Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we're going to learn about radiofrequency ablation for the treatment of chronic pain. Joining me is Dr. Philip Petrou. He's an Assistant Attending Anesthesiologist at New York-Presbyterian Weill Cornell Medical Center, and he's an Assistant Professor of Clinical Anesthesiology at Weill Cornell Medical College, Cornell University.

Dr. Petrou, thank you so much for joining us today. The field of pain management is relatively new. Can you just speak a little bit about what you do? And since pain is somewhat subjective, how do you measure it with people? How do you determine how much pain someone's in so that then you can discuss all the treatment options out there?

Philip Petrou, MD: Thank you so much for having me today, Melanie. It's my pleasure to join. So in terms of how I work with pain patients, I specifically work with chronic pain patients, so patients typically with their chronic back pain, or chronic like shoulder pain, knee pain, conditions that have been occurring for at least three months.

In terms of how we assess pain with patients, obviously, first and foremost, it's patient's own self-assessment, sort of their description of their discomfort. Is their pain burning? Is it stinging? Is it aching? And then, we also discuss with patients how has it impacted their life? What are their daily activities like?

We go into even more depth with them by providing them with a comprehensive survey that looks at how their pain symptoms are affecting their ability to socialize, their sleep, their mood, and using these both subjective measurements of pain from, again, the patients self-reported condition as well as these objective measurements of understanding how the pain is affecting their daily activities. It helps us give a complete and whole picture of the patient when they come to our pain clinic.

Melanie Cole, MS: Well, it sounds like a very comprehensive approach. So, speaking of that type of approach, when someone comes to you, how do you have that discussion about conservative pain measures? And then, when does that discussion become something interventional?

Philip Petrou, MD: Excellent question. So typically, when I speak with patients, I address in terms of doing more conservative approaches to more invasive. So ideally, a less invasive approach to a more invasive approach. Some patients, however, come in with a very specific mindset in terms of what they're looking for. Other patients, it is a conversation of first speaking about physical therapy, restrictions on sort of their aggravators of pain, maybe some medication management, while others are looking for interventions, for example, something like an epidural steroid injection, something like a lumbar medial branch radiofrequency ablation.

Melanie Cole, MS: Okay. So, tell us what that is.

Philip Petrou, MD: So, at our clinic at Weill Cornell, our focus is on spine. So, many patients are coming to us with chronic low back pain. And oftentimes, just as we age, if you can think about kind of the weight of the spine, especially the bottom of the spine or that lower lumbar region carries a lot of weight just through the years. As this weight builds up, we develop arthritis in the spine, those spine joints. Similarly how your knee joint, your shoulder joint, you have spine joints as well.

When you develop with age, that arthritis causes inflammation and you have nerve endings that innervate those spine joints. So when patients come with this axial low back pain, especially when it's aggravated by certain maneuvers that cause more grinding of the spinal joint, then we suspect that that arthritis in the joint is the source of their pain. In that case, what we offer is a two-step procedure. First step is a lumbar medial branch block. Essentially, what we do is we're targeting that nerve ending that innervates the spine joint, the idea being that the arthritis in the spine causes inflammation, and then this runs up those nerve endings and nerve fibers up to the brain that signal pain.

So, the goal of it is to block out that nerve. So, the first step is a nerve block where we just place some numbing medicine, like the Novocaine you get at the dentist. And then, if patients have benefit, that second step is what we call a radiofrequency ablation. And that's where we actually heat the nerve to 80 degrees, essentially burning those nerve endings so that patients can get six to nine months of pain relief.

Melanie Cole, MS: Wow. That was a great explanation. Thank you so much. You're really good at this. So, tell us about the procedure itself. So, you said that, you know, they get the numbing medication first. Then, how long does it take? Is this in office or in an outpatient setting? How does that all work?

Philip Petrou, MD: The advantage of this procedure is it's minimally invasive, so we can do it in our outpatient clinic. It doesn't require being in the hospital setting. So, the first step is the nerve block. So essentially, we do this under local and aesthetic. So, I give some numby medicine before placing a very small needle into the spine. I explain to most patients that if they can tolerate getting their blood drawn, they can tolerate this procedure. We place numbing medicine at the nerve endings on the spine. We do it very safely. We do it under x-ray or fluoroscopy so we can see exactly where we're going with the needle.

We actually do need two confirmatory tests. So, patients need two rounds of these medial branch blocks. in terms of the clinical data, it helps confirm that the source of the pain really is from the arthritis, there's no other contributing factors. Assuming that the patient has had more than 80% pain relief with the medial branch blocks, and that's two sets, we then move to the ablation.

I also explained to the patients that the radiofrequency ablation, again, is done in the outpatient clinical setting. It doesn't require hospital. And that it's very similar to the medial branch block. In terms of how we proceed, patients again will receive some numbing medicine. It'll be done again under x-ray or fluoroscopy, so we see exactly where we're going with the needle. And then, as I mentioned before, we heat the nerve to 80 degrees. Oftentimes the patients, they get a little concerned as, "Oh, are you burning me?" Yes. And the fact is it is a burn, but we minimize the pain from that by giving a strong dose of local anesthetic before the burn. So, I do explain to patients you will feel a gentle heat from the warmth of the probe. But in itself, it shouldn't cause any pain.

In terms of warnings or, you know, every procedure we do has some risk. But I do explain to patients that the benefit of this procedure is that there's no motor weakness. We're not hurting or damaging any motor neurons during this procedure.

Melanie Cole, MS: Well, I'm glad you brought up questions that patients ask you. So, are there any other fears besides the heat or burning? Do they ever feel like they're getting zapped? What do patients ask you that they're afraid of before they would do this?

Philip Petrou, MD: I think a common concern of patients is that, "Are we in the spinal cord?" And I do reassure patients that this is very different than epidural steroid injection, that this procedure is outside of the spinal cord completely. And I provide reassurance to them. One, we do x-rays so we can see exactly where the needle is going and that we can reassure the patient that we're not near the spinal cord. And then, we actually do testing in itself before we do the ablation.

So with that testing, we do both sensory and motor testing. And we basically stimulate the area to make sure that we're not near any motor neurons, essentially not in an area where we don't want to be. So, patients will feel it because it's a strong sensation in the back, strong electrical sensation in the back. And again, that's our safety measure to make sure that we're not in the wrong area or near a motor neuron where that can cause potential side effects.

Melanie Cole, MS: Thank you for clearing that up for us. Now, what's life like afterwards? How long does it take before they start to feel that pain relief? And I think you mentioned, you know, six months before-- you said something. How long does it work for?

Philip Petrou, MD: So, I'll address efficacy first. So, I tell patients it can last for six to nine months. It's not unreasonable to have to repeat it. Essentially, those nerve endings that were bleeding or burning, they do grow back. And typically, it's at that six to nine months. Most patients don't mind having to repeat it because, again, they're able to develop benefit. And again, benefit I'm aiming for is 50% pain relief. I wish I could cure everyone's pain a hundred percent. The reality is, with any procedure I do, it doesn't take away the pain completely. And then, in terms of when I see benefit, typically by two weeks I'm looking for benefit.

Melanie Cole, MS: Wow. So, what do patients tell you?

Philip Petrou, MD: So during the procedure, most patients are able to tolerate it without any difficulty. They can definitely feel that gentle warming. Afterwards, most patients, again, are pretty satisfied with that amount of pain relief that they've had. Again, aiming for at least 50%, because this allows them to engage more in their daily activities, they're not requiring as many as much medication if they're on any pain medication. And then, they'll also be able to engage more in physical therapy, which I find helpful for patients of all different chronic pain conditions.

Melanie Cole, MS: This is really Interesting, Dr. Petrou. So as we get ready to wrap up, I'd like you to offer your best advice for pain management, anything else that you think listeners would like to know that you use this radiofrequency ablation for. And what you want them to know about seeking help, because chronic pain is so debilitating. It affects, as you said, all the parts of your life, and the quality of life is so important. So, give us your best advice here.

Philip Petrou, MD: I think the best advice I could say is come see us as a pain physician. Obviously, there's literature out on the news, we do podcasts, there's YouTube, many patients are getting their information from social media. But really, the best way to learn about what Interventions or management is best for you is just to come see us in clinic. And that way, we can tailor therapy.

You know, when I'm speaking to you now about especially lumbar medial branch radiofrequency ablation, it's been around for a long time. However, we have new and innovative approaches to not just limit it to the lumbar spine. For example, we're using this methodology for shoulder arthritis pain, hip arthritis pain, knee arthritis pain. And then, even furthermore, we're using other advanced modalities such as peripheral nerve stimulators to target that similar type of pain area, including arthritis of the joints.

Melanie Cole, MS: Fascinating. Thank you so much, Doctor, for joining us today and sharing your incredible expertise and easing some of the fears that people might have had when they hear about these types of procedures. So, thank you so much for clearing that up for us. That was great. And Weill Cornell Medicine continues to see our patients in-person as well as through video visits. And you can be confident of the safety of your appointment at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review back to Health on Apple Podcast, Spotify, iHeart, and Pandora. And for more health tips, please visit weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. There's so many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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