Background & Aims

Chronic low back pain (CLBP) has been unfinished problem in our population. At National Brain Centre (NBC) Hospital Jakarta, the entity of CLBP which mostly has radiculopathy symptoms contribute for at least 15% of patients visit at the pain clinic1. Globally, CLBP has been estimated as much as 8.1% for all-cause of years with disability.2 As one of the modality of interventional pain management (IPM), pulsed radiofrequency on dorsal root ganglia (PRF-DRG) has been considered to be one of neuromodulation technique for CLBP which believed scramble the chronification process.3 Exercise and physical activity are also known as non pharmacological approach effective for many kind of chronic pain.4 Combination of these two modalities might be  beneficial for CLBP patients with radicular symptoms.

Methods

The early 2023 NBC protocol has been standardized to implement that the patients with CLBP underwent PRF-DRG will go through exercise 24 hours-immediately after the procedure. The PRF-DRG procedure was done using Cosman G4 electrode channel generator and cannulas with C-Arm guidance ipsilaterally to the CLBP radicular pain side and matched with previous magnetic resonance imaging (MRI) and electroneuromyography (ENMG) data for site of irritation and/or compression. After neuroanatomical confirmation using sensoric and motoric stimulation, we performed 8-minutes of 45 volt-42°C pulsed radiofrequency of DRG site followed by fixed mixture of non-particulate steroid and local anestetic (5 mg of dexamethason combined with 2ml of 2% lidocaine hcl) to prevent neuritis. The after-procedure exercise protocol was done using 10 minutes of combined self-assisted stretching method consist of McKenzie’s and William’s flexion exercise and pelvic mobilization exercise. Pre-procedural and post-exercise measurement of visual analogue scale (VAS) and Oswestry disability index (ODI) has been meticulously noted from the subject.

Results

As much as 28 subject with complete assessment has been reviewed retrospectively from the NBC hospital electronic health record (EHR) system.  Using paired-t test we found statistically significant differences on VAS pre- (7.68; SD 1.806) vs VAS post- (2.54; SD 1.374), p< 0.01; ODI pre- (52.82%; SD 14.62) and ODI post (32.96% ; SD 18.70), p< 0.01  before procedure and after exercise measurement. Both of the tools considered representative for pain intensity decrement and functional improvement, respectively.

Conclusions

A multimodal approach of PRF-DRG procedure followed immediately by exercise and physical activity may benefit the patients by reducing pain intensity and increase functionality of patients with CLBP. Further study with more subject recruitment warranted to elaborate these findings

References

  1. National Brain Centre (NBC) Hospital Pain Clinic Annual Survey. 2019
  2. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.
  3. Byrd, D., & Mackey, S. (2008). Pulsed radiofrequency for chronic pain. Current pain and headache reports12(1), 37–41. https://doi.org/10.1007/s11916-008-0008-3

4. Cardosa, M.S., Nicholas, M.K., Barus, J., Blyth, F., Chaudakshetrin, P., D’Uva, M.R. et al. (2011) Multidisciplinary Pain Center Development Manual. Pain Management Center Toolkit. Available at: https://www.iasp-pain.org/resources/toolkits/pain-management-center/

Presenting Author

Iswandi Erwin

Poster Authors

Iswandi Erwin

MD

National Brain Center (NBC) Hospital

Lead Author

Adi Sulistyanto

MD

National Brain Centre (NBC) Hospital Jakarta

Lead Author

Alvin Rahmawati

National Brain Centre (NBC) Hospital Jakarta

Lead Author

Wina Widiatul Hikmah

National Brain Centre (NBC) Hospital Jakarta

Lead Author

Jofizal Jannis

MD

National Brain Centre (NBC) Hospital Jakarta

Lead Author

Topics

  • Treatment/Management: Interventional Therapies – Neuromodulation