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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 173-175

Conventional radiofrequency ablation of the articular sensory branches of the obturator and femoral nerves under fluoroscopic guidance for chronic hip joint pain in a case of ankylosing spondylitis


Department of Pain Management, ESI Institute of Pain Management, Kolkata, West Bengal, India

Date of Submission16-Dec-2019
Date of Decision27-Jan-2020
Date of Acceptance03-May-2020
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Subrata Goswami
Flat 10, Doctor' Block, 3A Maharani Swarnamoyee Road, Kolkata - 700 009, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_94_19

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  Abstract 


Chronic hip pain is often a debilitating problem, especially ankylosing spondylitis (AS), and few patients with the problem are not good surgical candidates. Hence, other conservative approaches should be used. We report the case of a 37-year-old male, a known case of AS, who presented with severe hip pain along with other joint involvements. The hip joint pain was managed with radiofrequency (RF) ablation of the articular sensory branches of the hip joint after initially tested with positive diagnostic block. This case emphasizes the role of RF ablation as a safe alternative to hip replacement.

Keywords: Ankylosing spondylitis, femoral nerve, hip joint, obturator nerve, pain, radiofrequency ablation


How to cite this article:
Taran A, Sarkar B, Nandi G, Goswami S. Conventional radiofrequency ablation of the articular sensory branches of the obturator and femoral nerves under fluoroscopic guidance for chronic hip joint pain in a case of ankylosing spondylitis. Indian J Pain 2021;35:173-5

How to cite this URL:
Taran A, Sarkar B, Nandi G, Goswami S. Conventional radiofrequency ablation of the articular sensory branches of the obturator and femoral nerves under fluoroscopic guidance for chronic hip joint pain in a case of ankylosing spondylitis. Indian J Pain [serial online] 2021 [cited 2021 Nov 30];35:173-5. Available from: https://www.indianjpain.org/text.asp?2021/35/2/173/325211




  Introduction Top


Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects the axial skeleton. Hip involvement is common in AS patients, and the reported prevalence of clinical hip involvement in AS is from 24% to 36% and the prevalence of radiographic hip arthritis ranges from 9% to 22%. Unlike new bone formation in the axial spine, synovial inflammation within the hip joint causes bone erosion and joint space narrowing.[1] Hip pain is a common condition that is often seen in the rehabilitation setting in patients with multiple comorbidities. Often, surgery is not an option and conventional drugs have either too many side effects or are ineffective. Percutaneous radiofrequency (RF) lesioning of the articular branches of the obturator and femoral nerves is a novel alternative treatment for long-term pain relief for hip pain that has been previously reported in the literature.[2],[3]


  Case Report Top


A 37-year-old male patient, who was a diagnosed case of AS, came to the pain outpatient department with chief complaints of severe pain in the left hip joint for the past 2 years. Initially, the pain was mild, more during walking, but gradually, it increased in intensity and pain persisted even during rest, aggravated during mild movement in sitting or supine position. Tenderness was present around the left inguinal region. Pain intensity increased to a level that crippled him, and he was forced to use elbow crutch. He was from low socioeconomic status and was anxious because of his condition at such a young age. He was on conservative medications which include tablet indomethacin 50 mg BD and tablet sulfasalazine 1 g BD from the rheumatology department and previously been given multiple steroid injections (total 5 in the past 5 months) along with hyaluronic acid injections intra-articularly in the left hip joint, but pain relief was very transient for few weeks, and the patient was not satisfied by pain relief. He was advised hip joint replacement by the orthopedic department, but he refused to undergo surgery. On physical examination, active and passive movements of the hip joint were restricted with tenderness in the left inguinal region. There were degenerative changes with loss of joint space in X-ray of hip joints. The patient and his family members were explained about the plan of treatment and its possible consequences including the side effects, and the consent was taken for RF ablation of the articular sensory branches of the obturator and femoral nerves supplying the hip joint. The Numerical Rating Scale (NRS) score and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score for hip joint were recorded before the procedure, which were 7/10 and 63/96, respectively.

A diagnostic block was given with 1 ml of 0.25% bupivacaine at sensory branches of the obturator and the femoral nerves under fluoroscopy guidance, For the articular branches of the obturator nerve, a 22G 10-cm spinal needle was placed at the site below the inferior junction of the pubis and the ischium, which appears teardrop in shape in the anteroposterior radiograph [Figure 1], and for the articular branches of femoral nerve, the needle was inserted from a site below the anterior superior iliac spine to the anterolateral aspect of the extra-articular portion of the hip joint. The needle tip was located below and medial of the anterior inferior iliac spine near the anterolateral margin of the hip joint [Figure 2]. There was 90% pain relief after the diagnostic block.
Figure 1: Fluoroscopic picture of the needle positions. Upper needle is for femoral nerve branches at anterolateral aspect of the extra-articular portion of the hip joint. Lower needle for obturator nerve branches placed below the inferior junction of the pubis and ischium

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Figure 2: Fluoroscopic picture of the radiofrequency ablation of the sensory branches of obturator and femoral nerves

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With the positive response with diagnostic block, the patient was posted in operation theatre (OT) for RF ablation of the sensory branches of the obturator and the femoral nerves. Under fluoroscopic guidance, two RF cannulae with 10 cm length and 10 mm active tip were placed in the appropriate position similar to the diagnostic block. Sensory and motor stimulation testing was done; on sensory stimulation, pain produced around the hip joint in the same distribution, while the motor stimulation was negative. After obtaining proper sensory and motor stimulation, the conventional RF thermocoagulation was performed at 70°C, 75°C, and 80°C for 90 s using a COSMAN RF machine. The procedure was uneventful, and postprocedure, the patient was monitored in the recovery unit. In follow-up rounds, the patient was pain free and satisfied with pain relief, and he was discharged after 2 days, with a NRS score of 2/10 and WOMAC score of 45/96.

After 1-month follow-up of the patient, the NRS score was 3/10 and WOMAC score 50/96, and on 3-month follow-up, the NRS score was 3/10 and WOMAC score was 55/96. The patient was now able to sit without any discomfort. However, the only problem which persists was the constant friction between the articular surfaces of the hip joint which leads to pain while walking, which still affects his quality of life.


  Discussion Top


The effects of conservative pharmacologic treatment with drugs such as disease-modifying antirheumatic drugs and tumor necrosis factor inhibitors on hip involvement in AS are uncertain.[4] As our patient did not want to undergo surgery, so other conservative options have to be used, the same stated by Tinnirello et al., that often, surgery is not an option and conventional drugs have either too many side effects or are ineffective.[5] Hip joint innervation is provided by articular branches of the femoral, obturator, and sciatic nerves. The anterior part of the joint is innervated by branches of the femoral and obturator nerves while branches from the sciatic nerve provide innervation to the posterior part of the joint capsule.[6] Obturator and femoral articular branches are easily accessible with the use of relatively constant fluoroscopic markers. Articular branches from the sciatic (via the superior gluteal nerve) are more variable and deeper, so they are not routinely used for the neural blockade.[4]

As our patient had multiple intra-articular steroid injections, but the relief due to them was only temporary, Yavuz et al.[7] and Flanagan[8] also reported pain relief for few months with local anesthetic and steroid injections intra-articularly.

Kawaguchi et al. also performed the RF ablation of sensory branches of obturator and femoral nerves after performing the diagnostic block first with the local anesthetic.[8]

Tinnirello et al. also blocked obturator and femoral nerve sensory branches; however, they have used pulsed RF of the sensory nerves.[5]

Although we had used continuous RF which carries the risk of neuritis and neuroma formation,[9] to prevent this we had given 8 mg dexamethasone after ablation of nerves.

Kumar et al. also state in their review study that sensory denervation of the anterior hip joint using RF current is a viable treatment option for the management of chronic hip pain after conservative methods fail to do so.[10]

Bhatia et al. concluded in their study that RF treatments for the sensory innervation of the hip joint have the potential to reduce pain secondary to degenerative conditions.[11]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jeong H, Eun YH, Kim IY, Kim H, Lee J, Koh EM, et al. Characteristics of hip involvement in patients with ankylosing spondylitis in Korea. Korean J Intern Med 2017;32:158-64.  Back to cited text no. 1
    
2.
Malik A, Simopolous T, Elkersh M, Aner M, Bajwa ZH. Percutaneous radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of non-operable hip pain. Pain Physician 2003;6:499-502.  Back to cited text no. 2
    
3.
Vander Cruyssen B, Muñoz-Gomariz E, Font P, Mulero J, de Vlam K, Boonen A, et al. Hip involvement in ankylosing spondylitis: Epidemiology and risk factors associated with hip replacement surgery. Rheumatology (Oxford) 2010;49:73-81.  Back to cited text no. 3
    
4.
Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint-an anatomical study. Surg Radiol Anat 1997;19:371-5.  Back to cited text no. 4
    
5.
Tinnirello A, Todeschini M, Pezzola D, Barbieri S. Pulsed radiofrequency application on femoral and obturator nerves for hip joint pain: Retrospective analysis with 12-month follow-up results. Pain Physician 2018;21:407-14.  Back to cited text no. 5
    
6.
Yavuz F, Yasar E, Ali Taskaynatan M, Goktepe AS, Tan AK. Nerve block of articular branches of the obturator and femoral nerves for the treatment of hip joint pain. J Back Musculoskelet Rehabil 2013;26:79-83.  Back to cited text no. 6
    
7.
Flanagan J, Casale FF, Thomas TL, Desai KB. Intra-articular injection for pain relief in patients awaiting hip replacement. Ann R Coll Surg Engl 1988;70:156-7.  Back to cited text no. 7
    
8.
Kawaguchi 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.  Back to cited text no. 8
    
9.
Gekht G, Nottmeier EW, Lamer TJ. Painful medial branch neuroma treated with minimally invasive medial branch neurectomy. Pain Med 2010;11:1179-82.  Back to cited text no. 9
    
10.
Kumar P, Hoydonckx Y, Bhatia A. A review of current denervation techniques for chronic hip pain: Anatomical and technical considerations. Curr Pain Headache Rep 2019;1;23:38.  Back to cited text no. 10
    
11.
Bhatia A, Hoydonckx Y, Peng P, Cohen SP. Radiofrequency procedures to relieve chronic hip pain: An evidence-based narrative review. Reg Anesth Pain Med 2018;43:72-83.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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