Successful Treatment of Refractory Pudendal
Neuralgia with Pulsed Radiofrequency

Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy. Key words: pudendal neuralgia, pulsed radiofrequency, pudendal nerve, neuromodulation

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Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2017.e454 ◽

2017 ◽

Vol 3 (20;3) ◽

pp. E451-E454 ◽

Cited By ~ 1

Author(s):

Stephanie Jones

Keyword(s):

Radiofrequency Ablation ◽

Pain Relief ◽

Pelvic Pain ◽

Pudendal Nerve ◽

Pudendal Neuropathy ◽

Ischial Spine ◽

Pulsed Radiofrequency ◽

Pudendal Neuralgia ◽

Mr Neurography ◽

The Right

Pudendal neuralgia (PN) is a result of pudendal nerve entrapment or injury, also called “Alcock syndrome.” Pain that develops is often chronic, and at times debilitating. If conservative measures fail, invasive treatment modalities can be considered. The goal of this case report is to add to a small body of literature that a pulsed radiofrequency (PRF) ablation can be effectively used to treat PN and to show that high resolution MR neurography imaging can be used to detect pudendal neuropathy. Case Presentation: We present a case of a 51-year-old woman with 5 years of worsening right groin and vulva pain. Various medication trials only lead to limited improvement in pain. The first diagnostic right pudendal nerve block was done using 3 mL of 0.25% bupivacaine with 6mg of betamethasone using a transgluteal technique and a target of the right ischial spine; this procedure resulted in ~8 hours of > 50% pain relief. The patient was then referred for MR neurography of the lumbosacral plexus. This study revealed increased signal of the right pudendal nerve at the ischial spine and in the pudendal canal, findings consistent with the clinical picture of PN. Six weeks after the initial block, the patient underwent a second right transgluteal pudendal nerve block, utilizing 3 mL of 0.25% bupivacaine with 40 mg of triamcinolone acetonide; this procedure resulted in ~8 hours of 100% pain relief. Satisfied with these results the patient decided to undergo pudendal nerve PRF ablation for possible long-term relief. For this therapeutic procedure, a right transgluteal approach was again utilized. PRF ablation was performed for 240 seconds at 42° Celsius. Following this ablation the patient reported at least 6 weeks of significant (> 50%) pain relief. Discussion and Conclusion: In this paper we presented a case of successful treatment of PN with PRF ablation and detection of pudendal neuropathy on MR neurography. We believe that transgluteal PRF ablation for PN might be an effective, minimally invasive option for those patients that have failed conservative management. MR neurography employed in this case is not only helpful in confirming the diagnosis of PN but could also be useful in ruling out other causes of pelvic pain, such as genitofemoral neuropathy, endometriosis, adenomyosis, or pelvic mass lesion. To conclude, transgluteal PRF ablation can serve as a viable treatment option for mitigating symptoms of pudendal neuropathy and MR neurography is useful in confirming a clinically suspected diagnosis of PN. Key words: Pelvic pain, pudendal neuralgia, MR neurography, pulsed radiofrequency ablation, transgluteal technique, Alcock canal syndrome

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Management of pudendal neuralgia using ultrasound-guided pulsed radiofrequency: a report of two cases and discussion of pudendal nerve block techniques

Journal of Anesthesia ◽

10.1007/s00540-015-2121-x ◽

2015 ◽

Vol 30 (2) ◽

pp. 356-359 ◽

Cited By ~ 4

Author(s):

Myong-Joo Hong ◽

Yeon-Dong Kim ◽

Jeong-Ki Park ◽

Hyon-Joo Hong

Keyword(s):

Nerve Block ◽

Pudendal Nerve ◽

Pulsed Radiofrequency ◽

Pudendal Neuralgia ◽

Ultrasound Guided ◽

Pudendal Nerve Block

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Pulsed Radiofrequency of Pudendal Nerve for Treatment in Patients with Pudendal Neuralgia. A Case Series with Long‐Term Follow‐Up

Pain Practice ◽

10.1111/papr.12999 ◽

2021 ◽

Author(s):

Eva A. Krijnen ◽

Karlijn J. Schweitzer ◽

Albert J. M. Wijck ◽

Mariella I. J. Withagen

Keyword(s):

Pudendal Nerve ◽

Case Series ◽

Pulsed Radiofrequency ◽

Pudendal Neuralgia ◽

Long Term Follow Up

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Therapeutic Efficacy of Ultrasound-Guided High-Voltage Long-Duration Pulsed Radiofrequency for Pudendal Neuralgia

Neural Plasticity ◽

10.1155/2021/9961145 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Feng Ji ◽

Shuzhuan Zhou ◽

Caixia Li ◽

Yongyan Zhang ◽

Hua Xu

Keyword(s):

High Voltage ◽

Pudendal Nerve ◽

Complex Disease ◽

Remission Rate ◽

Sitting Time ◽

Pulsed Radiofrequency ◽

Pudendal Neuralgia ◽

Ultrasound Guided ◽

Long Duration ◽

Short Time

Pudendal neuralgia (PN) is a complex disease with various clinical characteristics, and there is no treatment showing definite effectiveness. This study is aimed at evaluating the clinical efficacy of ultrasound-guided high-voltage long-duration pulsed radiofrequency (PRF) for PN. Two cadavers (one male, one female) were dissected to provide evidence for localization of the pudendal nerve. Patients diagnosed as PN who failed or were intolerant in regular medication were screened for diagnostic local anesthesia block of the pudendal nerve before recruitment. Twenty PN patients were enrolled in this study. In the PRF procedure, the needle tip was inserted medially into the internal pudendal artery under ultrasound guidance. The position of the PRF needle tip was then adjusted by the response of the pudendal nerve to the electrical stimulation within the pudendal area (42°C, a series of 2 Hz, and 20 ms width pulses that lasted for 900 s). Alleviation of pain was assessed by the visual analogue scale (VAS) and sitting time pretreatment and on 7 d, 14 d, 1 m, 2 m, 3 m, and 6 m posttreatment in outpatient follow-up or by telephone interview. Two patients were lost due to intervention-irrelevant reasons. Patients showed significantly decreased VAS scores on 7 d after RFP, compared with pretreatment status ( 7.0 ± 0.9 vs. 3.2 ± 1.7 , P < 0.001 ). The efficacy remained steady till the end of 6 months, with a final remission rate of 88.9%. Sitting time also significantly lengthened following PRF (7 d, 14 d, 1 m, 2 m, 3 m, and 6 m vs. pretreatment, all P < 0.05 ). Only short-term ipsilateral involuntary convulsion of the lower extremity was reported in one patient, who recovered within 12 h. Six patients were treated with nonsteroidal drugs for a short time. All patients stopped taking medication finally. In conclusion, the ultrasound-guided high-voltage long-duration PRF approach not only reduced the pelvic pain caused by PN but also improved the quality of life by extending sitting time without nerve injury.

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Management of Refractory Trigeminal Neuralgia Using Extended Duration Pulsed Radiofrequency Application

January 2018 - Pain Physician ◽

10.36076/ppj.2015/18/e433 ◽

2015 ◽

Vol 3;18 (3;5) ◽

pp. E433-E435

Author(s):

Vanita Ahuja

Keyword(s):

Quality Of Life ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Sensory Stimulation ◽

Gasserian Ganglion ◽

Pulsed Radiofrequency ◽

Nerve Blocks ◽

Extended Duration ◽

Key Words Trigeminal Neuralgia

Trigeminal neuralgia (TN) produces incapacitating facial pain that reduces quality of life in patients. Thermal radiofrequency (RF) ablation of gasserian ganglion (GG) is associated with masseter weakness and unpleasant sensations along the distribution of the ablated nerve. Pulsed radiofrequency (PRF) of GG has minimal side effects but literature is inconclusive regarding its benefit in refractory TN. Increasing the duration of PRF application to 6 minutes in TN produced encouraging results. PRF application to the saphenous nerve for 8 minutes reported improved pain relief and patient satisfaction. We report successful management of two patients of classic TN, which were refractory to medical management and interventional nerve blocks. The lesion site were confirmed with motor and sensory stimulation through a 22 G, 10 cm RF needle with 5 mm active tip. Both the patients received four cycles of PRF at 42 °C with each cycle of 120 seconds (8 minutres). The visual analogue scale (VAS) in case 1 reduced from pre block score of 80 to score 10 postblock, while in case 2 the VAS reduced from pre-block score of 85 to score 15 postblock. During follow up both the patients are now pain free with minimal dose of carbamazepine at 12 and 6 months respectively. We used PRF for longer duration (8 minutes) in these patients, which resulted in improved VAS and WHOQOL-BREF score in these patients. PRF of mandibular division of GG for extended duration provided long-term effective pain relief and quality of life in patients of refractory classic TN. Key words: Trigeminal neuralgia pain, pulsed radiofrequency ablation, interventional approach

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How to Do It: Microsurgical DREZotomy for Pain After Brachial Plexus Injury: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa380 ◽

2021 ◽

Author(s):

Manon Duraffourg ◽

Andrei Brinzeu ◽

Marc Sindou

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Brachial Plexus ◽

Dorsal Horn ◽

Brachial Plexus Injury ◽

Dorsal Column ◽

Motor Deficit ◽

Complete Disappearance ◽

Burning Pain ◽

Root Entry Zone

Abstract More than three-quarters of victims of brachial plexus injury suffer from refractory neuropathic pain.1-6 Main putative mechanism is paroxysmal hyperactivity in the dorsal horn neurons at the dorsal root entry zone (DREZ) as demonstrated by microelectrode recordings in animal models7 and patients.8 Pain relief can be achieved by lesioning the responsible neurons in the spinal cord segments with avulsed rootlets.9,10 This video illustrates the technique for microsurgical DREZotomy.11,12 A C3-C7 hemilaminectomy is performed to access the C4-Th1 medullary segments. After opening the dura and arachnoid, and freeing the cord from arachnoid adhesions, the dorsolateral sulcus is identified. Identification can be difficult when the spinal cord is distorted and/or has a loss of substance. The dorsolateral sulcus is then opened with a microknife, so that microcoagulations are performed: 4 mm deep, at 35° angle in the axis of the dorsal horn, every millimeter in a dotted fashion along the avulsed segments. Care should be taken not to damage the corticospinal tract, laterally, and the dorsal column, medially. The patient consents to the procedure. In the presented case, surgery led to complete disappearance of the paroxysmal pain and reduced the background of burning pain to a bearable level without the need of opioid medication. There was no motor deficit or ataxia in the ipsilateral lower limb postoperatively. According to Kaplan-Meier analysis at 10 yr follow-up, in our overall series, microsurgical DREZotomy achieved total pain relief without any medication in 60% of patients, and in 85% without the need for opioids.10,13-15 Microelectrode recording at 1:26 reproduced from Guenot et al7 with permission from JNSPG.

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Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome

Medicina ◽

10.3390/medicina57020136 ◽

2021 ◽

Vol 57 (2) ◽

pp. 136

Author(s):

Pavel Ryska ◽

Jiri Jandura ◽

Petr Hoffmann ◽

Petr Dvorak ◽

Blanka Klimova ◽

...

Keyword(s):

Pain Relief ◽

Analogue Scale ◽

Pulsed Radiofrequency ◽

Ozone Therapy ◽

Ct Guided ◽

The Third ◽

Vas Score ◽

Radicular Syndrome ◽

Epidural Steroid

Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4–5 mL of an O2-O3 mixture (24 μg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman’s rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.

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