A back procedure that can weaken a young spine [PODCAST]

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A young patient walks in with ordinary back pain and leaves on a path that can quietly weaken the muscle holding the spine together. Francisco M. Torres is an interventional physiatrist who noticed these patients coming back to him sooner, and traced it to radiofrequency ablation denervating the multifidus, the back’s most important stabilizer, until the muscle atrophies and fills with fat. This episode is based on his article “Radiofrequency ablation and the young back pain patient,” published on KevinMD. You will hear why insurers began steering these patients toward the procedure, why most of the evidence comes from older patients with degeneration rather than people in their twenties, and why he believes the muscle damage should be spelled out in the consent form. He explains why generic core exercises fall short, how facet injections and targeted rehabilitation offer a lower-risk path, and the exact questions to ask before you agree. Press play to hear the questions worth asking before you let anyone burn a nerve in your back.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Francisco M. Torres, an interventional physiatrist. He co-wrote the KevinMD article “Radiofrequency ablation and the young back pain patient.” Francisco, welcome back to the show.

Francisco M. Torres: Thank you so much, Kevin, for having me.

Kevin Pho: All right, so tell us what led you to share this story and write this article on KevinMD.

Francisco M. Torres: It’s very interesting. As you know, I’m a spine physician, a physiatrist, an interventionalist. During my early years, I had this typical patient who came to see me, young, in their 20s or 30s, with a back problem that was not radiating, not radicular. Normally the MRI or the X-ray was very benign. I usually diagnosed them on the physical examination, with pain on extension and rotation, and I would finally say, “Well, this is facetogenic pain,” and I recommended a fluoroscopic-guided injection of the facet joint.

Normally this patient did very well. It allowed them to do the physical therapy, and I never heard from them for years. It was a pattern I was very comfortable with. But then, as time went on, health care changed, and the insurers started demanding a medial branch block before approving the facet joint.

That changed the way I handled them, because I don’t do the medial branch block. I thought it was excessive radiation for me and for the patient. So I sent them to the doctors who do the medial branch block. But somehow those patients were moved toward the ablation, the radiofrequency.

And then what I started noticing was that these patients began coming back to see me earlier. All of a sudden I said, “Well, what’s going on?” So I started figuring out that they were not just controlling the pain from the facet joint, they were denervating the multifidus muscle, which is critical for spine stability.

So I started looking at it a little bit myself, because at that time the radiologists were not mentioning the multifidus muscle at all. I started looking into that, and I started noticing some fat infiltration, some atrophy. In my mind I said, “There’s something going on here.” So I decided to start doing a little bit of research.

That’s why I wrote the paper. I’m not trying to badmouth radiofrequency ablation. It has a role, but the majority of the data we have is in the elderly, over 50, where they already have degeneration, and it doesn’t apply to the 20- and 30-year-olds who still have 40 years to go with a solid spine.

So I made a commitment that we have to rehabilitate these patients specifically for the back, for the multifidus, which is not the typical exercise people do when they say core. And this is something I learned this last year, when I had my prostate cancer surgery. The same principle applied with the Kegel exercises for the pelvic floor.

You cannot really train them. You cannot strengthen them. You can activate them, and the only way you can activate them is with some biofeedback, like surface EMG electrodes, the way I do with the pelvic floor. The same thing applies to the back. So it’s a little more complicated than just telling the patient to go to physical therapy and do core. It basically doesn’t work that well. That’s why I decided to explore it a little more in depth.

Kevin Pho: Tell us the type of patient who would lead to facet joint injections or radiofrequency ablation, because we’re talking about the younger patient, patients even in their 20s. Tell us the type of patients who would require that next step of treatment.

Francisco M. Torres: As I told you before, I used to see 20- and 30-year-olds who once a year, once every six months, would pull their back. At the time I thought it was because of a weakness of the ligaments, but now I think they had a predisposition, because they were not training their multifidus muscle correctly.

And like I said, it’s not an easy muscle to train. I think that if the way you are built leaves a little more weakness in that area, then you are going to be more predisposed, because you are more flexible at that time, at 20 or 30 years old.

Kevin Pho: So for those who aren’t familiar with radiofrequency ablation, just tell us a little bit more about that procedure and what that is.

Francisco M. Torres: Basically it depends on cauterizing the nerve that supplies the facet joint, which is the medial branch from the dorsal ramus. So the problem is that yes, you’re taking the pain away from the facet joint, but at the same time you’re denervating the muscle. Now you’re creating instability, because, again, as I said, the multifidus muscle is the most powerful stabilizer of your back.

And that’s what I think. My theory rests on the studies that Dreyfuss did in 2009. They did unilateral ablation, and two years later they saw atrophy and fat replacement of the multifidus, but they could not correlate it with pain and disability. So there is no long-term, longitudinal research to put those two together, but I think clinically it’s obvious.

And what I’m excited about right now, and we talked about this in the previous podcast, is that the same way AI can identify spinal stenosis very precisely, which will help me with my rehab, it can now do the same thing here. There are AI algorithms for describing the multifidus muscle, what we call segmental measurements.

And my goal, Kevin, is that when I train these patients for 12 months, I can see a change from MRI to MRI. It’s that specific right now. But again, it’s a burden for the MRI, for the radiologist, to do that, so I think we should just have AI narrow in on it. It would be fantastic in terms of the rehabilitation.

Kevin Pho: Tell us some of the risk factors young patients have for this multifidus injury that requires even potential radiofrequency ablation. How do these patients typically present, even to me as a primary care physician? How would I know that the multifidus was involved?

Francisco M. Torres: The main thing is that these are the typical patients who have pain with extension and rotation on physical exam, because that is basically where it comes from. And there are some specific tests you can do on the physical examination, like having the patient prone and bringing the legs up. If you feel that the patient cannot do it and it’s a 20- or 30-year-old, you know there is already instability or weakness there. But clinically, when they come to me, they come in with back pain, non-radiating, worse with extension and rotation, and the MRI and the X-ray show very soft findings.

Maybe a bulging disc, maybe a little bit of arthritis. And the other thing, Kevin, from doing this for so many years, is that when I do the facet joint injection, I always do an arthrogram. In a 20- or 30-year-old, it’s a perfect, beautiful arthrogram. Past 50, what I am really doing is a periarticular injection, because the joint is so arthritic that you cannot keep the dye within the capsule. So I think that is also one of the things you can differentiate.

Kevin Pho: Now, from the insurer perspective, what were some of the reasons they wanted to shift away from facet injections toward radiofrequency ablation?

Francisco M. Torres: Well, I think they meant well. They didn’t want to see doctors saying, “Oh, you have facet pain, let’s do an injection,” without going through some type of algorithm to prove that was the case.

And I respect that, because it will help. But unfortunately, because of the system, and because they reimburse the ablation very well, those patients were deviated to the ablation without an understanding of what you are actually doing. I was trained to remove the pain, and then I would be successful. But there are consequences that can happen 20 or 30 years down the road.

I’m not saying that everything comes from the ablation. But people who don’t train, who don’t properly exercise those muscles, are eventually the people we see with chronic lower back pain. I have to say, I do it myself, because it is not easy to train the muscle. It is very specific. It has to be somebody who knows what they are doing. I remember for many years we would say, “Do core, go and exercise,” without being very methodical about what we were trying to accomplish.

Kevin Pho: So in terms of those complications from radiofrequency ablation in younger patients 20, 30, 40 years down the road, is it chronic back pain? How do those complications present?

Francisco M. Torres: Chronic back pain, dysfunction, weakness. And it’s a snowball effect. They stop doing what they were used to doing, because “now my back hurts, I’m getting old, it’s not functioning.” And I think it inevitably is going to happen at the end of life.

I think one of the problems, and this is why I’m so passionate about this, Kevin, is that we need to treat ourselves as an athlete, no matter our age. And that is the way they were treating an athlete. To avoid the chronicity of back pain, they are going to be very specific, they are going to do surface EMG to know that you are activating the muscle, and now they can start seeing the changes on MRI, like I said.

For example, if I see a patient who comes in with back pain, and I do the MRI and the multifidus is already atrophied or replaced by fat, you say, “Well, that’s from arthritis,” or it was from an initial injury, or from the lack of exercise, and that is what’s happening. So now there is a way of quantifying what is going on with this. And if unfortunately a 20-year-old goes for an RFA ablation, then I can see whether it was really caused by the ablation, because hopefully a 20-year-old has a healthy multifidus to begin with. If we see atrophy later on, then we know it was induced by the ablation.

And then the other thing, Kevin, is that we have this mentality of taking away the pain. But imagine if we do ablation for shoulder pain. We are going to ablate the suprascapular nerve, and now we are going to have no pain, but instability of the shoulder and arthritis developing. So with that mentality of burning and doing ablation, you can do it for, they are doing it for the knee, and fortunately they are not causing too much muscle atrophy there. But if you do it for the shoulder, for the hip, I think you are going to see some of those changes eventually. So it applies to other structures in your body.

Kevin Pho: So tell us the type of conversations you’re having in your exam room with someone you suspect has a multifidus injury, when you’re talking about the various treatment options. When radiofrequency comes up, do you go through all these potential complications with the patient in front of you?

Francisco M. Torres: Well, that was part of the article, Kevin. I think it should be part of the consent form, and I do that with my patients: I explain to them that they are not only eliminating the pain, they are denervating a muscle that is very important for their back. I think that part should be part of the consent form, and I don’t think it is being told to the patient upfront.

Because many times when I tell that to the patient, they say, “No, I’m not doing that.” I think that if we don’t say that to them and they don’t know, they can come back years later and say, “Well, OK, you took the pain away, but now I have weakness, I have all this muscle instability and all that.” So I really think the patient has to agree to have their muscle denervated. I think that should be part of the consent form. That’s my thing.

Kevin Pho: So if radiofrequency ablation doesn’t fit those young patients, you mentioned specific exercises and facet injections as potential options. How effective are they in terms of removing multifidus-related pain?

Francisco M. Torres: Well, when we talk about multifidus pain, remember, the main source of the pain is really the facet joint. The multifidus can be unstable or weak and contribute, but the real source is the facet joint.

So that’s why, for the many years I did this in the past, I was blocking the facet joint, getting that inflammation under control to allow them to train and resume their life, but also with the exercise as part of their life. So what I’m saying is that in many cases, maybe you don’t need to do the ablation and you can just do the rehab and recover. But if we have the tool of the steroid injection to control the pain, then we may be able to minimize the damage.

And I can give you an example. My son, 21 years old, had back pain several years ago. Typical. He went through all the treatment, but then he was confronted with doing the medial branch block before the facet joint. I said, “You know what? It’s not worth it.” So he went, and in the end he finished up with regenerative injection therapy, completely cured. Fine. And he was heading in that direction, because they were already talking about ablation. So that’s just an example of somebody who would probably have suffered later on, 30 or 40 years down the road, with chronic back pain.

Kevin Pho: So for the patients who may be listening to you in this podcast, and they’re in a situation where they’re offered radiofrequency ablation, tell us the type of questions those patients should be asking their physicians before undergoing that procedure.

Francisco M. Torres: I think, and I don’t know, maybe because I know too much, but I would say, “Are you measuring the size and the quality of my multifidus muscle before you do it? Can I have a baseline? Can we repeat the MRI after training? Are you going to send me to a specific physical therapy that has a way of measuring the activity of the muscle to train it?” So I would just be sure that we have a plan.

Again, it goes back to the same thing with the pelvic floor. The data show that if you start the exercises six weeks before the procedure, you are much better off. So I think that the same principle applies here.

See, the thing is that if we do a facet injection with a steroid, there is no harm. You are just reducing the swelling. That is just no harm. But once you do the ablation, there is going to be an anatomical change, and that is one of the things I tell my patients. We are destroying something here. It is not a benign procedure. You are actually changing the anatomy. With the steroid, you are not changing the anatomy, so it sits a little more comfortably in their mind. So that’s basically what I would definitely want: an MRI evaluation of the multifidus and a follow-up with that.

Kevin Pho: We’re talking to Francisco M. Torres. He’s an interventional physiatrist. Today’s KevinMD article is “Radiofrequency ablation and the young back pain patient.” Francisco, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Francisco M. Torres: Well, I think that we as doctors should not let our management or our treatment be dictated by an algorithm from the people who pay your bill. You need to question what you are doing. And if you decide to go that route, the patient needs to be consented, needs to be specifically told. And I think the physical therapy should not be generic. With this condition, if we start treating them when they are 20 or 30, we are probably going to save their back from chronic pain.

Kevin Pho: Francisco, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Francisco M. Torres: Thank you for having me. Appreciate it.

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