Paper of the month August 2023

Endoscopic Radiofrequency Treatment of the Sacroiliac Joint Complex for Low Back Pain: A Prospective Study with a 2-Year Follow-Up
Ibrahim R, Telfeian AE, Gohlke K, Decker O.
Pain Physician. 2019 Mar;22(2):E111-E118.

This month I would like to share with you a paper by our SIMEG member Dr. Richard Ibrahim.

Dr. Ibrahim and his colleagues report a 2-year follow-up of 30 patients treated with endoscopic radiofrequency (RF) . The results were good and more effective than conventional RF.

1. The purpose of ablation of the dominant nerve near the posterior ligament of the sacroiliac joint is the same as in the conventional method, but why does the therapeutic effect last longer when using an endoscope?

  • Is it because the nerve branches can be directly identified and safely ablated?
  • Is it because the surrounding tissue, except for the nerve branches, is ablated less and nerve regeneration signals are not stimulated because the procedure is performed in an irrigation solution?
  • Is this because it prevents the tissue around the nerve from being covered by scarring?
  • I would like to hear from the author regarding above questions.

2. Surgical Technique

Endoscopic RF was performed using Joimax instrument. A 5 mm skin incision is made near the caudal aspect of the sacroiliac joint, a 7.9 mm diameter working cannula is inserted, and the lateral and cranial nerve branches from the S3, 2, and 1 foramen are ablated. Is the scope positioned within the sacral multifidus muscle? I could not figure out if the scope would go caudad to cephalad and dissect between the fibers of the multifidus muscle in the sacral region. When the nerve branches are first burned outside the S3 foramen, does an irrigation solution open up the space between the sacrum bone and the multifidus muscle and direct the endoscope along the bone to the cranial aspect so that it can immediately reach outside the S2 and S1 foramen and identify the nerve branches?

  • This would be easier to understand if Dr. Ibrahim provide a live intraoperative video on the SIMEG website.

We have experienced several cases of residual pain after sacroiliac joint fusion surgery that required RF to the posterior ligament.

  • On the other hand, how many of Dr. Ibrahim's cases still required fusion surgery after endoscopic RF in the long term?
  • I assume that Dr. Richard Ibrahim is an orthopedic surgeon, but what are the criteria for the use and selection of surgical treatment versus endoscopic RF?
  • Is this endoscopic RF introduced by the authors mainstream among pain physicians in Germany?

The treatment of sacroiliac joint pain is successful when the pain physicians, physical therapists, and surgeons work together to provide appropriate treatment for each condition. This is an excellent article, and we should consider the indications for SIJ fusion surgery on that basis, while recognizing these endoscopic RF cases of success.

Daisuke Kurosawa

Response from the author

The purpose of ablation of the dominant nerve near the posterior ligament of the sacroiliac joint is the same as in the conventional method, but why does the therapeutic effect last longer when using an endoscope?

Q: Is it because the nerve branches can be directly identified and safely ablated?  

  • A: The denervation itself and the area of denervation  is more precise under endoscopic control and you get a total overview about all structures around the facet joint (soft tissue, capsule, ligaments, joint arhropathy)

Q: Is it because the surrounding tissue, except for the nerve branches, is ablated less and nerve regeneration signals are not stimulated because the procedure is performed in an irrigation solution?

  • A: More over, You be able to remove pathological soft tissue structures and as You know soft tissues / ligament around the SIJ are also pain perceptions

Q: Is this because it prevents the tissue around the nerve from being covered by scarring?

  • A: We are collecting in a further prospective study the results (MRT, second surgical treatment) to judge the scaring rate after the first treatment, but by now we can confirm no further significant scarring (n> 150).  In patient with pre-surgery in lumbar spine with and without instrumentation we see a significant  pain release by removing the scarring, but not in general - prospective studies are in planing.

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