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Demonstration of Lesions Produced by Cooled Radiofrequency Neurotomy for Chronic Osteoarthritic Knee Pain: A Case Presentation
1 2 3 4 5 PM R XXX (2016) 1-4 www.pmrjournal.org 6 7 8 9 10 11 12 13 14 15 16 17 18 19Q10 20 21 22 23 24 25 Abstract 26 27 This case presentation demonstrates radiographic evidence of lesions created following cooled radiofrequency (cRF) neuro28 29 tomy of the knee. A 67-year-old man presented with chronic left knee osteoarthritis, pain, and disability. After a failed trial of 30 conservative treatments, the patient underwent diagnostic genicular nerve blocks and subsequent cRF neurotomy, of the left 31 knee. Shortly after cRF, magnetic resonance imaging (MRI) of the left knee was performed. On MRI, lesions created by cRF 32 33Q5 ablation were identified. The images presented in this case offer a visual explanation for the success of cRF in the treatment of 34 knee osteoarthritis. 35 36 37 38 39 40 several nerves including the femoral, common peroneal, Introduction 41 42 saphenous, tibial, and obturator [7] innervate the joint 43 capsule. For consistency, we will refer to the targeted Chronic knee osteoarthritis (OA) ranks among the 44 45 sensory nerves of the knee as “genicular,” as this has most common diseases of advancing age [1,2]. 46 become the common nomenclature within the literature Population-based studies reveal that symptomatic knee 47 when referring to these nerves [8]. The complexity of OA is present in 20%-30% of the elderly population (age 48 49 the regional anatomy of the knee has prompted a need >65 years), and its prevalence is increasing due in part 50 for more effective methods of delivering ablative to the aging of the population [3]. Treatment of chronic 51 52 technologies to decrease the technical demands of the knee OA often consists of conservative therapy with 53 procedure and to increase the likelihood of success, pharmacological options, intra-articular steroid and 54 55 which is associated with improved outcomes. hyaluronic acid injections, acupuncture, bracing, and 56 One such advancement is the development of cooled targeted exercise, as well as more invasive approaches 57 radiofrequency (cRF) ablation (Halyard Medical, such as surgery. Although surgical procedures, such as 58 59 Alpharetta GA). The proposed advantages of cRF over total knee replacement (TKR), are generally an effec60 traditional RF neurotomy are alteration in size, shape, tive terminal therapy for patients with advanced dis61 62 and distribution of the lesions compared to those ease [4], patients with significant comorbidities may not 63 produced by non-cRF probes [9]. The larger lesion is be appropriate candidates. For these patients, the 64 achieved by circulating room temperature water application of radiofrequency (RF) neurotomy offers a 65 66 throughout the probes, dissipating heat immediately potential alternative to surgery [5]. 67 adjacent to the probes, and preventing “char” of nearby Radiofrequency neurotomy operates on the principle 68 69 tissues, thus maintaining heating efficiency across larger that disrupting the sensory innervation to a painful 70 areas. In vitro models have demonstrated that cRF structure should result in the alleviation of pain, with 71 creates a larger, more spherical lesion that may ablate a secondary restoration of function. For management of 72 73 larger portion of the targeted nerve, thereby creating chronic knee pain, RF neurotomy has proved challenging 74 a larger gap in the pain signal transmission pathway. The due to the complexity and interpatient variability of 75 76 larger lesion theoretically facilitates a longer duration nerves that traverse the knee [6]. Articular branches of 77 78 79 1934-1482/$ - see front matter ª 2016 by the American Academy of Physical Medicine and Rehabilitation 80 http://dx.doi.org/10.1016/j.pmrj.2016.09.001
Case Presentation
Demonstration of Lesions Produced by Cooled Radiofrequency Neurotomy for Chronic Osteoarthritic Knee Pain: A Case Presentation Michael E. Farrell, DC, Genaro Gutierrez, MD, Mehul J. Desai, MD, MPH
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce
81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160
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241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 Case Presentation 262 263 A 67-year-old man with a significant past medical 264 265 history of degenerative joint disease was referred by his 266 orthopedic surgeon for pain management consultation 267 268 to address severe left-sided knee pain. He presented 269 with pain in his left knee rated 9 out of 10 on a nu270 271 merical rating scale (NRS), with daily discomfort limiting 272 function including severe limitations of walking and 273 Q6 climbing stairs. His pain was refractory to treatment 274 275 with medications, physical therapy, intra-articular ste276 roid injections, viscosupplementation, and autologous 277 278 stem cell therapy injection by his surgeon. On physical Q7 279 examination, there was visible deformity of the left 280 knee in comparison to the right. Palpable mild effusion 281 282 was noted with medial joint line tenderness. Range of 283 motion was full but painful, particularly at end range. 284 285 Mild medial joint laxity was noted. Positive provocation 286 maneuvers included Appley grind and McMurray testing. 287 Imaging of the knee, including radiographs and mag288 289 netic resonance imaging (MRI), showed extensive joint 290 space narrowing and medial compartment subchondral 291 292 bone edema as well as insufficiency fractures of the 293 anterior and posterior medial femoral condyle. Before 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 Figure 1. Fluoroscopic sagittal images of the knee demonstrating probe placement, along with sagittal magnetic resonance image of the left knee 318 319 showing radiointense lesions (arrows) at anatomic landmarks created during cooled radiofrequency (cRF) genicular neurotomy. A lesion measuring Q9 320 12.8 mm is shown.
of pain relief than treatment provided by a non-cRF probe [8]. There are several ongoing trials regarding the proposed advantages of cRF, including a randomized controlled trial that recently completed enrollment comparing cRF to intra-articular corticosteroid injection for knee pain (NCT02343003), and a randomized trial comparing cRF to RF in the treatment of recalcitrant knee pain (NCT02260869). This case presentation offers radiographic evidence of the lesions created during cRF neurotomy, offering a plausible explanation for the substantial pain relief the patient experienced following cRF of the left knee.
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Cooled Radiofrequency Neurotomy of the Knee
undergoing surgery, the patient expressed his desire to pursue all available alternatives to total knee replacement. It was recommended that the patient undergo diagnostic genicular nerve blocks of the left knee as a precursor to cRF, pending adequate relief from the diagnostic blocks. At the time of the diagnostic nerve blocks, the patient continued to report a pain level of 9 out of 10 on NRS. Diagnostic genicular nerve blocks were performed of the left knee without complication using the protocol described by Choi et al [5]. According to the patient’s pain diary, he reported greater than 80% relief of his left knee pain with significant improvement in his function and ability immediately following diagnostic block, which dissipated over several hours. After informed consent, the patient decided to proceed with cRF neurotomy, and the procedure was scheduled for 1 week after the diagnostic block. On the day of cRF neurotomy, the patient presented with a score of 9 out of 10 left knee pain, his pain gradually having returned following his diagnostic block. The patient was placed in a comfortable supine position with sterile preparation and drape. True anterior/posterior (AP) radiograph images of the left knee were obtained for the identification of target sites using bony landmarks. The skin was anesthetized with 1% lidocaine. The cannula is advanced using the tunnel technique until bony contact is made with each target. The superior lateral geniculate nerve was approximated by placing the cannula at the junction of the lateral femoral shaft and the epicondyle. The superior medial geniculate nerve was approximated where the medial femoral shaft meets the epicondyle. The inferior medial geniculate nerve was approximated where the medial tibial shaft meets the epicondyle. A lateral image was then obtained, ensuring that the needle tip was at approximately 50% of the diaphysis. The stylet was removed and the probe was inserted. Each nerve
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce
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Figure 2. Fluoroscopic sagittal images of the knee demonstrating probe placement, along with coronal magnetic resonance image of the left knee showing radiointense lesions (arrows) at anatomic landmarks created during cooled radiofrequency (cRF) genicular neurotomy. Two lesions measuring 12.7 mm on the right and 12.3 mm on the left are shown.
received radiofrequency treatment at 60 C for 2.30 minutes. The procedure was tolerated well under local anesthesia, without any adverse events reported. In the days following the procedure, the patient reported relief of pain in the anterior knee compartment of greater than 80%. At 19 days after cRF neurotomy, the patient began experiencing pain in the posterior aspect of his knee. Magnetic resonance imaging with contrast was ordered to rule out infection. Although not the primary purpose, the MRI findings did demonstrate evidence of the cRF lesions at the superiomedial and superiolateral sites (Figures 1 and 2) as well as a 4 5-cm cyst/effusion in his popliteal fossa, consistent with a Baker cyst. This was an unexpected finding following the procedure, as the authors are unaware of any evidence suggesting that RF neurotomy may lead to cyst/effusion formation. Aspiration was performed under ultrasound guidance without injection of corticosteroid, and yielded 20 mL of serosanguinous fluid that was culture negative. No further posterior knee pain was reported by the patient at subsequent visits. The patient was seen at 1-month and 3-month intervals following cRF neurotomy. At these visits, he continued to report significant pain reduction and improvement of his function. At the 1-month and 3month follow-up visits, his average pain score was 3 out of 10, with self-reported improvement in function. The patient did not return after 3 months. Discussion Patients with chronic knee pain that is unresponsive to conservative therapy and who do not wish to undergo TKR or are poor candidates for TKR may choose RF neurotomy as a treatment option. In anticipation of offering this treatment option, physicians must account for the anatomic variability of the nerve supply to the knee, which may adversely affect success rates. To limit
the potential influence of anatomic variations, newer technologies such as cRF might be considered a preferable option. In cRF, room temperature water circulating inside the probe reduces extremes in heat, which prevents charring of the tissue. The charring is believed to decrease the efficiency of heat transfer to adjacent tissues. Theoretically, cooling is believed to improve the size, shape, and projection of the lesions compared to those produced by traditional RFN probes [9]. The lesions presented in this case offer a visual explanation for the mechanism of cRF neurotomy in the treatment of knee osteoarthritis and are the first such images of in vivo lesion formation with cRF. Further studies are indicated to further compare and contrast in vitro lesions produced following cRF and RF neurotomy. The large spherical lesions seen support the hypothesized advantages of cRF over traditional RF neurotomy. The altered lesions produced by cRF may account for the substantial pain relief experienced by our patient, and support further prospective investigation of the use of cRF over traditional RF neurotomy in peripheral joints such as the knee. Conclusion This case provides the first in vivo images of the lesions created by cRF ablation. The patient experienced 3 months of pain reduction after undergoing cRF neurotomy of the left knee. A plausible explanation for the duration of his pain relief is the creation of the large spherical lesions demonstrated in the images presented. References 1. Felson DT. An update on the pathogenesis and epidemiology of osteoarthritis. Radiol Clin North Am 2004;42:1-9. 2. Felson DT. The sources of pain in knee osteoarthritis. Curr Opin Rheumatol 2005;17:624-628.
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce
401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480
4 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500Q2 501 502 503Q3 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565
Cooled Radiofrequency Neurotomy of the Knee
3. Masahiko I. Percutaneous radiofrequency treatment for refractory anteromedial pain of osteoarthritic knees. Pain Med 2011;12: 546-551. 4. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 Update. Arthritis Rheum 2000;43:1905-1915. 5. Choi WJ, Hwang SJ, Song JG, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: A double-blind randomized controlled trial. Pain 2011;152:481-487.
Disclosure M.E.F. International Spine, Pain & Performance Center, Washington, DC Disclosure: nothing to disclose G.G. George Washington University, Washington, DC Disclosure: nothing to disclose
566 6. Gardner E. The innervation of the knee joint. Anat Rec 1948;101: 567 109-130. 568 7. Hirasawa Y, et al. Nerve distribution to the human knee joint: 569 Anatomical and immunohistochemical study. Int Orthop 2000;24:1-4. Q8 570 571 8. Menzies RD, Hawkins JK. Analgesia and improved performance in a 572 patient treated by cooled radiofrequency for pain and dysfunction 573 postbilateral total knee replacement. Pain Pract 2015;15:E54-E58. 574 9. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo575 576 controlled study to assess the efficacy of lateral branch neuro577 tomy for chronic sacroiliac joint pain. Pain Med 2012;13:383-398.
578 579 580 581 582 583 584 M.J.D. International Spine, Pain & Performance Center, 2141 K Street NW, Suite 585 600, Washington, DC 20037; George Washington University, Washington, DC. Q4 586 587 Address correspondence to: M.J.D.; e-mail: [email protected] 588 Disclosures related to this publication: nothing to disclose; Disclosures outside 589 this publication: Halyard Health, Medtronic. 590 591 Submitted for publication March 19, 2016; accepted September 8, 2016. 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650
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Case Presentation
Demonstration of Lesions Produced by Cooled Radiofrequency Neurotomy for Chronic Osteoarthritic Knee Pain: A Case Presentation Michael E. Farrell, DC, Genaro Gutierrez, MD, Mehul J. Desai, MD, MPH
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce
81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160
2
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241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 Case Presentation 262 263 A 67-year-old man with a significant past medical 264 265 history of degenerative joint disease was referred by his 266 orthopedic surgeon for pain management consultation 267 268 to address severe left-sided knee pain. He presented 269 with pain in his left knee rated 9 out of 10 on a nu270 271 merical rating scale (NRS), with daily discomfort limiting 272 function including severe limitations of walking and 273 Q6 climbing stairs. His pain was refractory to treatment 274 275 with medications, physical therapy, intra-articular ste276 roid injections, viscosupplementation, and autologous 277 278 stem cell therapy injection by his surgeon. On physical Q7 279 examination, there was visible deformity of the left 280 knee in comparison to the right. Palpable mild effusion 281 282 was noted with medial joint line tenderness. Range of 283 motion was full but painful, particularly at end range. 284 285 Mild medial joint laxity was noted. Positive provocation 286 maneuvers included Appley grind and McMurray testing. 287 Imaging of the knee, including radiographs and mag288 289 netic resonance imaging (MRI), showed extensive joint 290 space narrowing and medial compartment subchondral 291 292 bone edema as well as insufficiency fractures of the 293 anterior and posterior medial femoral condyle. Before 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 Figure 1. Fluoroscopic sagittal images of the knee demonstrating probe placement, along with sagittal magnetic resonance image of the left knee 318 319 showing radiointense lesions (arrows) at anatomic landmarks created during cooled radiofrequency (cRF) genicular neurotomy. A lesion measuring Q9 320 12.8 mm is shown.
of pain relief than treatment provided by a non-cRF probe [8]. There are several ongoing trials regarding the proposed advantages of cRF, including a randomized controlled trial that recently completed enrollment comparing cRF to intra-articular corticosteroid injection for knee pain (NCT02343003), and a randomized trial comparing cRF to RF in the treatment of recalcitrant knee pain (NCT02260869). This case presentation offers radiographic evidence of the lesions created during cRF neurotomy, offering a plausible explanation for the substantial pain relief the patient experienced following cRF of the left knee.
web 4C=FPO
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Cooled Radiofrequency Neurotomy of the Knee
undergoing surgery, the patient expressed his desire to pursue all available alternatives to total knee replacement. It was recommended that the patient undergo diagnostic genicular nerve blocks of the left knee as a precursor to cRF, pending adequate relief from the diagnostic blocks. At the time of the diagnostic nerve blocks, the patient continued to report a pain level of 9 out of 10 on NRS. Diagnostic genicular nerve blocks were performed of the left knee without complication using the protocol described by Choi et al [5]. According to the patient’s pain diary, he reported greater than 80% relief of his left knee pain with significant improvement in his function and ability immediately following diagnostic block, which dissipated over several hours. After informed consent, the patient decided to proceed with cRF neurotomy, and the procedure was scheduled for 1 week after the diagnostic block. On the day of cRF neurotomy, the patient presented with a score of 9 out of 10 left knee pain, his pain gradually having returned following his diagnostic block. The patient was placed in a comfortable supine position with sterile preparation and drape. True anterior/posterior (AP) radiograph images of the left knee were obtained for the identification of target sites using bony landmarks. The skin was anesthetized with 1% lidocaine. The cannula is advanced using the tunnel technique until bony contact is made with each target. The superior lateral geniculate nerve was approximated by placing the cannula at the junction of the lateral femoral shaft and the epicondyle. The superior medial geniculate nerve was approximated where the medial femoral shaft meets the epicondyle. The inferior medial geniculate nerve was approximated where the medial tibial shaft meets the epicondyle. A lateral image was then obtained, ensuring that the needle tip was at approximately 50% of the diaphysis. The stylet was removed and the probe was inserted. Each nerve
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce
321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400
3
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M.E. Farrell et al. / PM R XXX (2016) 1-4
Figure 2. Fluoroscopic sagittal images of the knee demonstrating probe placement, along with coronal magnetic resonance image of the left knee showing radiointense lesions (arrows) at anatomic landmarks created during cooled radiofrequency (cRF) genicular neurotomy. Two lesions measuring 12.7 mm on the right and 12.3 mm on the left are shown.
received radiofrequency treatment at 60 C for 2.30 minutes. The procedure was tolerated well under local anesthesia, without any adverse events reported. In the days following the procedure, the patient reported relief of pain in the anterior knee compartment of greater than 80%. At 19 days after cRF neurotomy, the patient began experiencing pain in the posterior aspect of his knee. Magnetic resonance imaging with contrast was ordered to rule out infection. Although not the primary purpose, the MRI findings did demonstrate evidence of the cRF lesions at the superiomedial and superiolateral sites (Figures 1 and 2) as well as a 4 5-cm cyst/effusion in his popliteal fossa, consistent with a Baker cyst. This was an unexpected finding following the procedure, as the authors are unaware of any evidence suggesting that RF neurotomy may lead to cyst/effusion formation. Aspiration was performed under ultrasound guidance without injection of corticosteroid, and yielded 20 mL of serosanguinous fluid that was culture negative. No further posterior knee pain was reported by the patient at subsequent visits. The patient was seen at 1-month and 3-month intervals following cRF neurotomy. At these visits, he continued to report significant pain reduction and improvement of his function. At the 1-month and 3month follow-up visits, his average pain score was 3 out of 10, with self-reported improvement in function. The patient did not return after 3 months. Discussion Patients with chronic knee pain that is unresponsive to conservative therapy and who do not wish to undergo TKR or are poor candidates for TKR may choose RF neurotomy as a treatment option. In anticipation of offering this treatment option, physicians must account for the anatomic variability of the nerve supply to the knee, which may adversely affect success rates. To limit
the potential influence of anatomic variations, newer technologies such as cRF might be considered a preferable option. In cRF, room temperature water circulating inside the probe reduces extremes in heat, which prevents charring of the tissue. The charring is believed to decrease the efficiency of heat transfer to adjacent tissues. Theoretically, cooling is believed to improve the size, shape, and projection of the lesions compared to those produced by traditional RFN probes [9]. The lesions presented in this case offer a visual explanation for the mechanism of cRF neurotomy in the treatment of knee osteoarthritis and are the first such images of in vivo lesion formation with cRF. Further studies are indicated to further compare and contrast in vitro lesions produced following cRF and RF neurotomy. The large spherical lesions seen support the hypothesized advantages of cRF over traditional RF neurotomy. The altered lesions produced by cRF may account for the substantial pain relief experienced by our patient, and support further prospective investigation of the use of cRF over traditional RF neurotomy in peripheral joints such as the knee. Conclusion This case provides the first in vivo images of the lesions created by cRF ablation. The patient experienced 3 months of pain reduction after undergoing cRF neurotomy of the left knee. A plausible explanation for the duration of his pain relief is the creation of the large spherical lesions demonstrated in the images presented. References 1. Felson DT. An update on the pathogenesis and epidemiology of osteoarthritis. Radiol Clin North Am 2004;42:1-9. 2. Felson DT. The sources of pain in knee osteoarthritis. Curr Opin Rheumatol 2005;17:624-628.
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce
401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480
4 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500Q2 501 502 503Q3 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565
Cooled Radiofrequency Neurotomy of the Knee
3. Masahiko I. Percutaneous radiofrequency treatment for refractory anteromedial pain of osteoarthritic knees. Pain Med 2011;12: 546-551. 4. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 Update. Arthritis Rheum 2000;43:1905-1915. 5. Choi WJ, Hwang SJ, Song JG, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: A double-blind randomized controlled trial. Pain 2011;152:481-487.
Disclosure M.E.F. International Spine, Pain & Performance Center, Washington, DC Disclosure: nothing to disclose G.G. George Washington University, Washington, DC Disclosure: nothing to disclose
566 6. Gardner E. The innervation of the knee joint. Anat Rec 1948;101: 567 109-130. 568 7. Hirasawa Y, et al. Nerve distribution to the human knee joint: 569 Anatomical and immunohistochemical study. Int Orthop 2000;24:1-4. Q8 570 571 8. Menzies RD, Hawkins JK. Analgesia and improved performance in a 572 patient treated by cooled radiofrequency for pain and dysfunction 573 postbilateral total knee replacement. Pain Pract 2015;15:E54-E58. 574 9. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo575 576 controlled study to assess the efficacy of lateral branch neuro577 tomy for chronic sacroiliac joint pain. Pain Med 2012;13:383-398.
578 579 580 581 582 583 584 M.J.D. International Spine, Pain & Performance Center, 2141 K Street NW, Suite 585 600, Washington, DC 20037; George Washington University, Washington, DC. Q4 586 587 Address correspondence to: M.J.D.; e-mail: [email protected] 588 Disclosures related to this publication: nothing to disclose; Disclosures outside 589 this publication: Halyard Health, Medtronic. 590 591 Submitted for publication March 19, 2016; accepted September 8, 2016. 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650
CRP 5.4.0 DTD PMRJ1779_proof 24 September 2016 5:09 am ce