It is a condition that affects over 50 million Americans, chronic pain. And while there are many types of chronic pain, there are many options to alleviate the discomfort without major back surgery or heavy medications. Today we’re talking with Dr. Robert Wilson of Piedmont Interventional Pain Care in Salisbury. Dr. Wilson is both board-certified in anesthesia and pain medicine and has helped thousands of patients across the state of North Carolina. Today, you aer going to discuss a procedure for pain called radiofrequency ablation? So what is, radiofrequency ablation?
Dr. Robert Wilson 0:39
What it consists of is an energy source, a radio frequency waveform that goes into a tissue plane. What happens when that energy is dispersed into the tissue plane it causes ionic friction, the destruction of tissue causing heat to be generated and again destroying the tissue.
It’s been described as nerve burning. Is that what it is? That sounds sort of scary.
Dr. Robert Wilson 1:10
It’s a term I like to use but when I talk to patients, the real term is radiofrequency ablation or facet rhizotomy or facet neurolysis is how I use it quite a bit. When I say that to a patient, it is hard for them to understand what I am talking about. So when I simplify and say “nerve burning” procedure, you always have to follow with a description that really isn’t painful. It sounds like it is but it’s not because reality is, we have to find the nerve, we sense it, find out where it’s at. Before the thermal ablation actually takes place, we numb up the nerve tract and they never feel any burning taking place. It really is not a painful procedure at all.
Who are the candidates for this type of procedure?
Dr. Robert Wilson 1:42
The patient’s my clinic. I’ve treated patients as young as 18 years of age and my oldest patient is 99 years old who I have done this procedure on. It really varies anywhere between but generally speaking if I’m trying to treat low back pain and I want to find out and diagnose the problem is being from the facet joints, the joints of the lower spine. The age range of patients are somewhere between 55 and 75. But really anybody is a candidate for it. I never ceased to be amazed by the people that I think would be a person that wouldn’t benefit from this diagnostic procedure to locate the problem, that will do the diagnostic block, we did ascertain injection to find out that this is the problem with the facet joints. That precedes onto the facet rhizotomy or nerve burning procedure.
One thing I do want to cover is that the procedure itself is something that should be done only after you’ve located the source of the problem. In other words, if I were to just conclude that I think the facet joints cause the problems and do the radiofrequency ablation, there is some inherent risk of doing the procedure. So, always before I do that at least once if not twice, I’ll do a diagnostic procedure that will inject a small amount of local anesthetic and a small amount of steroids sometimes into the facet joint. What that does is that knocks out the function of the joint. The patient then calls me back a week later which you’re instructed to do, and they tell me their pain was at least 50% better. That tells me how I slayed the problem, so again, if facet rhizotomy radiofrequency ablation procedure should be performed after diagnostic injection before the person diagnosed the problem.
So, it’s done in the office?
Dr. Robert Wilson 3:23
They’ve been in my office in situations is very common versus going to a hospital setting of M4 surgery setting where the whole entire registration process is much more clingy, etcetera. But now it can be done very safely in an office setting. I generally do not have to sedate for these procedures. In fact, it’s important for me to say that when I perform this unless the patient truly has an anxiety disorder and just cannot sit still for the procedure.
Again, has concerns about it. We have to be able to communicate with the patient when we do the nerve sensing. For example. We have to have the patient tell me when they feel that drawing or tingling, pressure sensation. If they’re sedated and drowsy and don’t respond to me, it’s difficult for me to get the right information I need. So, again we localize the skin very well. The needles that do go in are initially very small, there’s a stick and a sting that’s involved with that.
Beyond that, patients generally feel the tingling in the motor sensation in the back, maybe thumbing a little bit with the testing. Again, the burning it’s is painless.
Are there side effects or dangers from the procedure?
Dr. Robert Wilson 4:27
What I tell patients with any procedure I perform, bleeding, infection, nerve damage are three things that can always happen. If you’re on a blood thinner and anticoagulant such as Coumadin or Plavix, or any more of an aggressive blood thinner, not just daily aspirin. And, by the way, daily aspirin is fine to stay on if you were to have this procedure. That would be a potential problem if you’re taking a blood thinner and we have to get approval to stop that medication before we do the procedure. If you’re taking that for a history of stroke or heart attack, I need to talk to your cardiologist or your primary care doctor to make sure it’s okay to stop that.
Infection, again, I’ve been doing these procedures for over 10 years and doing epidural type injections in the setter for 37 years, never had that occur. Nerve damage is the same way. Going back to the other question, if you’re trained and watch what you’re doing, you know what to look for because, again, you have a motor and sensory test. You also have an x-ray device that gives you a view from above and then from the side. Placement of the needle is important, you have to know the anatomy. So if somebody is qualified, it would be a very safe
Is there anything that the patient needs to do to prepare for the procedure?
Dr. Robert Wilson 5:37
We ask a couple of hours ahead, you not eat or drink anything. Especially the first time we do injections on patients and do procedures, that they have not done before. The medications we use again are very benign and they usually don’t cause allergic reactions with the first time you treat someone. It’s always better to have an idea that their stomach is empty if they’re having an on tour reaction.
Are there other options for this type of pain?
Dr. Robert Wilson 5:59
There are certain cases and in sometimes with patients, we have to understand is that there are four, five, or six reasons why someone’s back can hurt. It can simply be the muscles, it can be the ligaments, you can be the nurse or speaking up, it can be the nerve roots causing some of the lower back pain so, what we do in pain medicine, we try to ascertain. Talking to the patient, I was always taught this early on and it still used today that if you listen to the patient, you can figure out what’s going with them about 90% of the time. You just need to listen to what they’re telling you. I’m not saying that x-rays and MRI’s don’t help you and assist you, but there’s something to add to their history.
The physical exam will help you pinpoint some of the reasons why this is the best procedure to perform. I’ve been doing pain medicine for about ten years now and I still have patients that I get for a little bit when I think it’s truly a muscle problem and it’s not a nerve root problem. Because their symptoms are a-typical. But, again, there’s different reasons why they have pain and to try and figure that out. It may take two or three different types of injections to do that but once you center in where the problem is and you do that particular injection for that problem they generally get good pain relief.
Describe a little bit about your philosophy of care. I know that you try to keep your patients off of heavy narcotics if at all possible.
Dr. Robert Wilson 7:14
Whenever it is possible. Our goal is always to try and keep patients off of a narcotic medication and keeping them as functional as we can. Several reasons for that one, it gets more and more press all the time is the drug diversion problem that we have in this country. As pain doctors and other primary care doctors and really every physician has to be very prudent about writing a prescription, narcotic medication. We in our office a lot of random urine screens to make sure patients are compliant with their medication. We hold them to very strict guidelines when we do that. But, I never want anyone from my practice to take a prescription out and sell that drug on the street or to use more than once and have an overdose and have a problem with it. So, if I can avoid writing that prescription and do procedures that’ll keep them off medications like that altogether or certainly keep it to a minimum, that is a goal of mine.
The reality of life is that I may accept a patient who’s had their fourth, fifth back operation. Narcotic medications are the only things that, at least in part, can keep them going. Again, if I can find a procedure with that patient and reduce the number of narcotics they’re on and get them more functional to feel better and be less dependent on narcotic medication, that’s always better.
But, first and foremost in my practice, my name of the practices is Piedmont Interventional Pain Care. Stress injections in all because there’s a very good reason for that. Patients can do better and be less dependent on narcotic medications and prevent a bigger, widespread problem that this country deals with drug diversions as well.
I know that you do a lot of community education and that you have a lot of information on your website as well as videos, but you also talk around the country as well.
Dr. Robert Wilson 9:01
I do informational talks for Medtronic corporation and talk to a division more on a spinal cord stimulation therapy. I’ve been using their products for some 10 or 11 years now. They’re kind of a leader in the industrial pain therapies and spinal cord stimulation is one that I use quite extensively when the time calls for it. But, again, I’ve spoken all around the country, at least in the eastern half of the country; talking to other physicians, teaching them the technique for spinal cord stimulation therapy. I get called upon different times to speak more locally physicians about that as well. I even have physicians from all over the country come to my office and observe me doing spinal cord stimulation trials and implants as well.
So, tell us a little bit about your practice.
Dr. Robert Wilson 9:54
What I see now in my practice is mainly chronic pain and chronic pain can be defined by any pain that persists beyond three months, three to six months. I do see some cases where surgeons or medical providers will call me when a patient has an acute episode of pain and maybe it’s a shingles pain or Postherpetic neuralgia is another name for it. Anything like that, I had a surgeon just the other day call me about a lady who had surgery about six weeks before and had some incisional pain. Again, acute pain that we can treat with two or three injections to hopefully calm it down and keep her pain from becoming a chronic problem.
In my practice, the majority of what I see and do is chronic in nature, a lot of my patients, I tell them that treating chronic pain is like treating diabetes and high blood pressure, you can never cure it. All you can do is treat it and continue to make it better and to keep it under control. In our case, keeping their pain under control and keeping them more functional is what we aim to do.
So, what happens after the procedure, like, what can a patient expect shortly after and months after the procedure?
Dr. Robert Wilson 10:59
After the radiofrequency ablation procedure for said joint pain, generally, patients may have tenderness at the site where the needles went in but it is very short-lived. Putting ice on it is something that would be required at most, the other thing I tell patients is that it can take up to two weeks for the nerves to eventually die off. Because of this thermal ablation procedure that we do, the cells of the small branch nerves start to die. Immediately before they die and after to the point where they stop sending signals to the spinal cord. It may take up to two weeks and that’s the most I’ve seen. Generally, patients feel better within two or three days.