Category: Education Procedure

Knee Pain: Genicular Nerve Ablation.

Knee Pain: Genicular Nerve Ablation.

Here is a recent study on GNB:

Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial., Choi WJ1, Hwang SJ, Song JG, Leem JG, Kang YU, Park PH, Shin JW., Pain. 2011 Mar;152(3):481-7. doi: 10.1016/j.pain.2010.09.029. Epub 2010 Nov 4.

Radiofrequency (RF) neurotomy is a therapeutic alternative for chronic pain. We investigated whether RF neurotomy applied to articular nerve branches (genicular nerves) was effective in relieving chronic OA knee joint pain. The study involved 38 elderly patients with (a) severe knee OA pain lasting more than 3 months, (b) positive response to a diagnostic genicular nerve block and (c) no response to conservative treatments. Patients were randomly assigned to receive percutaneous RF genicular neurotomy under fluoroscopic guidance (RF group; n=19) or the same procedure without effective neurotomy (control group; n=19). Visual analogue scale (VAS), Oxford knee scores, and global perceived effect on a 7-point scale were measured at baseline and at 1, 4, and 12weeks post-procedure. VAS scores showed that the RF group had less knee joint pain at 4 (p<0.001) and 12 (p<0.001) weeks compared with the control group. Oxford knee scores showed similar findings (p<0.001). In the RF group, 10/17 (59%), 11/17 (65%) and 10/17 (59%) achieved at least 50% knee pain relief at 1, 4, and 12 weeks, respectively. No patient reported a post-procedure adverse event during the follow-up period. RF neurotomy of genicular nerves leads to significant pain reduction and functional improvement in a subset of elderly chronic knee OA pain, and thus may be an effective treatment in such cases. Further trials with larger sample size and longer follow-up are warranted.

  • Genicular Nerve AblationGenicular Nerve Ablation for chronic knee pain following total knee arthroplasty.

Genicular nerve ablation is a promising new treatment approach to chronic knee pain. The knee pain can be either knee pain that is chronic after a failed knee replacement or knee pain that has no other reasonable surgical or treatment solution.

If the patient is adverse to surgery, or if the surgical risks are too great then this is a consideration.

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Intradiscal (Inside the Disc) “Stem Cell” Injection

Intradiscal (Inside the Disc) “Stem Cell” Injection

Intradiscal Stem Cell Injection (Autologous “self”) “Auto-ISCI”


Auto-ISCI is quite different from “Allogenic” stem cell injection.  At-ISCI involves taking either fat or bone marrow harvest from the same patient who is receiving the cells and then separating the stem cells from the harvested tissue and re-injecting the stem cells into the spinal discs.  This approach and procedure is FDA approved as long as any manipulation of the cells occurs at the point of injection. Presently we do Auto-ISCI for painfully degenerative lumbar discs.

Allogenic “Allo-ISCI” is very different (NOT FDA APPROVED)

It involves taking already prepared stem cells from a foreign tissue donor and then injecting those stem cells into the patient’s discs.  Often the cells are manipulated, cultured or tissue expanded (multiplied without specific tissue expression) before they are injected. (See Mesoblast website.)


Post Procedure Protocol:


Day (0-3) (Harvest and Injection day+ next two days): Try to stay horizontal as much as possible. Start taking your antibiotics the day of the procedure.  If vertical (either standing or sitting) limit it to maximum of ten minutes.  Lying on back or in recliner is best.  Do pressure reliefs if vertical.   A pressure relief is anything that takes the weight off the spine for 1-2 minutes, either lying down, sitting in a chair and suspending your self by pushing down on the arms of the chair.  Another method would be to lean over on a counter on your folded arms and suspending your legs off the floor.


Week 1:  May sit or stand for no greater than 10 minutes without a pressure relief.

Week 2:  May sit or stand for no greater than 20 minutes without a pressure relief.

Week 3:  May sit or stand for no greater than 30 minutes without a pressure relief.

Week 4:  May sit or stand for no greater than 40 minutes without a pressure relief.


This can be challenging but good compliance with the protocol does seem to predict success with the intradiscal injection. Flying and driving can be difficult especially in the first week or two, but you can use the arms of the seat to help with pressure relief.

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Peripheral Neuromodulation for Chronic Knee pain following surgery

Peripheral Neuromodulation for Chronic Knee pain following surgery


Novel approach for peripheral subcutaneous field stimulation for the treatment of severe, chronic knee joint pain after total knee arthroplasty. © 2009 International Neuromodulation Society Neuromodulation 2010; 13: 131–136

William Porter McRoberts, MD, Martin Roche, MD

Objective: The objective of this study is to present a novel approach for the treatment of severe, chronic knee joint pain following total knee arthroplasty utilizing peripheral subcutaneous field stimulation and discuss the role of this treatment modality in patients with symptoms that are refractory to conventional pharmacologic, surgical, and physical therapies.

Materials and Methods: Presented are two case reports of patients with chronic intractable knee pain where peripheral nerve stimulation via a permanent neurostimulating implant was introduced successfully. Both patients presented with persistent knee pain, for greater than one year, after having had total knee arthroplasty. The patients’ symptoms failed to be alleviated by a variety of interventions including non-steroidal anti-inflammatory drugs (NSAIDS), oral antidepressants, membrane stabilizers, opioids, physical therapy, surgical revisions, manipulation under anesthesia, local anesthetic patches, and transcutaneous electrical nerve stimulation. In each case, direct stimulation of the knee was achieved utilizing a peripheral nerve stimulator via a periarticular approach.

Results: Neuromodulation daily has produced both significant pain relief and functional improvement. Significant decreases in pain visual analog scale (VAS) scores and improvement in functional capacity were observed during the stimulation trial and during the follow-up after permanent implantation. The mean VAS score changed dramatically.

Conclusions: Introduction of a peripheral subcutaneous field stimulation directly to the painful knee area is a novel and simple procedure that was extremely effective for the relief of pain and may provide a breakthrough in the treatment of chronic intractable knee pain following total knee arthroplasty. The periarticular approach has several advantages, including only small incisions over the lateral and medial knee, proximal thigh and abdomen resulting in minimal strain on the lead array with flexion and extension contributing to overall stability of this system.

Keywords: Chronic intractable pain, knee joint pain, neuromodulation, peripheral nerve field neuromodulation (PSFS), peripheral subcutaneous field stimulation, peripheral subcutaneous implant, subcutaneous targeted neuromodulation (STN), total knee arthroplasty

Conflict of interest: The authors reported no conflicts of interest.




Peripheral neuromodulation is gaining wider acceptance either in the form of peripheral subcutaneous field stimulation or targeted periph- eral nerve stimulation for intractable chronic pain states of various etiologies. This is a very good work that adds to the already extensive applications of peripheral neuromodulation. Although it includes just two patients, this series opens a new mode of treatment for patients who derive insufficient pain relief from conventional treatments and it is less invasive than dorsal column stimulation. The authors have given a very good account of knee innervation and why peripheral field neurostimulation would be effective. Only long term follow up will tell us how stable the leads would be in their implanted position. Certainly more work is needed to recommend it as an alternative and I am sure we will read more about this application in future. All in all a very good effort and is worth disseminating to colleagues already into peripheral neuromodulation as well as others not aware of this mode of pain relief.

Dr. Riaz Khan Khyshza

Consultant in Anesthesia and Pain Management Royal Free Hospital London, United Kingdom


This article shows still another application of the new and growing field of Peripheral Subcutaneous Field Stimulation. Intractable pain following total knee arthroplasty is a difficult condition to treat. The pain is usually severe and it substantially impairs the ambulatory capabilities of the affected individual. Neurostimulation options until now included spinal cord stimulation or intraspinal nerve root stimulation. Both require electrode placement in the spinal canal. The authors have successfully reduced the pain in two patients who had undergone arthroplasty by placing the leads in the subcutaneous tissues around the knee. The stimulation of the small peripheral nerve fibers resulted in a significant reduction of the pain. This modality, if proven to have good results in a larger number of patients, could become the preferred neuromodulation option in patients with “failed” knee arthroplasty.


Giancarlo Barolat, MD

Director Barolat Neuroscience Presbyterian/St. Luke’s Medical Center Denver, Colorado, USA

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Spine Surgery

Spine Surgery

Sometimes you must have spine surgery. The risk::reward ratio must be undeniably in your favor.

It is that simple.

My aim is, of course,  to help you avoid the risk of spine surgery, however, that said, sometimes the very best thing for you IS spine surgery.  It may seem counter-intuitive with the bad press surrounding spine surgery.   But here’s why.

I submit rather that poor outcomes are predicated upon poor selection.  I want to marry your problem with the very best tool for the job, and sometimes that tool will not be in my toolbox, but in that of a surgeon.  When that happens, when I identify a particular problem that I think will be well treated with a surgical solution, I refer to a surgeon.  And to THE surgeon who is best for that particular spine or pain problem.

For example: Microendoscopic Discectomy: 97% of patients satisfied.  Amazing.  Here is a great treatment for a particular problem.  Low Risk::High Satisfaction.  To avoid this kind of outcome would be failing my patients.


Surgery is not what you do when there is nothing else to do.

Surgery is what you do when you have a plan for success.

Why would you want spine surgery?

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