For Physicians: How to Help Back Pain Patients When Choosing Between RFA and Short-Term PNS

When it comes to treating chronic back pain using a medial branch approach, short-term, or temporary, peripheral nerve stimulation (PNS) and radiofrequency ablation (RFA) commonly come up as options. Both offer patients potential reductions in pain, but when it comes to deciding which is right for a specific patient, three things are important:

1.  Ensuring patients are educated about their back pain treatment options
2.  Fostering a transparent discussion about the risk vs. benefit ratio of each treatment option
3.  Understanding the patient’s preference for RFA, temporary PNS or another treatment option (e.g., permanently implanted PNS)

Explaining Temporary PNS and RFA is Key to Patient Comfort and Confidence

Most patients aren’t medical experts, so they may not understand how temporary PNS and RFA work, or the risks and benefits of each. That’s why it’s important to educate patients on what temporary PNS and RFA treatments are and to clearly explain the differences between the two.

You may find the following table helpful in your patient discussions. It compares the key differences between RFA and a short-term PNS option (in this case, the SPRINT PNS System), written in a patient-friendly way:

Radiofrequency Ablation (RFA)	The SPRINT PNS System (Temporary PNS)
Uses an electrical current produced by a radio wave to heat up an area of nerve tissue in an attempt to decrease pain signals.	Sends mild electrical pulses directly to the nerves in an attempt to decrease pain signals.
Ablates (destroys) the selected nerve area.	Stimulates (activates) the selected nerve (doesn’t destroy the nerve).
Performed via fluoroscopic (x-ray) guidance using a needle with an electrode that delivers electrical current to burn the targeted nerve.	Performed under ultrasound (sound waves) or fluoroscopic (x-ray) guidance to place a small, thin, coiled wire lead that is connected to a small stimulator worn on the body. The system is left in place for up to 60 days, after which the wire is removed by the doctor.   Patients can control the intensity of the stimulation using a hand-held remote.
Provides relief from pain by destroying the surrounding pain fibers.	Believed to provide pain relief by sending healthy nerve signals to the brain to reset how the brain processes pain signals.
Outpatient treatment	Outpatient treatment
RFA has been shown to provide patients with pain relief that often lasts from six to 12 months, and in some cases, longer. *	Temporary PNS has been shown to provide patients with pain relief that often lasts from six to 12 months, and in some cases, longer. *

*Patient results are unique to each individual and will vary for both RFA and PNS treatments. For SPRINT PNS, results may vary and important safety and risk information can be found here.  

Consider the Patient’s Preference

A pain treatment plan is a partnership between the patient and their interventional pain physician. That’s why it is important to consider patient preference when it comes to deciding on a treatment approach. Innovations such a temporary percutaneous PNS have shifted the traditional algorithms for pain management — which previously favored nerve blocks followed by radiofrequency ablation (RFA).

Lead researcher and President of World Academy of Pain Medicine United Dr. Amit Gulati and colleagues recently shared data from a two-part survey that helps to characterize patient preference among back pain treatment options, including:

• The specific preferences involving temporary treatments versus permanent implants
• The specific preferences regarding Temporary PNS versus RFA  

From the survey results, Gulati, et al., concluded patients prefer temporary PNS as a first-choice interventional treatment for low back pain. And while this conclusion is specific to the group of patients in this survey, the important thing to note is the patient’s treatment-of-choice is heavily dependent on their understanding of the available treatment options and corresponding risks and benefits.

TIP: Keep the following in mind when educating patients about treatment options:

• Use clear verbal descriptors to help them evaluate their treatment options
• Ensure treatment descriptors are accurate, clear, and aren’t accidentally misleading
• Be sure to include information about each treatment’s potential for efficacy as well as adverse events

Considering the Risk-Benefit Ratio of Short-term PNS and RFA

As mentioned above, while traditional algorithms favored nerve blocks and RFA, recent innovations in temporary PNS have encouraged physicians to reconsider their approach. Specifically, the risk-benefit ratio when choosing short-term PNS or RFA. While both are minimally invasive procedures, the difference in how each delivers pain treatment may impact next-step pain treatment options for a patient, if necessary.

Board-certified anesthesiologist and interventional pain specialist Dr. Samir Sheth recently shared his own experience on this topic in a guest article, outlining his reasoning for choosing temporary PNS as a first-step treatment choice, before RFA or DRG and SCS implants:

“For those patients in whom SPRINT PNS works, it has helped them avoid or delay invasive, costly procedures such as DRG and SCS implants, or surgery. And even when it doesn’t work for a patient as well as I’d hoped, it has still: (1) allowed me to know I’ve exhausted a nearly non-invasive option for the patient; and (2) given me a clearer idea of what treatments to explore next.

The same cannot be said for RFA. Once a nerve is burned, that is it. And if I implanted a permanent stimulator and it didn’t work, it becomes a more complex situation. But with SPRINT, there isn’t that patient hesitation to consider a permanently implanted device, just a potential for benefits. So, I believe it’s a smart choice for the patient, because even on a small level — providing temporary pain relief, indicating next-steps for further treatment, it is very helpful.”

While this is one physician’s experience, considering the risk-benefit ratio for any procedure in relation to an individual patient’s pain relief and health needs is an important factor in determining the proper pain treatment approach.

Helping Your Back Pain Patients Choose

In summary, when helping a patient to select the treatment that will lead to the best long-term, sustained pain relief, it’s best to have an informative discussion. Use simple language to clearly educate the patient about his or her treatment options and the risks and benefits of each. Be open to listening to the patient about their preferences. And lastly, after talking with the patient and accounting for their preferences, carefully consider the risk-benefit ratio(s) present.

Every patient is unique, and therefore, every pain treatment plan should be customized. By keeping these three things in mind, it may help you and your patient arrive together at the best decision for them in treating their chronic back pain.