knee and hip pain –new approaches and options but don’t

24th Annual Pain Management Symposium 10/23/2020

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Basic Fluoroscopic and Lumbar Spine Anatomy

Knee and Hip Pain – New Approaches and Options but Don’t Forget the Basics

Zachary L. McCormick, MD FAAPMRAssociate Professor, PM&R; University of Utah School of Medicine

Chief, Spine and Musculoskeletal Rehabilitation Section

Director, Clinical Spine Research

Director, Interventional Spine Fellowship

[email protected]

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The BasicsDisclosures

• Research Grants: Foundation of PM&R, SIS, RSNA Research & Education Foundation, EpiMed, Avanos, Relievant

• Board of Directors: SIS, PSPS

• Speaker: AAN, AAPM, NASS, PSPS, SIS

• Journal Editorial Boards: Pain Medicine, The Spine Journal, Physical Medicine & Rehabilitation

• Consulting: medicolegal, Soal Therapeutics

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Spectrum of Care

Continued Pain and Disability Despite Treatment

Weight loss

Bracing

Cane/assistive device

Ice/cryotherapy, Heat

Oral Anti-inflam meds

Targeted Exercise- Quad, hip girdle, core- Bike/swimming

Surgery-Arthroplasty

Formal Physical Therapy- Strength, mobility- Gait- Ergonomics- Pacing- Graded home exercise

program

Joint Injection- Steroid- Hyaluronic Acid- Regenerative agents

Joint Denervation or Neuromodulation

- Radiofrequency- Phenol/alcohol- Peripheral nerve stimulation?

- Dorsal root ganglion stimulation?

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Weight Loss

Bracing





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program

Individualized to unique anatomy and biomechanics

Active > Passive

Quadriceps, hip girdle, core strength - Address imbalances

Gait, movement, lifting mechanics

Techniques for pain exacerbations, pacing

Graded independent exercise program

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AAOS

2013 2017

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AAOS

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AAOS

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AAOS

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Injectables?

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Laudy ABM, et al. Br J Sports Med2015;49:657–672.

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Pas HIMFL, et al. Br J Sports Med 2017;0:1–10.

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AAOS Injectables?

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Injectables?

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Joint Denervation

Indications• Continued pain and functional disability despite conservative

management • Desire to avoid surgery• Inability to undergo surgery

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• Thermocoagulation of sensory nerves

• Radiofrequency Energy– Vibration of H2O molecules ‐> heating

– Predictable + Controlled lesion size

Joint Denervation- Radiofrequency

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Knee Joint Denervation

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The BasicsGenicular Nerve Radiofrequency Ablation

• Genicular nerves– Sensory– No motor fibers

• Generally Safe


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The Basics

• Genicular RFA > sham RFA (Choi)• Genicular RFA > IA steroid injection (Davis)• Genicular RFA > IA hyaluronic acid + prp (Shen)• Genicular RFA > PT and NSAIDs

50% pain reduction responder rate at 6 month f/u: 55‐75% *practice audit data demonstrates responder rate as as low as 35%

Current Outcome Literature

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The BasicsOptimizing Outcomes: Predictive Factors

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The Basics

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The BasicsOptimizing Outcomes: Prognostic Block Paradigm

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Prognostic Genicular Blocks

Choi et al: 2mL of 2%; >50% relief

Typical: 1mL of 2% lidocaine; >50% relief

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Prognostic Block: 1mL of 2% lidocaine; >50% relief

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Prognostic Block: 1mL of 2% lidocaine; >50% relief

‐ Choi et al: 2mL of 2%; >50% relief

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The BasicsOptimizing Outcomes: Correct Targets?

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Horner & Dellon 1994

Horner G, Dellon AL: Innervation of the human knee joint and implications for surgery. Clin Orthop 301:221‐226, 1994.

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Choi et al 2011

Choi W‐JJ, Hwang S‐JJ, Song J‐GG, Leem J‐GG, Kang Y‐UU, Park P‐HH, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: A double‐blind randomized controlled trial. Pain. 2010/11/09. 2011 Mar;152(3):481–7.

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Franco et al 2015

Franco C, Buvanendran A, Petersohn J, Menzies R, Menzies L. Innervation of the anterior capsule of the human knee. Implications for radiofrequency ablation. RegAnesth Pain Med 2015; 5:363–8.

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Tran et al. 2018. Anatomical Study of the Innervation of Anterior Knee Joint Capsule: Implication for Image‐Guided Intervention. Regional Anesthesia and Pain Medicine.

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Tran et al. 2018. Anatomical Study of the Innervation of Anterior Knee Joint Capsule: Implication for Image‐Guided Intervention. Regional Anesthesia and Pain Medicine.

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Hip Joint Denervation

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Obturator branchesJoint Denervation

- Radiofrequency

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Femoral branchesJoint Denervation

- Radiofrequency

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Limitations

• Multiple nerves supply sensation to the hip joint• Obturator nerve branches• Femoral nerve branches• Accessory femoral and accessory obturator nerves• Nerve to the quadratus femoris• Superior gluteal nerve• Direct branches from the sciatic nerve

• Parallel placement of electrode?• Femoral Artery and Vein

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2. Currently limited evidenceAuthor, Year N

Time of Follow‐up Assessment Outcome

Akatov, 1997 13 36 months 92% (12) patients with “pain relief”*

Kawaguchi, 2001 141 month‐11 months

86% (12) patients with >50% pain reduction*‐60% pain reduction†

Malik, 2003 43 months‐1‐3 months

75% (3) patients with >50% pain reduction*‐30‐70% pain reduction†

Rivera, 2012 18 6 months44% (8) patients with > 50% pain reduction‐33% pain reduction at 6 months†

Cortiñas‐Sáenz, 2014 3

1 month‐6 months

100% (3) of patients with >50% pain reduction* **50‐80% pain reduction‐100% (3) of patients with >50% pain reduction**50‐80% pain reduction†

Kapural, 2018 23 6 months >80% pain reduction*

*Categorical †Con nuous**Calculated from primary data

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2. Currently limited evidenceAdverse Events

Author, Year Complication

Akatov, 1997 Paresthesia in 1/13 patients

Malik, 2003 Paresthesia in 1/4 patients

Rivera, 2012 Subcutaneous Hematoma in 3/18 patients

Cortiñas‐Sáenz, 2014 Paresthesia in 1/3 patients

Gooding, 2016 Quadriceps paralysis (case report)

Kapural, 2018 Neuritis for 1 week in 1/23 patients

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Spectrum of Care

Continued Pain and Disability Despite Treatment

Weight loss

Bracing





Surgery-Arthroplasty


program

Joint Injection- Steroid- Hyaluronic Acid- Regenerative agents

Joint Denervation or Neuromodulation

- Radiofrequency- Phenol/alcohol- Peripheral nerve stimulation?

- Dorsal root ganglion stimulation?

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Summary• Treatments range from conservative to surgical

‐ Guideline Concordant: weight loss, PT, NSAIDs, Tramadol, steroid injection (mild/mod OA), HMW hyaluronic acid.

‐ Lack of positive or negative rec: passive PT modalities, TENS, acupuncture, medial compartment unloading (foot orthotic, knee brace), steroid injection (all grades of OA), PRP injection.

‐ Guideline Discordant: LMW hyaluronic acid, stem cell injection.…A guidelines is just that… may not apply to each unique patient

• Regenerative treatments ‐ Theoretical benefits vs. repeated steroid injections; Literature is fairly young.

• Radiofrequency neurotomy‐ Encouraging outcomes; not yet optimized

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Thank You!

Zachary McCormick, MDAssociate Professor, PM&R; University of Utah School of Medicine

Chief, Spine and Musculoskeletal Rehabilitation SectionDirector, Clinical Spine Research

Director, Interventional Spine [email protected]

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knee and hip pain –new approaches and options but don’t

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