Cardiovasc Intervent Radiol (2023) 46:1538–1550

https://doi.org/10.1007/s00270-023-03393-2

REVIEW MUSCULOSKELETAL INTERVENTIONS

Image-Guided Radiofrequency Ablation for Joint and Back Pain:

Rationales, Techniques, and Results
Felix M. Gonzalez1 • Junjian Huang2 • Jan Fritz3

Received: 19 September 2022 / Accepted: 10 February 2023 / Published online: 10 March 2023
 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe
(CIRSE) 2023

Abstract Image-guided minimally invasive radiofre- Keywords Shoulder pain
Hip joint
Back pain

quency ablation (RFA) of sensory nerves has emerged as a Osteoarthritis
Radiofrequency ablation

treatment option for pain and swelling associated with Basivertebral ablation
advanced symptomatic joint and spine degeneration to
bridge the gap between optimal medical therapy and sur-
gical treatments. RFA of articular sensory nerves and the
basivertebral nerve use image-guided percutaneous
approaches resulting in faster recovery time and minimal
Introduction
risks. The current published evidence indicates clinical
effectiveness; however, further research must be performed
Osteoarthritis and spine degeneration are among the most
comparing other conservative treatments with RFA to
common diseases worldwide. The number of symptomatic
understand further its role in different clinical settings, such
patients is expected to increase as the general population
as osteonecrosis. This review article discusses and illus-
ages. Nonsteroidal anti-inflammatory drugs can be effec-
trates the applications of RFA for treating symptomatic
tive in early stages and mild symptoms; however, they may
joint and spine degeneration.
have limited effectiveness in advanced stages and with
higher-intensity pain. Opioid-based pain management can
be useful for short-term treatment, but long-term treatment
compounds the problem of opioid addiction. Joint
replacement and spinal fusion surgeries can be effective
& Jan Fritz but best considered after other treatment options have been
jan.fritz@nyulangone.org exhausted. In addition, there is a group of patients where
Felix M. Gonzalez comorbidities prevent surgeries. Hence, there is a rising
fgonzalez401142@gmail.com demand for minimally invasive treatment options, such as
Junjian Huang image-guided minimally invasive radiofrequency (RFA)
junjianhuang@uabmc.edu ablation, to bridge the gap between pain medication and
1
surgical treatments and for patients without surgical
Department of Radiology, Musculoskeletal Interventional
Radiologist, AdventHealth Orlando, 601 E Rollins St,
options.
Orlando, FL 32803, USA Radiofrequency ablation (RFA) delivers localized sup-
2 raphysiological heat to destroy specifically targeted tissues,
Department of Radiology, Division of Vascular and
Interventional Radiology, University of Alabama at such as pain-transmitting sensory nerves. Successful RFA
Birmingham, Birmingham, AL, USA of sensory nerves interrupts pain transmission, resulting in
3
Department of Radiology, New York University Grossman longer-lasting pain relief. The heat is created by high-fre-
School of Medicine, New York University, 660 1St Ave, quency radio waves and is directed at the target nerves
New York, NY 10016, USA

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F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
through the tip of a percutaneous metallic probe. RF-ab-
lated nerves may grow back over time. However, the nerve
regeneration process is slow, with approximately 1 mm per
day, explaining pain relief of up to 24 months, for example,
in the knee. Imaging guidance is useful for RFA to identify
landmarks and targets accurately. While we prefer fluo-
roscopy guidance, RFA of nerves may also be performed
under ultrasonography, computed tomography, and mag-
netic resonance imaging guidance. Procedures may be
performed with local anesthesia or sedation; however, we
prefer moderate sedation due to better pain coverage in our
experience. Probe selections vary based on anatomic
regions and targets, including 2 mm active tip probes in the
shoulder and 4 mm active tip probes in the hip and knee.
Sensory nerves may be ablated for 2.5 min at 60 C. In
RFA performed for pain relief, sensory nerves are targeted,
while motor nerves must be spared. For this reason, stim-
ulating motor testing should be performed after needle
placement and before RFA to ensure adequate probe dis-
tance from any nearby motor nerves.
This review article discusses the applications of RFA in
treating symptoms of advanced symptomatic joint and
spine degeneration.
Knee Joint Radiofrequency Ablation
Knee osteoarthritis is estimated to affect 52.5 million
Americans or 22.7% of adults in the USA [1]. Almost 60%
of the population with osteoarthritis has metabolic syn-
drome [2], which makes them less suitable for surgical
intervention and puts them at greater risk of poor surgical
outcomes. There is a higher risk of infection in obese
patients, among whom the incidence of revision surgery is
also higher [3]. An ideal body mass index is recommended
for best postoperative outcomes, making conservative
treatments essential for symptomatic relief until the goal
weight is reached.
Furthermore, there is a lack of compelling evidence for
improvements in function and quality of life in obese
patients with total knee replacement. There are no clear
indications that total knee replacement improves weight
management after surgery, and there is evidence that
obesity is associated with accelerated implant failure [4, 5].
Therefore, non-operative treatments in the intermediate
term could be an important part of a multi-stage treatment
plan.
Patients may choose to avoid surgery for various reasons
or consider it the ultimate option due to the associated
risks. Almost half of the individuals diagnosed with
symptomatic knee osteoarthritis are younger than 65, and
about 15% are younger than 45, necessitating two or more
revision surgeries for many patients [6]. This is especially
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true for patients that may have advanced knee osteoarthritis
radiographically but may have intermittent tolerable
symptoms or do not have the social support available
during the postoperative period. Symptomatic knee
osteoarthritis contributes to indirect costs such as loss of
function, work, and wages [7], as well as downstream
healthcare costs due to significant associated morbidity
with knee osteoarthritis when a more sedentary lifestyle is
adopted, including cardiovascular and pulmonary disease,
obesity, osteoporosis, and higher risk of falls.
From public health and economic standpoints, effective
non-surgical knee osteoarthritis treatments are an unmet
clinical need with the potential to impact a significant
portion of the population.
Patient Selection and Contraindications
RFA is currently applied to treat knee pain and discomfort
in patients with moderate to severe osteoarthritis (i.e.,
Kellgren and Lawrence grades 3 and 4) that have failed
other conservative treatments and are not surgical candi-
dates. Chronic knee pain related to mild (grade 2)
osteoarthritis may also represent an indication for RFA if
refractory to pharmacological or physiotherapy treatments.
Standing weight-bearing knee radiographs in different
views are acquired of the affected or both knees to assess
the degree of osteoarthritis. Patients treated are typically
refractory to anti-inflammatory analgesia and intra-articu-
lar lidocaine-steroid injections are ineffective. In candi-
dates for RFA, preprocedural selective image-guided
geniculate diagnostic nerve blocks should result in 50% or
greater relief of typical knee pain. RFA may be effective in
patients after arthroplasty [8].
Contraindications include a recent or present history of
septic arthritis, inflammatory or crystal-related arthropathy,
and immunocompromised or current treatment with ster-
oids or other immunosuppressive drugs. Patients with only
mild pain, minimal degree of degenerative process on
radiographs, traumatic knee pain, and inflammatory or
infectious pain should undergo thorough evaluation with
physical examination and CT or MRI.
Preprocedural Diagnostic Nerve Block
We perform preprocedural selective diagnostic geniculate
nerve blocks to aid in patient selection for RFA. Patients are
placed supine on a fluoroscopy table with the symptomatic
knee(s) at 30 flexion. After superficial skin anesthesia,
22-gauge 3.5-inch spinal needles are advanced to three
locations to block the superolateral, superomedial, and
inferomedial genicular nerves (Fig. 1 and Fig. 2). The
superolateral and superomedial genicular nerves travel along
the concave transitions of the femoral metadiaphysis and
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1540 F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...

Fig. 1 Anatomy of the sensory knee branches in anteroposterior (A), (SLGN), superomedial genicular nerve (SMGN), suprapatellar genic-
mediolateral (B), and lateromedial (C) views. The circles indicate the ular nerve (SPGN), and inferomedial genicular nerve (IMGN)
target areas for needle placement for the superolateral genicular nerve

Fig. 2 Fluoroscopy-guided
radiofrequency ablation of the
sensory knee branches.
Anteroposterior (A) and later
(B) fluoroscopy images showing
the needle locations for ablation
of the superolateral genicular
nerve (SLGN), superomedial
genicular nerve (SMGN),
suprapatellar genicular nerve
(SPGN), and inferomedial
genicular nerve (IMGN). The
appropriate needle placement on
the A.P. view is at the central
aspect of the metaphyseal flare.
The needle should cover at least
60% of the total A.P. dimension
of the distal femur or proximal
tibia on the lateral view

femoral condyles (Fig. 2), whereas the inferomedial genic-
ular nerve site is located at the concave transition between
the tibial plateau and adjacent metadiaphyseal shaft. The
suprapatellar genicular nerve can also be blocked in
advanced patellofemoral osteoarthritis patients with anterior
knee pain. This fourth needle is placed at the midline anterior
distal femoral diaphysis 3 cm cephalad to the superior aspect
of the patella. At each genicular nerve site, 1.0 mL of local
anesthetic is injected to anesthetize each genicular nerve
selectively. Patients are assessed within 15 min of the nerve
blocks by physical examination. Pain relief of 50% or greater
is considered a positive pain response and predictor for
successful pain relief after RFA [9].
Procedural Anesthesia
Moderate sedation can be given with 1–2 mg of intra-
venous midazolam or 25–100 mcg of intravenous fentanyl.

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For the entire procedure, vitals are monitored, and patients
are given supplemental oxygen through a nasal cannula. A
grounding pad is placed ipsilaterally to the joint receiving
RFA. Grounding pads near metal prostheses, bony promi-
nences, significant scar tissue, and potential areas of edema
should be avoided to ensure adequate conduction [9–11].
Patients with sleep apnea and difficult airways should be
considered for general anesthesia under the close supervi-
sion of a trained anesthesiologist.
Image Guidance and Anatomical Landmarks
for Needle Tip Position
The RFA procedure is best performed under fluoroscopy
guidance with the patient in the prone position. If patients
require both knees to be treated, foam blocks may be used
to position one knee higher than the contralateral knee to
reduce fluoroscopic superimposition and beam artifacts.
Before introducer needles are placed, local lidocaine skin
anesthesia is employed at each ablation site (1). Using
fluoroscopic guidance, 17G introducer needles are
advanced to the superolateral genicular nerve (SLGN),
superomedial genicular nerve (SMGN), suprapatellar
genicular nerve (SPGN), and inferomedial genicular nerve
(IMGN) locations (Figs. 1 and 2), using the same land-
marks as for the nerve blocks. The final position of the
electrode is confirmed with fluoroscopy in anterior–poste-
rior and lateral fluoroscopic views. Motor activity testing is
performed (see below). 1 mL of 2% lidocaine is adminis-
tered through the introducer needle for deep anesthesia at
each location. Subsequently, an 18G RFA electrode with a
4 mm active tip is placed through the introducer needle.
Sensory and Motor Testing
Both sensory and motor activity testing is performed.
Sensory stimulation using 50 Hertz at 0.5 Volt is useful to
confirm the proximity of the electrode to the nerve. Using
1–2 Volt at 2 Hertz and 1 milliAmp, motor nerve activity
is excluded before deep local anesthesia is applied and the
actual ablation is performed. If motor activity is seen by
muscle twitching, the electrode is repositioned while
remaining in the introducer, and motor nerve activity is
tested again.
RFA Ablation Settings and Duration
After the exclusion of motor nerve activation and deep
local anesthesia, each nerve undergoes ablation for
150–180 s at a temperature of 60 C [9–11].
1541
Tips and Tricks
The introducer needle should be at least 1–2 cm deep under
the skin surface to avoid a skin burn. It is essential to test
for motor innervation, and if motor activity occurs during
the test phase, we recommend modifying the needle posi-
tion to slightly superior or inferior to the desired location.
However, subtle local but not lower extremity twitches
might be acceptable. A rule of thumb is that the closer the
needle is to the articular surface, the closer the proximity to
a sensory nerve branch is. The farther the needle tip
location is from the joint, the higher the risk for motor
nerve selection.
To be accurate, we recommend administering no more
than 1 ml of local anesthetic during the nerve block phase,
as the injectant typically spreads a few centimeters, which
may increase the probability of a false positive nerve block.
It is necessary not to inject the local anesthetic before
motor testing as that would create a nerve block which
would render the motor test inaccurate.
Postoperative Recommendations
After the ablation procedures, patients are informed to
progress with physical activity gradually and restrict car-
rying anything heavier than 5 pounds during the first week.
The RFA portals are expected to be sensitive for a week or
two. We recommend that patients not submerge the abla-
tions sites under a body of water for at least five days while
showering with adhesive patch coverage can be resumed
the day after the procedure.
Potential Complications
Complications are rare but include hematoma, infection,
allergic reactions, and motor nerve injury. High-intensity
physical activity within two weeks after RFA may increase
the risk of ligamentous, tendinous, or muscle injury.
Normal Postoperative Course
Patients with positive outcomes after the procedure may
report different degrees of symptom improvement. A sub-
set of patients experiences gradual pain relief with maxi-
mum relief usually after a month following the ablation.
Another subset reports a fast course to significant or
complete pain relief within days after the ablation. In
patients with less than favorable responses, symptoms may
return to baseline or, at times, worse than baseline. A small
subset of patients may report pain worsening initially for a
few days, followed by gradual pain decrease, which sug-
gests early post-ablation neuritis that may occur when the
nerve is partially treated.
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Follow-Up Evaluation
Knee injury and Osteoarthritis Outcome Score (KOOS) and
Western Ontario and McMaster Osteoarthritis Index
(WOMAC) questionnaires may be used to evaluate the
overall function and pain after RFA. These evaluations
include subscales of pain, function in sports and recreation,
daily living, and quality of life [9–11]. A visual analog
scale (VAS) can be used as a single-item evaluation for
pain.
Clinical Results and Outcomes
patients considered for crossover were not deemed medi-
cally appropriate candidates for RFA based on diagnostic
nerve block criteria.
Hip Joint Radiofrequency Ablation
Patient Selection and Contraindications
The indications and contraindications are similar to the
knee joint. There are limited data on the effectiveness of
RFA after arthroplasty.

Several clinical studies have evaluated the effectiveness of Preprocedural Diagnostic Nerve Block
RFA in treating osteoarthritis. The first case series exam-
ining the clinical effects encompassed nine patients The preceding nerve blocks should target the sensory
reporting significant improvement in pain score at one branches of the obturator and femoral nerves. The
month post-treatment (baseline VAS scores 8.0 ± 1.5 were acetabular incisura is used as the landmark to target the
reduced to 2 ± 0.5), with a sustained benefit up to obturator nerve (Figs. 3 and 4). The femoral vascular
12 months (2.2 ± 0.2) [12]. Functional assessment using bundle may be located by palpation or ultrasonography.
Western Ontario McMaster Universities OA index The injection needle is inserted approximately 2 cm medial
(WOMAC) scores (baseline 88 ± 1.9) also showed to the femoral vessels. The needle is advanced until it
improvements one month and 12 months post-treatment contacts the bony cortex of the target zone. Using fluo-
(20 ± 2 and 20 ± 1.0, respectively). There is evidence that roscopy, the needle is advanced while remaining deep to
RFA can provide more consistent benefits than intra-ar- the femoral neurovascular sheath until the needle contacts
ticular injections of corticosteroid (IACS), based on results the bony ischium adjacent to the tear drop. The femoral
from a randomized crossover clinical trial of 151 patients artery is palpated and marked below the inguinal ligament
with knee pain C 6 months that were unresponsive to for the femoral nerve block. The nerve block needle is
conservative treatment [11]. This study reported a 50% advanced under fluoroscopy guidance to the 12:00 o’clock
reduction in numeric rating scale (NRS) pain in 74% of the position at the superior acetabular dome until the intro-
RFA group compared with 16% of the IACS group 6 ducer contacts the acetabular cortex approximately
months after treatment. The percentage of non-responders 2–3 mm away from the articular surface. A physical
was lower in RFA (25.9%) compared with IACS (83.8%). examination and ambulation are used to evaluate patients
The RFA group showed a greater reduction in NRS score
(4.9 ± 2.4) than the IACS group (1.3 ± 2.2). Only a small
number of patients (n = 4) did not cross over from IACS to
RFA, who reported comparable NRS to the RFA group. At
18 months, 12/25 subjects (48.0%) continued to report
C 50% pain relief, and 20 patients (80.0%) reported
improvement from their chronic pain after RFA. At
24 months, 11/18 patients reported C 50% pain relief.
These data suggest that the benefits of RFA may extend up
to 24 months.
RFA has also demonstrated more consistent benefits
than hyaluronic acid (HA) injections in a clinical trial of
179 patients with symptomatic knee OA. In this random-
ized crossover trial design, 71.1% of patients treated in the
RFA group reported more than a 50% reduction in NRS
pain score compared with 37.8% in the HA group [13]. The
RFA group reported significantly better NRS scores at 1, 3, Figure. 3 Sensory innervation of the anterior hip in anteroposterior
view. The white arrows indicate the expected anatomic course of the
and 6 months. The HA group that crossed over to RFA
sensory branches from the femoral nerve along the superior acetab-
showed similar pain reduction at 6 months compared with ulum. The black arrow indicates the sensory branches of the obturator
the randomized RFA group. However, 16% of the HA nerve innervating the inferomedial aspect of the joint

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F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
Fig. 4 Fluoroscopy-guided radiofrequency ablation of the sensory
hip branches. A Anteroposterior fluoroscopy image showing the
probe-target location (arrow) for the obturator branch in the region of
the incisura. B The needle in position A is then retracted
15–30 min after the nerve block. Pain relief of 50% or
greater is considered a positive pain response and predictor
for successful pain relief after RFA.
Procedural Anesthesia
Same as for knee joint RFA.
Image Guidance and Anatomical Landmarks
for Needle Tip Position
The sensory innervation of the hip joint is intricate and
originates from multiple sources. The femoral and obtu-
rator nerves innervate the anterior joint capsule, which
contains a high concentration of nociceptors and
mechanoreceptors, currently recognized as a primary pain
generator site [14, 15]. Fluoroscopy is the primary
modality to place the ablation probes, using the same
landmarks as the nerve blocks. Motor activity testing is
performed, followed by deep local anesthesia and ablation
probes [14, 15].
Sensory and Motor Testing
Same as for knee joint radiofrequency ablation.
RFA Ablation Settings and Duration
Same as for knee joint radiofrequency ablation.
Tips and Tricks
Sonographic evaluation of the main femoral vasculature is
recommended before introducing needles through the thigh
to target the obturator sensory branch. The entry point
should be medial to the vessels.
1543
approximately 3 mm distally for the second probe-target location
(circle) for the obturator branch. C Anteroposterior fluoroscopy image
showing the probe-target location (arrow) for the femoral branch at
the 12 o’clock position in the acetabular dome
Postoperative Recommendations
Same as for knee joint radiofrequency ablation.
Normal Postoperative Course
Same as for knee joint radiofrequency ablation.
Potential Complications
Please see the complications for knee joint radiofrequency
ablation.
Clinical Results and Outcomes
RFA has been shown to result in significant pain reduction,
with follow-up times that ranged from 8 days to 3 years
and pain-relieving benefits varying between 30 and 90%
from baseline scores [34]. Kapural et al. found a significant
reduction in hip pain almost a year after the first ablation,
with pain changing from a baseline VAS score of
7.61 ± 1.2 to 2.25 ± 1.4 after RFA [16]. In a third study
including 11 patients with hip pain related to advanced
osteoarthritis, RFA was revealed to lead to significant pain
reduction at 6-month follow-up, with the overall VAS
score significantly changed from 8.3 ± 1.1 to 2.5 ± 0.5
[35].
Shoulder Joint Radiofrequency Ablation
Shoulder arthritis can affect patients regardless of age, with
a prevalence previously described at 11.1% in patients
younger and 20.3% older than 65 [17]. Risk factors include
age, diabetes, obesity, prior shoulder dislocations or frac-
tures, rotator cuff arthropathy, inflammatory arthritis, and
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1544 F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
avascular osteonecrosis [18]. Conservative treatments of
shoulder osteoarthritis include physical therapy, lifestyle
modifications, and intra-articular injections with anesthet-
ics and corticosteroids, among others [19]. Surgical
approaches include surgical procedures such as total
shoulder arthroplasty, hemiarthroplasty, resurfacing, and
reverse arthroplasty. Three main sensory nerves innervate
the glenohumeral joint: the suprascapular, axillary, and
lateral pectoral nerves [20] (Fig. 5).
Patient Selection and Contraindications
The indications and contraindications are similar to the
knee joint. There are limited data on the effectiveness of
RFA after arthroplasty.
Preprocedural Diagnostic Nerve Block
The posterior shoulder joint is innervated by the supras-
capular and axillary nerves, whereas the anterior shoulder
joint is innervated by the lateral pectoral nerve (Fig. 5).
The diagnostic nerve block and successive RFA target the
sensory branches of these three nerves to select and treat
patients with symptomatic degenerative arthrosis properly.
To determine optimal candidates for RFA, patients receive
a diagnostic nerve block beforehand the RFA procedure.
The nerve block involves administering 0.5–1.0 mL of
local anesthetic at each nerve site. The suprascapular nerve
is targeted along the superior one-third of the glenoid rim,
about 2–3 mm from the articular surface. The axillary
nerve is targeted at the inferior lateral border of the greater
tuberosity above the surgical neck level. The lateral pec-
toral nerve is targeted at the midpoint of the coracoid
process. Patients who report at least a 50% reduction in
their pain, 15–20 min after the nerve block screening, are
considered candidates for a RFA procedure performed
3–4 weeks later. Patients who report at least a 50% pain
reduction are indicated for RFA [20].
Fig. 5 Sensory innervation of
the posterior (A) and anterior
(B) shoulder. Posteriorly (B),
the suprascapular nerve sensory
branches (1) course at the upper
one-third of the glenoid and the
axillary nerve sensory branches
(2) course more inferiorly at the
level of the surgical neck and
greater tuberosity. Anteriorly
(B), the pectoralis major sensory
branch (3) projects over the
coracoid process
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Procedural Anesthesia
Same as for knee joint radiofrequency ablation.
Image Guidance and Anatomical Landmarks
for Needle Tip Position
Most patients present with circumferential shoulder pain;
hence, all three nerve sites are targeted for thermal abla-
tion. If patients experience shoulder pain in one specific
area, then only the nerve that supplies that area may be
ablated. The capsular branch of the suprascapular nerve is
located along the posterior–superior one-third of the gle-
noid rim, about 2–3 mm from the articular surface. The
capsular branch of the axillary nerve is situated at the
inferior lateral border of the greater tuberosity. The cap-
sular branch of the lateral pectoral nerve is targeted at the
midpoint of the coracoid process (Figs. 5 and 6).
For the posterior shoulder nerve ablation, the patient is
placed on the fluoroscopy table in a prone position with the
hand corresponding to the symptomatic shoulder internally
rotated with the forearm pronated. The grounding pad is
applied to the patient’s flank ipsilaterally, and the posterior
shoulder is sterilely prepared. In this position, to target the
suprascapular nerve, the posterior border of the glenoid
process is visualized by rotating the C-arm 15–45 from the
anterior–posterior position in the direction of the symp-
tomatic shoulder. To profile the glenoid, an additional 15
caudal tilt is added to project acromion out of the humerus
head and glenoid fossa. The capsular branch of the
suprascapular nerve’s expected location is along the upper
one-third of the glenoid rim near the articular surface,
superolateral to the spinoglenoid notch. Caution should be
taken to avoid needle insertion into the joint space, with the
needle placed approximately 2–3 mm medial to the artic-
ular surface. 1 mL of iodinated contrast medium may be
injected to confirm the extra-articular positioning of the
needle. The second capsular branch of the suprascapular
nerve location is about 3 mm inferior to the first capsular
F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
Fig. 6 Fluoroscopy-guided radiofrequency ablation of the sensory
shoulder branches. A Posteroanterior fluoroscopy image shows the
ablation probe (arrow) targeting the suprascapular nerve sensory
branch of the upper one-third at the glenoid rim. B Posteroanterior
fluoroscopy image shows the ablation probe (arrow) targeting the
branch of the suprascapular nerve site (Fig. 6). The intro-
ducer is repositioned by using the same skin entry site.
Two sites are selected to target the capsular branch of
the axillary nerve branches. The C-arm is focused on the
humeral head. The needle is introduced at the most lateral
aspect of the greater tuberosity, just superior to the level of
the surgical neck (Fig. 6). It is then advanced until it makes
contact with the lateral cortex. For motor nerve stimulation,
the deltoid and teres minor muscles are observed for
aroused movement. If provoked movement occurs, the
introducer is then repositioned superiorly and laterally to
separate it from the axillary motor nerve trunk. For the
second capsular branch of the axillary nerve site, through
the same skin entry site, the needle can be positioned
3–4 mm inferior to the greater tubercle (where it tapers and
transitions into the humeral diaphysis) while remaining on
the most lateral border of the humerus (Fig. 6).
After RFA of the capsular branches of the suprascapular
and axillary nerves, the patient is turned from prone to
supine on the table for the lateral pectoral nerve. The
anterior aspect of the shoulder is sterilized, and a ground-
ing pad is reconfirmed on the flank ipsilateral to their
symptomatic shoulder. The C-arm is then rotated 15
toward the symptomatic shoulder from the P.A. view and
medially to superimpose the coracoid process to the
glenohumeral joint (Fig. 6). The ideal position of the
coracoid process is a ‘‘thumbs down’’ appearance, which is
usually achieved with a 15 cephalic C-arm tilt. Conse-
quently, the lateral pectoral nerve is targeted at the central
aspect of the coracoid process (Fig. 6).
Sensory and Motor Testing
After removing the introducer stylet, the RFA probe (tip
length being 2 mm) is placed, and motor neurons are
stimulated to exclude them from being damaged during
1545
axillary nerve sensory branch at the base of the greater tuberosity.
C Anteroposterior fluoroscopy image shows the ablation probe
(arrow) targeting the pectoralis major sensory branch at the level of
the coracoid process
ablation. If the corresponding rotator cuff muscles twitch or
move during the stimulation, then the introducer should be
repositioned, usually toward the articular surface or either
superiorly or inferiorly from the current needle position.
Deep local anesthesia is injected after motor nerve place-
ment has been excluded for the ablation to commence.
RFA Ablation Settings and Duration
Same as for knee joint radiofrequency ablation.
Tips and Tricks
To avoid skin burns, the introducer should be at least
1–2 cm deep into the skin, especially with the lateral
pectoral nerve sensory branches being so superficial.
Postoperative Recommendations
Same as for knee joint radiofrequency ablation.
Potential Complications
Same as for knee joint radiofrequency ablation.
Normal Postoperative Course
Same as for knee joint radiofrequency ablation.
Clinical Results and Outcomes
RFA has been shown to reduce pain for 6 months, with
VAS scores significantly improving from 8.8 ± 0.6 to
2.2 ± 0.4. Gabrhelik et al. retrospectively studied pulsed
RFA to the suprascapular nerve in 28 patients and com-
pared the combination of local anesthetic, pulsed RFA, and
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steroid to local anesthetic and pulsed RFA treatment. They months, failure of non-surgical management for greater
found that both groups had a significant reduction in VAS than 6 months, and MRI demonstrating Modic type I/II
scores at 6 months (steroid group: 4.6, 95% CI: 3.7–5.6 vs. endplate degeneration pattern. In the USA, ablation is only
2.6, 1.5–3.6; nonsteroid group: 5.1, 4.5–6.7 vs. 1.6, indicated for L3–S1 (Fig. 7).
0.5–2.6) with no statistically significant difference between Contraindications to treatment include the following
the steroid and nonsteroid group, implying that pulsed RFA [29–31]:
is an effective method of treatment that is not affected by
• Skeletal immaturity
steroid injections [21–24].
• Pregnancy
• Electronic implants
• Severe cardiopulmonary compromise
Basivertebral Nerve Ablation
• Proximity of spinal canal to ablation zone \ 10 mm
• Radicular pain
Low back pain is one of the most common musculoskeletal
• Spinal stenosis
ailments worldwide [25, 26]. The treatment for low back
• Uncorrectable coagulopathy
pain varies but typically starts with conservative manage-
• Active infection
ment such as oral nonsteroidal anti-inflammatory, avoid-
• Poor compliance
ance of aggravating activities, physical therapy, and
lifestyle modifications [27, 28]. When refractory to these,
non-surgical management such as epidural steroid injec- Anesthesia
tions and local regional blocks may be employed before
surgical decompression. Intraosseous radiofrequency abla- These procedures can be performed under moderate seda-
tion of the basivertebral nerve is a novel technique that has tion with fentanyl and versed or under general anesthesia
demonstrated efficacy in treating patients with back pain per operator preference. Biofeedback during ablation can
resistant to non-surgical management [29–31]. be helpful. Therefore, our center prefers to perform these
Since the basivertebral nerve is targeted within the procedures under sedation when possible.
vertebral body, the initial step in the procedure involves
gaining vertebral body access. Access to the targeted ver-
tebral body is achieved through a transpedicular approach.
The ablation is performed within the posterior one-third of
the vertebral body, with the tip just across the midline. The
radiofrequency probe is then inserted into position under
direct fluoroscopic guidance.

Patient Selection and Contraindications

Appropriate patient selection is critical for basivertebral

nerve ablation. Patient selection differs from region to
region; however, it typically will have elements of the
following:
• Chronic lower back pain greater than 6 months
• Failure of non-surgical management for greater than 6
weeks
• Imaging findings supportive of vertebrogenic etiology
Evaluation for chronic lower back pain should include
determining if the pain is axial versus radicular, as axial
pain will be better treated by ablation of the basivertebral
nerve ablation. It is important to note that non-surgical Fig. 7. A 41-year-old man with chronic lower back pain and a history
management includes but does not require local regional of epidural injections that did not relieve his pain. Sagittal fat-
blocks, so there is no requirement to perform a block suppressed short-tau inversion recovery M.R. image of the lumbar
spine shows L3–L4 and L4–L5 disk degeneration (arrows) and type
before ablation.
I/II Modic endplate degeneration (asterisks), suggestive of a disco-
In the USA, the accepted indication for basivertebral genic back pain etiology. There were no signs of neural element
nerve ablation is for chronic lower back pain greater than 6 compression

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F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
Image Guidance
Basivertebral nerve ablation can be performed under
computed tomography or fluoroscopic guidance (Fig. 8).
Patients should be prone with arms up above their heads if
possible. Unipedicular access is obtained using an access
cannula. A diamond tip is typically used to engage the
pedicle at its upper outer margin, with the tip directed
inferomedially. A beveled tip introducer is sometimes used
if there is a need to redirect the cannula. The cannula tip
(not the introducer tip) should be just past the body–pedicle
junction before the introduction of the curved osteotome to
avoid unintentional violation of the central canal, although
the operator may decide to retract the cannula into the
pedicle to allow for optimal positioning if the initial access
is not medialized or inferior enough. The gauge of the
access cannula varies based on the ablation platform being
utilized.
Anatomical Landmarks for Needle Tip Position
The needle tip position should be midline on anteroposte-
rior images, with the ablation centered at the junction
between the posterior and middle third of the vertebral
body (Fig. 9).
Sensory and Motor Testing
Not required.
RFA Ablation Settings and Duration
Ablation system and probe may be chosen to achieve an
ablation zone of 2 cm 9 1.5 cm, an ablation temperature
of 50 C at the proximal thermocouple (10 mm away from
Fig. 8 Fluoroscopy-guided needle placement for basivertebral nerve
ablation via L4 transpedicular access. Anteroposterior (A) and lateral
(B) fluoroscopy images of transpedicular access through the left
pedicle of L4 (arrows) with needle tip at the posterior wall of the
vertebral body and well clear of the medial cortex of the pedicle
1547
the source), and ablation times of 5–10 min when per-
formed at 3W.
Tips and Tricks
The approach for basivertebral nerve ablation is more
posterior than traditional balloon kyphoplasty. When using
a system, ensure that the center of the ablation zone is
centered on the basivertebral nerve, as it is very easy to be
off-center. (Fig. 10) Also, having a pillow under their
pelvis is beneficial to flex the lumbar spine to allow for
more spacing to place the ablation probe.
Postoperative Recommendations
Bed rest for 3 h with neuro checks every 30 min for the
first 2 h and then every 60 min afterward.
Potential Complications
Complications are rare with basivertebral nerve ablation.
Minor complications include exacerbation of low back pain
and transient nerve injury. Major complications are
exceedingly rare but include vertebral compression fracture
and retroperitoneal hemorrhage [32, 33].
Normal Postoperative Course
Expect same-day discharge with moderate postoperative
pain. Typically, 1–2 days of oral opioids are sufficient to
treat postoperative pain. A clinic visit should be arranged if
the patient experiences more pain. Retreatment is possible
after a minimum of 6 months, as long as the patient
experiences temporary pain relief at that level.
(asterisk in A). This is a safe approach. The basivertebral nerve
(yellow lines) entry point is located near the junction of the posterior
and middle third of the vertebral body at the inferior edge of the
pedicles (center of the yellow lines)
123
1548 F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
Fig. 9 Fluoroscopy-guided ablation probe placement for basiverte-
bral nerve ablation via L4 transpedicular access. Anteroposterior
(A) and lateral (B) fluoroscopy images show the ablation probe
(Spinestar, Merit, South Jordan UT USA) centered at the spinous
Fig. 10 Fluoroscopy-guided ablation probe placement for basiverte-
bral nerve ablation via L5 transpedicular access. Anteroposterior
fluoroscopy image shows the ablation probe tip at the spinous process
(white dashed line). The resulting ablation zone (tan circle) would
provide inadequate coverage of the basivertebral nerve. In this case,
probe advancement of another 1 cm midline will result in adequate
coverage of the basivertebral nerve
Clinical Results and Outcomes
Up to 96.5% of those who undergo basivertebral nerve
ablation can expect improvements in Oswestry Disability
Index of 25–32 and VAS of 1.6–4.3 cm in 3–12 months,
with sustained improvements in approximately 60% of
patients at 5 years [29–31]. In properly selected patients,
basivertebral nerve ablation has significantly improved
axial low back pain with minimal procedural risks.
123
process (A, red dash line) and the junction of the posterior-to-middle
third of the vertebral body (blue dashed line) at the level of the
pedicle. With this probe location, the ablation zone (circles in A and
B) will encompass the basivertebral nerve
Conclusion
RFA has been demonstrated to reduce pain and improve
mobility among treated patients with advanced knee, hip,
and shoulder osteoarthritis and spinal degeneration. RFA
can bridge the gap between medical drug treatment and
surgery. All procedures can be performed successfully and
safely under fluoroscopy using anatomic landmarks. The
rate of complications is generally low. The current pub-
lished evidence indicates clinical effectiveness; however,
further research must be performed comparing other con-
servative treatments with RFA to understand further its role
in different clinical settings, such as osteonecrosis.
Declarations
Conflicts of interest FG: Avanos Medical: Consultant. JH: JH
received institutional research support from Siemens/Varian and is on
the MSK ad board for Varian. Is a consultant for Siemens/Varian;
Relievant; and Merit. Society of Interventional Radiology: Board or
committee member. JF: Jan Fritz received institutional research
support from Siemens AG, Zimmer Biomed, DePuy Synthes, QED,
and SyntheticMR; is a scientific advisor for Siemens AG, Synthetic
MR, GE Healthcare, QED, ImageBiopsy Lab, Boston Scientific,
Mirata Pharma, and Guerbet; and has shared patents with Siemens
Healthcare, Johns Hopkins University, and New York University. (a)
American college of radiology: Board or committee member;
(b) American roentgen ray society: Board or committee member;
(c) Association of university radiologists: Board or commit-
tee member; (d) International Society of Magnetic Resonance In
Medicine: Board or committee member; (e) Society of skeletal radi-
ology: Board or committee member; (f) European society of skeletal
radiology: Board or committee member; (g) Radiological society of
north America: Board or committee member; (h) Current radiology
reports: Editorial or governing board; (i) Investigative radiology:
Editorial or governing board; (j) Cardiovascular and Interventional
F. M. Gonzalez et al.: Image-Guided Radiofrequency Ablation for Joint and Back Pain...
Radiology: Editorial or governing board; (k) Skeletal radiology:
Editorial or governing board; (l) RoFo: Editorial or governing
board; (m) Korean Journal of Radiology: Editorial or governing
board.
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