, it's impossible to know how close to the spinal cord the procedure will be. The most likely scenario, I think, would be a facet denervation. This structure is separated from the spinal cord by 2-3 cm of bone--so it's pretty safe, from a paralysis point of view. IANAD, but as I understand it, cryoablative procedures are reversible. So yes, you could be right--doing the freezing first is a test run to see if it relieves her pain. If it doesn't, then there's no reason to go forward with the burning which will permanently destroy the nerves. The doctor would instead present her with other options.
posted by oceanmorning at 12:04 AM on February 2, 2010

I have had the non-surgical radiofrequency rhizotomy done on my back (spine) twice with (what I consider to be) good results.
I have a herniated disc (L4-L5) and pretty bad sciatic pain.
While the procedure I had done was not surgical (no incisions) it was still considered outpatient surgery. I was sedated with what is called a "twilight" general IV and needed a driver to take me home. Restrictions included no lifting or driving for that day; able to return to work the next day.
I did not undergo the freezing portion that you describe.
I have had a number of facet-joint injections with limited to no success.
This RF procedure gave the most relief, about 6 months pain lessened to almost pain free.
Good luck to your friend.
posted by Drasher at 5:48 AM on February 2, 2010

Is it like a test run to see if the surgery will work?

I have had the first part of this done, without success. It was super awesome, as there was a real-time x-ray of my neck that I could watch as a giant needle went right up to [but not *into*] my spine. They inject a numbing agent [one of the 'caines in my case] and then you see if it helps you out for the next few hours until it wears off. If it works, then next week they kill the nerve with the radiofrequency rhizotomy. I was able to walk out and drive home after about an hour of hanging around and making sure things were okay.

[the rest of your questions in order]
I don't know the name of the procedure. Paralysis could happen if the doctor slipped and stabbed you in the spine, but there is a protective bony layer which would have to be crunched through first. I wasn't worried about that possibility at all. This will be really close to the spine, though. The nerves you're looking for run along the outside of it. The surgeries must be done a week apart to see if the second [permanent] one is a good idea or not. She will likely not be under anaesthesia.
posted by Acari at 7:10 AM on February 2, 2010

Without knowing exactly what type of back pain your friend has, I can't know exactly what kind of surgery she will be undergoing. It sounds like she's having some kind of ablative surgery done. The freezing/burning part is likely to be what Acari describes: first using a sodium-channel blocker (novocaine, lidocaine, etc.) to block the region that they suspect is causing the pain (have you ever heard someone say that they got their teeth "frozen" at the dentist, meaning that they were injected with novocaine?) Then, if that works, they'll use radiofrequency to cause either mild or complete damage to the nerves responsible for causing the pain. (For many conditions, they'll go with pulsed radiofrequency, which isn't as destructive as traditional radiofrequency, which just burns everything away. Without knowing your friend's condition, I can't say what the treatment of choice should be.)

This treatment has a good outcome as far as neuropathic pain treatments go -- run a search on PubMed instead of Google, and look for stuff like "interventions low back pain" instead of "freezing and burning spines".

Depending on which structures are causing your friend's pain, they might be working inside or outside the vertebral column (the dorsal root ganglia and dorsal roots are both inside the vertebrae -- I know, I've dug my share out of dead rodents). It should be OK though; the procedures for this are very well-established and I would say that there is a miniscule risk that they will damage any structures that they aren't planning on damaging. This procedure is not riskier in nature than the epidurals she's already been getting: there's not really any reason she should be nervous at having needles stuck between her vertebrae for this (after all, they'll be looking at her spine using either CT or fluoroscopy) if she wasn't nervous about having needles stuck between her vertebrae for an epidural.

I also wanted to comment on oceanmorning's statement regarding cryoablation -- cryoablation is not reversible. You can't unfreeze frozen tissue. Cryomapping is reversible, but it is a slightly different procedure. Also, the anaesthesiologists and pain-medicine types I chat with at journal club are always chattering about doing nerve blocks, but I've never heard of them using cryoablation -- the nerve block is cheaper, less-risky, and probably more effective than literal freezing with cold temperatures would be.

IANAD, so take a lot of the clinical stuff with whatever grains of salt you want, but this is closely related to my research field, so I know a fair amount about it.
posted by kataclysm at 11:09 AM on February 2, 2010

Thank you all, this is at least some more information I can look at. I have seen my friend's MRI films and I know she has 3 bulging discs at L3-L5. She has had sciatic pain in the past before her left hip replacement and she says this pain is not the same... it doesn't shoot around to the front and down her leg. Her pain is very low, almost down into her buttocks, and from midline to slightly to the right of midline. IIRC when the doctor asks how bad the pain is on a scale of 1-10, she rates it a 6 or 7 constantly, but has flare-ups if she bends the wrong way to a 10.
posted by IndigoRain at 11:20 AM on February 2, 2010

OK, that can let me be a bit more specific. Probably they are trying to figure out whether your friend's pain is due to the bulging discs putting pressure on the lumbar roots (lumbar radiculopathy). What the literature tells me that they probably should be doing is a diagnostic block (checking whether blocking signals from the affected neurons will actually alleviate the pain) followed by pulsed radiofrequency. For lumbar radiculopathy, the evidence that this treatment will actually work is not as clear-cut as it is for facet joint pain. Still, since it sounds like epidural injections and analgesic patches aren't working for her, this procedure might be worth a try, particularly in the case of PRF (which doesn't cause as much damage as continuous RF).

Radiofrequency treatments are a bit less risky than traditional surgical approaches. Unless the surgeons screw up and hit the wrong nerve (which really shouldn't EVER happen if they are doing their jobs correctly), the worst outcome from this is that the pain won't get better. From what I can tell (the literature reviews frequently reach different conclusions because they are looking at different patient populations, time points, etc.), there's a pretty good chance that your friend will get some short-term relief from this procedure; whether the relief will last more than eight months to a year is an open question.

I would definitely urge your friend to seek a second opinion -- most likely her doctor is being completely reasonable, but at this point she is looking at fairly major interventions. If the radiofrequency stuff fails, or if the doctor is using continuous RF, completely denervates the area, and still doesn't get a good result, she will possibly end up needing surgery. A doctor should not get offended when their patients seek a second opinion. It isn't rude, or bad, or anything like that. I would especially get a second opinion, preferably from a pain clinic, if your friend's doctor is not affiliated with a pain clinic.
posted by kataclysm at 6:54 AM on February 3, 2010

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