Korean J Pain.  2016 Jan;29(1):3-11. 10.3344/kjp.2016.29.1.3.

Neural Ablation and Regeneration in Pain Practice

• Choi EJ
• Choi YM
• Jang EJ
• Kim JY
• Kim TK
• Kim KH

• KMID: 2151653
• DOI: http://doi.org/10.3344/kjp.2016.29.1.3

Abstract

A nerve block is an effective tool for diagnostic and therapeutic methods. If a diagnostic nerve block is successful for pain relief and the subsequent therapeutic nerve block is effective for only a limited duration, the next step that should be considered is a nerve ablation or modulation. The nerve ablation causes iatrogenic neural degeneration aiming only for sensory or sympathetic denervation without motor deficits. Nerve ablation produces the interruption of axonal continuity, degeneration of nerve fibers distal to the lesion (Wallerian degeneration), and the eventual death of axotomized neurons. The nerve ablation methods currently available for resection/removal of innervation are performed by either chemical or thermal ablation. Meanwhile, the nerve modulation method for interruption of innervation is performed using an electromagnetic field of pulsed radiofrequency. According to Sunderland's classification, it is first and foremost suggested that current neural ablations produce third degree peripheral nerve injury (PNI) to the myelin, axon, and endoneurium without any disruption of the fascicular arrangement, perineurium, and epineurium. The merit of Sunderland's third degree PNI is to produce a reversible injury. However, its shortcoming is the recurrence of pain and the necessity of repeated ablative procedures. The molecular mechanisms related to axonal regeneration after injury include cross-talk between axons and glial cells, neurotrophic factors, extracellular matrix molecules, and their receptors. It is essential to establish a safe, long-standing denervation method without any complications in future practices based on the mechanisms of nerve degeneration as well as following regeneration.

Keyword

Axon; Chemical Neurolysis; Denervation; Electromagnetic field; Myelin; Nerve degeneration; Nerve regeneration; Peripheral nerve injury; Pulsed radiofrequency treatment; Wallerian degeneration

MeSH Terms

Axons
Classification
Denervation
Electromagnetic Fields
Extracellular Matrix
Myelin Sheath
Nerve Block
Nerve Degeneration
Nerve Fibers
Nerve Growth Factors
Nerve Regeneration
Neuroglia
Neurons
Peripheral Nerve Injuries
Peripheral Nerves
Pulsed Radiofrequency Treatment
Recurrence
Regeneration*
Sympathectomy
Wallerian Degeneration
Nerve Growth Factors

Figure

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  Fig. 1 Comparison between Seddon's and Sunderland's classification of peripheral nerve injury. Sunderland subdivided axonotmesis into 3 types with different degrees of nerve disruption and different capabilities for spontaneous regeneration [7].

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  Fig. 2 Sympathetic neurolysis for visceral cancer pain. (A) Celiac plexus neurolysis, (B) Superior hypogastric neurolysis, and (C) Ganglion impar neurolysis.

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  Fig. 3 Conventional radiofrequency ablation in the (A) thoracic medial branch of the posterior ramus, (B) supraorbital branch, (C) infraorbital branch, and (D) mental branch of the trigeminal nerve.

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  Fig. 4 Pulsed radiofrequency ablation in the thoracic dorsal root ganglia for the treatment of postherpetic neuralgia (PHN). (A) Oblique view: The target point is below the pedicle. (B) Anteroposterior view: The needle is advanced to the dorsal root ganglion below the pedicle. (C) Lateral view: The depth of the needle is adjusted under the lateral view. A contrast medium spreads to the left posterior epidural space, and the dorsal root ganglia become apparent.

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  Fig. 5 Degeneration and regeneration after peripheral nerve injury. (A) Normal neuron and nerve fiber. (B) Wallerian degeneration. The axotomy results in fragmentation of the distal axon and myelin sheaths. Schwann cells proliferate. Macrophages invade the distal nerve segment, and phagocytize degrading materials. (C) Schwann cells in the distal segment line up in bands of Büngner. Axonal sprouts advance embedded in the Schwann cells and are attracted by gradients of neurotrophic factors. (D) Axonal reconnection with end organs and maturation and remyelination of the nerve fiber [22].

Reference

1. Joo YC, Park JY, Kim KH. Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain. J Anesth. 2013; 27:390–395. PMID: 23192698.

2. Vargas ME, Barres BA. Why is Wallerian degeneration in the CNS so slow? Annu Rev Neurosci. 2007; 30:153–179. PMID: 17506644.

3. Ross LM, Lamperti ED. Arteries & veins of the rhoracic wall. In : Gilroy AM, MacPherson BR, Ross LM, editors. Atlas of anatomy. New York (NY): Thieme Medical Publishers, Ins;2005. p. 57.

4. Seddon HJ. A classification of nerve injuries. BMJ. 1942; 2:237–239. PMID: 20784403.

5. Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951; 74:491–516. PMID: 14895767.

6. Burnett MG, Zager EL. Pathophysiology of peripheral nerve injury: a brief review. Neurosurg Focus. 2004; 16:E1. PMID: 15174821.

7. Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol. 2008; 119:1951–1965. PMID: 18482862.

8. Hsu M. Significance of clinical treatments on peripheral nerve and its effect on nerve regeneration. J Neurol Disord. 2014; 2:168.

9. Koyyalagunta D, Burton AW. The role of chemical neurolysis in cancer pain. Curr Pain Headache Rep. 2010; 14:261–267. PMID: 20524161.

10. American Society of Anesthesiologists Task Force on Chronic Pain Management. American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010; 112:810–833. PMID: 20124882.

11. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg. 1995; 80:290–295. PMID: 7818115.

12. Iannuccilli JD, Prince EA, Soares GM. Interventional spine procedures for management of chronic low back pain-a primer. Semin Intervent Radiol. 2013; 30:307–317. PMID: 24436553.

13. Hong JH, Oh MJ. Comparison of multilevel with single level injection during lumbar sympathetic ganglion block: efficacy of sympatholysis and incidence of psoas muscle injection. Korean J Pain. 2010; 23:131–136. PMID: 20556215.

14. Kim WH, Kim SK, Lee CJ, Kim TH, Sim WS. Determination of adequate entry angle of lumbar sympathetic ganglion block in Korean. Korean J Pain. 2010; 23:11–17. PMID: 20552067.

15. Rocco AG, Palombi D, Raeke D. Anatomy of the lumbar sympathetic chain. Reg Anesth. 1995; 20:13–19. PMID: 7727322.

16. Chu KF, Dupuy DE. Thermal ablation of tumours: biological mechanisms and advances in therapy. Nat Rev Cancer. 2014; 14:199–208. PMID: 24561446.

17. Erdine S, Bilir A, Cosman ER, Cosman ER Jr. Ultrastructural changes in axons following exposure to pulsed radiofrequency fields. Pain Pract. 2009; 9:407–417. PMID: 19761513.

18. Chua NH, Vissers KC, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications-a review. Acta Neurochir (Wien). 2011; 153:763–771. PMID: 21116663.

19. Rozen D, Parvez U. Pulsed radiofrequency of lumbar nerve roots for treatment of chronic inguinal herniorraphy pain. Pain Physician. 2006; 9:153–156. PMID: 16703977.

20. Liuzzi FJ, Tedeschi B. Peripheral nerve regeneration. Neurosurg Clin N Am. 1991; 2:31–42. PMID: 1821734.

21. Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep. 2008; 12:37–41. PMID: 18417022.

22. Fu SY, Gordon T. The cellular and molecular basis of peripheral nerve regeneration. Mol Neurobiol. 1997; 14:67–116. PMID: 9170101.

23. Allodi I, Udina E, Navarro X. Specificity of peripheral nerve regeneration: interactions at the axon level. Prog Neurobiol. 2012; 98:16–37. PMID: 22609046.

24. Grinsell D, Keating CP. Peripheral nerve reconstruction after injury: a review of clinical and experimental therapies. Biomed Res Int. 2014; 2014:698256. PMID: 25276813.

25. Bíró T, Tóth BI, Marincsák R, Dobrosi N, Géczy T, Paus R. TRP channels as novel players in the pathogenesis and therapy of itch. Biochim Biophys Acta. 2007; 1772:1004–1021. PMID: 17462867.