Indian Journal of Pain

CASE REPORT
Year
: 2014  |  Volume : 28  |  Issue : 2  |  Page : 121--123

Percutaneous radio frequency ablation for relief of pain in a patient of hip joint avascular necrosis


Prasad Kasliwal1, Vidya Iyer2, Sapana Kasliwal1,  
1 Consultant Pain Physicians, Pushp Hospital, Pushp Spine and Pain Clinic, Nashik, Maharashtra, India
2 Department of Anaesthesiology and Pain Medicine, Chennai Medical College and Research Center, Trichirapalli, Tamil Nadu, India

Correspondence Address:
Prasad Kasliwal
Pushp Hospital«SQ» Pushp Spine and Pain Clinic, B/H Satyam Sweets, Chowk No. 2, Govind Nagar, Nashik - 422 009, Maharashtra
India

Abstract

Avascular osteonecrosis (AVN) of the femoral head is one of the most common skeletal complications of kidney transplantation. Patients with hip joint avascular necrosis usually undergo joint arthroplasty. However, if a patient is unfit for surgery due to some comorbidities, hip joint articular branches denervation can be done to control pain and improve functional life. There is a large variation in the contribution as well in the position of the articular branches to hip joint by obturator, femoral, and sciatic nerves. Several authors have proposed percutaneous radio frequency denervation of the hip joint to eliminate pain.In our case, the patient was having an intractable hip joint pain which was not responding to conservative drug therapy as well physiotherapy. In our patient, hip arthroplasty was contraindicated because of the high risk of infection and anticoagulants. After diagnostic block, the pain in his groin and hip disappeared immediately. The patient noted a decrease in pain (Visual Analog Scale, VAS 9-10 to 1-2) and an improvement in the ability to walk. Then we performed percutaneous radio frequency ablation of the articular branches of the obturator nerve and the femoral nerve. Nerve blocks were performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. Because optimal coagulation requires electrodes to lie parallel to the nerves, a perpendicular approach probably produced only a minimal lesion. A perpendicular approach is likely to puncture femoral vessels. Vessel puncture can be avoided if an oblique pass is used. The patient had improved ability to ambulate and the patient can carry out his daily routine activites at home without much pain and can sleep comfortably. There were no complications like motor deficit, neuritis, bleeding, or infection. Our case report gives few impressions. First, it shows that if radio contrast agent (omnipaque dye) use is restricted or contraindicated, a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve and articular branch of femoral nerve. Second, it confirms the radiological anatomy of articular branches of hip joint. Third, oblique approach is safe and gives optimum lesion.



How to cite this article:
Kasliwal P, Iyer V, Kasliwal S. Percutaneous radio frequency ablation for relief of pain in a patient of hip joint avascular necrosis.Indian J Pain 2014;28:121-123


How to cite this URL:
Kasliwal P, Iyer V, Kasliwal S. Percutaneous radio frequency ablation for relief of pain in a patient of hip joint avascular necrosis. Indian J Pain [serial online] 2014 [cited 2019 Dec 9 ];28:121-123
Available from: http://www.indianjpain.org/text.asp?2014/28/2/121/132855


Full Text

 Introduction



Avascular osteonecrosis (AVN) of the femoral head is one of the most common skeletal complications of kidney transplantation. [1],[2],[3],[4] Patients with hip joint avascular necrosis usually undergoes joint arthroplasty. However, if a patient is unfit for surgery due to some comorbidities, hip joint articular branches denervation can be done to control pain and improve functional life. There is a large variation in the contribution as well in the position of the articular branches to hip joint by obturator, femoral, and sciatic nerves. [5] Several authors have proposed percutaneous radio frequency denervation of the hip joint to eliminate pain. [6],[7],[8],[9] We performed percutaneous radio frequency ablation of the articular branches of the obturator nerve and the femoral nerve successfully for long-term pain relief and improve fuctional life.

 Case Report



A 25-year-old young man had undergone re-renal transplant 1 year back. After which he was on immunosuppressants, steroids, and anticoagulants. He was complaining of bilateral constant and severe pain in his thigh and groin since 6 months, right hip more than the left. The patient initially responded well to conservative drug therapy, but he experienced gradually worsening pain in the right groin and hip area to the level that he could not walk, sit, take care of himself at home, and sleep well (VAS 9-10). He was unable to move without support. The pain was constant, severe, sharp, and deep in his groin and hip. It radiated to the right knee. Patient was also suffering from pulmonary tuberculosis and was on Akt. Hip arthroplasty was contraindicated because of the high risk of infection and anticoagulants. The hip magnetic resonance imaging (MRI) of pelvis also indicated bilateral hip joint degeneration and destruction. So, right hip joint articular nerve branches radio frequency ablation was planned.

A diagnostic block test was performed on the right articular branches of the obturator nerve through the anteromedial approach and the femoral nerve through the anterolateral approach. After the placement of needle, needle position confirmed with fluoroscopic anteroposterior (AP), oblique, and lateral view. Diagnostic block was given with 3 ml of 1% lignocaine. After diagnostic block, the pain in his groin and hip disappeared immediately. The patient noted a decrease in pain (VAS 9-10 to 1-2) and an improvement in the ability to walk. Then percutaneous radio frequency ablation of articular branches was planned.

The patient was placed supine with his right leg in slight abduction. Local anesthesia was given with 2 ml of 2% lignocaine at the site of injection. A 22-gauge 10-cm electrode with a 4-mm exposed tip and a Radio Frequency Generator (Diros Model 2AP) was used. Nine-inch high frequency (HF) C-arm AP view taken to expose right pelvic bone and right hip joint. First, needle was advanced perpendicularly to the skin until it reached the superior-lateral corner of obturator foramen and hit the superior ramus of the pubic bone and was redirected to pass underneath it. The needle is advanced slightly obliquely to enter in obturator canal 7 to make the needle parallel to the nerve. [10] As radio contrast agent (omnipaque dye) use is restricted due to renal transplant, needle placement was checked C-arm AP, oblique and lateral view and confirmed by electrical stimulation of the target nerve. [8] With sensory stimulation at 50 Hz, parasthesia elicited in groin and hip region at 0.6 V. After negative aspiration, 1 ml of 2% lignocaine was injected. Then a radio frequency ablation of articular branch of obturator nerve was carried out at 80°C for 90 seconds twice [Figure 1].{Figure 1}

Coagulation of the articular nerve branches of the femoral nerve was carried out at the point of its exit from the hip joint capsule [Figure 1]. [11] The needle was inserted by the anterolateral approach. Under fluoroscopic control, redirection of the needle was performed until stimuation of the nerve by less than 0.7 V at 50 Hz reproduced the usual pain of the patient's right hip and lateral thigh area. The nerve was anesthetized with 2 ml of 2% lidocaine. Then a radio frequency lesion of the articular branch of the femoral nerve was carried out at 80°C for 90 seconds twice. Procedure was uneventful and without any complications.

Post-procedure patient noted a decrease in pain (VAS 9-10 to 1-2) and motion pain also decreased. The patient had an improved ability to ambulate for 6 months. Now the patient can carry out his daily routine activites at home without much pain and can sleep comfortably. Till 6 months follow-up, patient had good pain relief in right hip joint. For left hip joint pain, he requires analgesics (Tramadol 50 mg) intermittently.

 Discussion



AVN is one of the major causes of morbidity after transplantation. [2] A review of the literature including early studies showed that AVN affects 3-41% of renal allograft recipients [3] AVN develops in weight bearing bones, femoral head being the most common site. [4]

There is a separation between the anterior and posterior sensory innervation of the hip joint capsule. The anteromedial innervation is determined by the articular branches of the obturator. Additionally, the anterior hip joint capsule is innervated by sensory articular branches from the femoral nerve. In the posterior part, articular branches from the sciatic nerve, which in addition to the articular branches from the nerves to the quadratus femoris muscle, innervate the posteromedial section of the hip joint capsule. Moreover, articular branches of the superior gluteal nerve are found, which innervate the posterolateral section of the hip joint capsule. Among these nerves, the most important innervations to the hip joint are branches of the obturator nerve and the femoral nerve. [5],[12]

Other anatomical studies [5],[7],[11] have demonstrated that obturator nerve block is insufficient for the treatment of hip joint pain. Effective neural blockade of the hip joint had to include the articular branch of the femoral nerve. Peripheral nerve test blocks of the articular branch of the obturator or femoral nerve were used to help determine the origin of the pain. Percutaneous radio frequency lesioning of sensory branches of the obturator and femoral nerves is an alternative treatment in patients with hip joint pain, especially in those where operation is not applicable. [6],[7],[8],[9] Nerve blocks were performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. [12] Because optimal coagulation requires electrodes to lie parallel to the nerves, a perpendicular approach probably produced only a minimal lesion. A perpendicular approach is likely to puncture the femoral vessels. Vessel puncture can be avoided if an oblique pass is used. [10]

In our case, the patient was having an intractable hip joint pain, which was not responding to conservative drug therapy as well physiotherapy. In our patient, hip arthroplasty was contraindicated because of the high risk of infection and anticoagulants. After diagnostic block, the pain in his groin and hip disappeared immediately. The patient noted a decrease in pain (VAS 9-10 to 1-2) and an improvement in the ability to walk. Then radio frequency ablation of the articular branches of the obturator or the femoral nerve was done. The patient had improved ability to ambulate and the patient can carry out his daily routine activites at home without much pain and can sleep comfortably. There were no complications like motor deficit, neuritis, bleeding, or infection.

Our case report gives few impressions. First, it shows that if radio contrast agent (omnipaque dye) use is restricted or contraindicated, a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve and articular branch of femoral nerve. Second, it confirms the radiological anatomy of articular branches of hip joint. Third, oblique approach is safe and gives optimum lesion.

References

1Tang S, Chan TM, Lui SL, Li FK, Lo WK, Lai KN. Risk factors for avascular bone necrosis after renal transplantation. Transplant Proc 2000;32:1873-5.
2Julian BA, Benfield M, Quarles LD. Bone loss after organ transplantation. Transplant Rev 1993;7:82-95.
3First MR. Long-term complication after transplantation. Am J Kidney Dis 1993;22:477-86.
4Julian BA, Qualres LD, Niemann KM. Musculoskeletal complications after renal transplantation: Pathogenesis and treatment. Am J Kidney Dis 1992;19:99-120.
5Wertheimer LG. The sensory nerves of the hip joint. J Bone Joint Surg 1952;34-A:477-87.
6Akatov OV, Dreval ON. Percutaneous radiofrequency destruction of the obturator nerve for treatment of pain caused by coxarthrosis. Stereotact Funct Neurosurg 1997;69:278-80.
7Fukui S, Nosaka S. Successful relief of hip joint pain by percutaneous radiofrequency nerve thermocoagulation in a patient with contraindications for hip arthroplasty. J Anesth 2001;15:173-5.
8Kawaguchi M, Hashizume K, Iwata T, Furuya H. Percutaneous radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of hip joint pain. Reg Anesth Pain Med 2001;26:576-81.
9Wu H, Groner J. Pulsed radiofrequency treatment of articular branches of the obturator and femoral nerves for management of hip joint pain. Pain Pract 2007;7:341-4.
10Locher S, Burmeister H, Böhlen T, Eichenberger U, Stoupis C, Moriggl B, et al. Radiological anatomy of the obturator nerve and its articular branches: Basis to develop a method of radiofrequency denervation for hip joint pain. Pain Med 2008;9:291-8.
11Birnbaum K, Prescher A, Heþler S, Heller KD. The sensory innervation of the hip joint-an anatomical study. Surg Radiol Anat 1997;19:371-5.
12Viel EJ, Perennou D, Ripart J, Pélissier J, Eledjam JJ. Neurolytic blockade of the obturator nerve for intractable spasticity of adductor thigh muscles. Eur J Pain 2002;6:97-104.