The case involves a young man who underwent radiofrequency ablation to address his refractory chronic pain. During the procedure, the patient suffered a bowel perforation from thermal injury which resulted in the placement of a colostomy bag. The patient was told that he would be able to have the colostomy bag reversed, but his bowel function still has yet to be restored. An expert in pain medicine, familiar with radiofrequency ablation, was sought to review the matter and comment on any potential lapses in the standard of care.
Question(s) For Expert Witness
- 1. How often do you perform radiofrequency ablation for chronic pain?
- 2. What is the standard of care to prevent thermal injury in a patient during the ablation?
Expert Witness Response E-024812
I am a board certified Anesthesiologist and board-certified Pain Medicine specialist. I am in 100% clinical practice for Pain Medicine/Interventional Pain Medicine, with my current role as the Director of Pain Management for a community hospital in the northeast. I have reviewed approximately 40 workers’ comp-related cases, with case review split relatively evenly between plaintiff and defendant.
I perform approximately 4-5 radiofrequency ablation (RFA) procedures per week. Most of these RFA procedures are for chronic spine pain related to facet joint mediated pain, although I also perform RFA procedures for chronic neuropathic pain unrelated to the spine (e.g. ilioinguinal neuralgia, meralgia paresthetica, intercostal neuralgia). I also perform neuroablative procedures utilizing chemical ablation to achieve neurolysis, for palliative procedures such as celiac plexus neurolysis and splanchnic plexus neurolysis (often used for pain palliation in pancreatic cancer-related pain).
The standard of care to prevent any injury, including thermal injury, during interventional procedures such as RFA, involves multiple factors. Appropriate training is mandatory, typically accomplished through an ACGME-accredited Pain Medicine fellowship, or equivalent. For the procedure itself, appropriate imaging guidance is mandated. Depending on the anatomical region and the skill level of the proceduralist, this may be ultrasound, fluoroscopy, CT guidance, etc. Imaging guidance allows the performing physician to clearly identify needle placement at all times, to ensure that surrounding anatomical structures are not injured. For fluoroscopically guided procedures multiplanar fluoroscopy, utilizing images captured in multiple views (i.e. AP, Lateral, Oblique, etc.) to clearly identify appropriate anatomy and needle placement with respect to target structures and surrounding (non-targeted) structures. Typically nerve stimulation is also utilized to ensure proper needle placement prior to initiating thermal ablation. If sedation is utilized, sedation should be provided only to the level necessary to safely perform the procedure, as appropriate sedation will often allow a patient to report unanticipated procedural pain that may warn the performing physician of inadvertent aberrant needle placement.