Genicular Neurotomy (aka Genicular Nerve Ablation)
If you suffer from osteoarthritis of the knees and want to do everything possible to avoid surgery, or you have already had knee surgery that has failed to relieve the pain, this cutting-edge treatment option may be for you.
What is Genicular Neurotomy?
Genicular Neurotomy (aka ablation) is a brand new, innovative option for treating knee pain without surgery. This highly advanced procedure is on the absolute cutting edge of medicine. By selectively applying a sophisticated type of radio wave to the nerves surrounding the knee (the genicular nerves), one can effectively relieve pain in the knee from any number of causes.
Genicular Neurotomy is a procedure of absolute elegance. There is no steroid involved – in fact, no medication of any kind is injected into the knee at all. The entire procedure is actually performed outside the knee capsule, making it ideal for use before or even after knee surgery if necessary.
Perhaps the greatest advantage of genicular neurotomy is the fact that the entire procedure is performed OUTSIDE the knee capsule. This is what allows it to succeed where other procedures like cortisone injections, hyaluronic acid injections, and even surgery fail. In fact, this procedure can be done up to one month before knee surgery and even after surgery.
Genicular neurotomy is indicated for a variety of conditions:
Chronic Knee Pain
Degenerative Joint Disease
Total Knee Replacement (before or after)
Partial Knee Replacement (before or after)
Patients unfit for knee replacement
Patients who want to avoid a knee replacement
While surgery is considered to be the accepted treatment option for patients with advanced joint disease, many individuals have comorbidities that may prevent them from being an appropriate surgical candidate. Others may simply want to avoid surgery, as they may be unable to take off the necessary time from work for the procedure and post-operative recovery period. In these cases, radiofrequency neurotomy of the genicular nerves is a safe, potential alternative to joint replacement for pain.
Despite the general efficacy of knee replacements, many patients complain the pain persists after surgery. In these unfortunate cases, patients have traditionally had few options, if any, that did not involve additional surgery. With the advent of genicular nerve neurtomy, patients can look forward to pain relief without any potential further surgeries.
The innervation of the knee is comprised of branches of femoral, saphenous, common peroneal, tibial and obterator nerves. Small, articular branches of these nerves, known as the genicular nerves, surround the knee and provide innervation to the joint.
Genicular nerves consist of 5 relevant branches:
- Superior lateral (SL)
- Superior medial (SM)
- Inferior lateral (IL)
- Inferior medial (IM)
- Recurrent tibial genicular nerve
Radiofrequency Neurotomy, when applied to the genicular nerves of the knee, can provide a therapeutic alternative to surgery in effectively treating chronic knee pain. The targets in this treatment modality are the SL, SM and IM. These 3 branches make ideal targets for the procedure, as they are easily accessible by percutaneous approach under fluoroscopic guidance – they lie on the surface of bone at the confluence of the femur with the medial and lateral epicondyles and the confluence of the tibia with the medial epicondyle.
It is a minimally invasive, nonsurgical treatment option with the potential to relieve pain where other more conventional therapies have failed. When compared to a total knee replacement:
|Genicular Nerve Neurotomy||Traditional Joint Replacement|
|Inexpensive and covered by most insurance||Can be extremely expensive even with good insurance|
|Performed in your doctor’s office||Performed in hospital|
|Outpatient procedure||Inpatient admission|
|Can be done with only local anesthetic||Required general anesthesia and regional anesthesia|
|Minimal risk of infection||Risk of post-surgical or nosocomial infection|
|No need for blood thinners||Requires 4 weeks of blood thinners (anticoagulation)|
|Virtually non-existent recovery period||Long postoperative recovery period requiring inpatient rehab|
|In many cases, can go back to work the same day||Can be weeks to months before returning to work|
|Little to no postoperative pain, typically controlled with NSAIDs||Significant postoperative pain|
|Can return to normal activities in a matter of days||Can be months before returning to normal activities|
For those patients where a knee replacement is the only option, genicular nerve neurotomy can offer a number of benefits in the postoperative phase. By performing this procedure preoperatively, there is a decrease in postoperative pain, allowing the patient to begin physical therapy earlier. Thus improving knee strength and leading to shorter hospital stay. Decrease postoperative pain has also been linked to decreased morbidity in the postoperative phase.
For many patients who have to wait several months for surgery, genicular nerve neurotomy can significantly reduce their pain making the waiting period more tolerable.
After the procedure, the degree of pain relief can vary, depending on the cause and location of the pain. In most cases, pain relief from the procedure can last from 6 to 12 months; in other cases, relief can last for years. During the pain relief period, patients are typically able to participate in physical therapy and improve their overall activity level.
Chronic knee osteoarthritis (OA) is one of the most common conditions associated with advanced age. Greater than 12% of the American population will experience the pain and functional limitations of chronic knee OA. There are various treatments for a degenerated knee joint, such as steroid injections, viscosupplementation injections, arthroscopic surgery and total joint replacement surgery. Of the 20 million adults in the United States suffering from chronic knee OA,  close to 700,000 patients will progress to total knee replacement. Not all individuals want or are candidates for surgery, and many elect to have surgery only to find that afterward the pain persists. One of the latest innovations in knee pain management is using radiofrequency ablation to treat the nerves around the knee.
Radiofrequency ablation of the genicular nerves has been shown to significantly reduce chronic knee pain in patients in lieu of major surgery to replace the knee or revise an already existing joint replacement. One of the most impressive aspects of this procedure is its ability to offer immediate pain relief, thus allowing patients to participate in physical therapy, restore function, and return to their normal daily activities.
The procedure uses a breakthrough technology called Radiofrequency Ablation (RFA) to stun the painful nerves and prevent the signals from reaching the brain. This amazing technology has been used for decades with excellent success, traditionally to treat pain in the neck and back. The nerves grow back over time which makes the procedure reversible if necessary.
RFA harnesses the energy of radio waves to treat pain at the source, without the need for incisions of any kind. The most appealing aspect of RFA is that there is no need for steroid or cortisone injections, making it ideal for patients with high blood pressure and Diabetes.
This procedure is performed in 2 phases:
- Diagnostic Genicular Nerve Block – This procedure consists of placing a small amount of a local anesthetic, like Lidocaine or Bupivacaine, on the genicular nerves to test the patient’s response and see if there is sufficient enough relief in the knee to justify performing a therapeutic neurotomy.
- Genicular Nerve Ablation – This is the therapeutic portion of the treatment whereby the physician will perform a radiofrequency ablation (RFA) of the genicular nerves, thus alleviating pain to the knee and restoring function.
Both portions of the procedure are performed as an outpatient under direct fluoroscopic guidance.
Before performing a genicular neurotomy, your doctor will first schedule you for a diagnostic genicular nerve block to see if you are a candidate for the ablation procedure. The pain relieving effects of the genicular neurotomy can last up to a year or longer.
The effects of the diagnostic block can be felt almost immediately, but will typically wear off in just a few hours – THIS IS NORMAL. This is just to let your doctor know if the actual ablation procedure will work for you. Relief from the genicular neurotomy proper typically takes effect in a few days.
Is Genicular Neurotomy Right for Me?
If traditional treatments like physical therapy and injections with cortisone or hyaluronic acid have not provided you with relief, genicular neurotomy may be an option for you. The procedure involves minimal to no scarring, and can be performed as an alternative to surgery to relieve pain, and even for patients still experiencing pain after surgery.
Contact the Ainsworth Institute to set up an initial evaluation to find out if you are a candidate for this life-changing procedure.
Procedure - Diagnostic Genicular Nerve Block
This procedure is generally well tolerated with patients often requiring only a small amount of local anesthetic. In cases where patients have particularly painful joints, light sedation or anesthesia can be provided to make them more comfortable. You will be asked to lay flat on your back, and padding will be added for additional comfort. The skin around your knee will be thoroughly cleaned with sterile soap to minimize the risk of infection. The target areas around the knee where the genicular nerves are suspected to be located are visualized using fluoroscopy (a real time X-ray device) and then marked on the skin. Your doctor will thoroughly numb the skin and underlying tissue with local anesthetic for added comfort.
At this point, 3 thin needles will be inserted. The target points are the confluence of the femur with the medial and lateral epicondyles and the confluence of the tibia with the medial epicondyle. Once the needles are in proper position, a small amount of contrast dye will be injected to ensure the needles are in the appropriate spots. At this point a small amount of local anesthetic will be injected and the procedure is complete.
After a successful blockade of the genicular nerves, there will be a reduction in sensation in the knee as well as a slight numbness and tingling sensation around the knee.
After this portion of the procedure is completed there are 2 possible outcomes:
–Your pain is improved or even eliminated for several hours – this indicates an obvious therapeutic value in treating the genicular nerves and qualifies you to proceed onward to genicular nerve neurotomy.
–There is no pain relief. This will equally guide your physician’s decision making in coming up with future treatment plans.
A positive response is considered to be at least 50% pain relief for more than 24 hours following the procedure.
Procedure - Genicular Nerve Ablation
Once the diagnostic portion of the procedure has been completed and a positive block has been documented, Radiofrequency Neurotomy of the Genicular Nerves is the next step. This procedure has many synonyms, all referring to the same procedure:
Genicular Nerve Neurotomy
Genicular Nerve Ablation
Genicular RF Neurotomy
This procedure is based on the theory that cutting the nerve supply to a painful structure (in this case the knee), one can alleviate pain and restore function.
As with the diagnostic nerve block described above, it is typically performed under local anesthetic but sedation can be provided where necessary. Radiodfrequency ablation of the genicular nerves is performed in a nearly identical fashion as the diagnostic nerve block. The major difference is the application of radio waves rather than local anesthetic at the conclusion of the procedure.
Special needles are used called cannulas. These cannalas are inserted in the same fashion as the needles in the diagnostic test and are just as thin. Once they are properly positioned adjacent to the genicular nerves, a small, hair-thin electrode is placed within. To confirm the cannulas are in the correct position, your physician will “test” them by stimulating the nerves and muscles in the immediate area.
–Sensory Testing: A painless signal will be transmitted through the electrode that will selectively stimulate sensory nerves only thus making sure there are no other nerves nearby the cannula that transmit sensation in the leg.
–Motor Testing: A completely different signal will now be transmitted that will selectively stimulate motor nerves to make sure there are no nerves close to the cannula that are responsible for moving muscles in the leg.
Once the testing is completed and your doctor has made sure the needle is safely away from any important sensory or motor nerves, some local anesthetic will be injected through the cannula to make the genicular nerves and surrounding tissue numb. Once everything is numb, radiowaves are transmitted from the tip of the cannula for 90-180 seconds. There are two different types of radiofrequency ablation that can be applied at this point:
–Conventional Radiofrequency Ablation – A thermal lesion is created at 80 to 85 degrees Celsius.
–Cooled Radiofrequency Ablation – Performed at 60 degrees Celsius, however a larger, spherical lesion is created thus decreasing the likelihood of missing the genicular nerves.
After the radio waves are finished, the probes and cannulas are removed and 3 small dressings are applied.
The process takes less than 30 minutes to complete.
Complications from a diagnostic genicular nerve block and genicular nerve neurotomy are rare. This procedure is a safe, non-surgical option for treating chronic knee pain. Bleeding, infection, nerve damage and muscle weakness are all possible complications; however these risks are minimized with a proper technique and correct needle placement. Neuritis is another infrequent but potential side effect whereby the skin near the area of the neurotomy can become irritated or overly sensitive for a short period of time.
Most patients tolerate the procedure extremely well without complaint. Some individuals report mild soreness and/or spasm in the area of the procedure; both of which are easily controlled with oral medications your doctor can prescribe upon discharge after the procedure.
In some cases, pain relief may take up to 4-6 weeks to be noticeable.
Evidence of Performance
For those patients where a knee replacement is seemingly inevitable, radiofrequency (RF) neurotomy of the genicular nerves can offer a substantial amount of pain relief without the need for an invasive surgery.
In a double-blind randomized-controlled study by Choi et al in 2011, 38 elderly patients with severe OA lasting a minimum of 3 months were enrolled. All patient were initially evaluated with diagnostic genicular nerve blocks at the SL, SM, and IM branches. A positive response was noted if the patient reported a minimum of 50% pain relief for more than 24 hours. In the study, 19 patients received percutaneous RF genicular neurotomy, and the other 19 were the control, only receiving an additional nerve block. The patients were randomized by a computer-generated schedule. They were then evaluated at 1, 4 and 12 weeks. The authors reported a statistically significant decrease in pain in the neurotomy group of 59%, 65% and 59% reporting at least 50% decrease in pain at 1 week, 4 weeks and 12 weeks respectively.
In those cases where pain persisted after surgery, genicular nerve neurotomy has additional benefit. Studies have demonstrated this procedure can be used in patients who have already had knee replacements. This procedure can be life changing as further surgery to revise the prosthesis can be successfully avoided. In a study by Protzman et al in 2013, patients with pain after total knee arthroplasty were treated with radiofrequency ablation of the genicular nerves.
The utility of genicular nerve neurotomy extends even further as it can also be used to potentially decrease post-operative pain for patients who have no other choice but having a knee replacement. When performed in the preoperative phase, genicular nerve ablation can decrease post-operative pain and decrease the recovery phase.
As this procedure is typically performed in an outpatient setting, and is substantially less invasive than surgery, there is a drastically decreased requirement for narcotic medications in the postoperative period leading to significant improvements in the quality of patient’s life.
The Ainsworth Institute is Here to Help
If you are suffering from chronic knee pain secondary to moderate/severe OA and want to avoid surgery, or you have already had surgery and find the pain persists, you may be a candidate for a genicular nerve ablation. Contact the Ainsworth Institute of Pain Management today to schedule a diagnosis genicular nerve block and find out if can benefit from this truly groundbreaking procedure.
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