Specialists in Image-Guided Procedures
What is Radiofrequency Ablation (RFA, aka “Rhizotomy”)?
Nerves transmit all pain signals in our bodies. No other tissues send any pain signals. Not bones. Not muscles. The only tissues that can send signals or electrical impulses of pain from joints or muscles are the nerve branches that plug into these painful tissues. Without those signals being sent, patients don’t have to feel pain. For example, if an Interventional Pain Specialist stops a nerve from firing, patients don’t have to feel their arthritic knee, shoulder, neck, or back pain, among other pains.
Radiofrequency Ablation (RFA) is a procedure during which small nerve endings are heated and melted down so that there is a loss of feeling to the painful area. This is a long-lasting and safe therapy.
These procedures should always be performed with X-ray guidance (fluoroscopy) or ultrasound-guidance in a specially-built procedure suite in a clinic, or an operating room, like those at Bloor Pain Specialists. The x-ray or ultrasound machine is used to take pictures as the radiofrequency needle is moved into each correct position to target each nerve branch. Each nerve branch is then heated using radiofrequency energy and the heat causes the inner lining of the nerve to break down, separating the connection from the painful joint or tissue from the signal being sent to the patient through the patient’s nerves.
How long does RFA last?
Unlike cutting the wiring to plug in your blender or toaster, our wiring (nerve tissue) grows back. Since nerve tissue grows back after being broken down, RFA is rarely a permanent treatment, but it can be long lasting. Its longevity depends on age, metabolism, and the length of each nerve involved. Shorter nerves in younger patients with faster metabolisms will grow back faster, and pain relief can be as short as a few months. Longer nerves in elderly patients with slower metabolisms grow back slower and their pain relief can be for over a year.
RFA is 85% more effective than other pain injections!
Leading researchers from Ontario have analyzed OHIP (Ministry of Health) data for 4,653 Ontario patients who underwent Radiofrequency Ablation for their spine-related pain and found the following:
- 3,445 (85.7% no longer needed pain injections)
- 1 in 5 (19.66%) of patients on opioids were able to stop using opioids
- 42% reduction in patients seeking their GP (family doctor) for pain related issues
How long has RFA been around and how available is the therapy?
RFA has been around since 1973, but very few Specialists in Ontario are trained to do this procedure. Although there are over 40,000 manuscripts for the use of RFA for various medical indications, there are only a few dozen Interventional Pain Specialists credentialed for its use in all of Ontario, servicing a population of over 14 million people. At Bloor Pain Specialists, this is a major focus of our practice and we have no limitations in procedural or operating room time, so the wait times are kept to a minimum for patients.
What kind of doctor can perform Radiofrequency Ablation (RFA) Procedures?
Only certain specialists can perform RFA procedures. Typically, after completing their specialty (usually anesthesiology, physiatry, or neurosurgery), they will undergo additional sub-specialty training called a “fellowship” or another form of additional education to sub-specialize in doing this type of procedure. In each province, the regulatory body will inspect the physician’s credentials prior to approving the physician to perform these procedures in his or her province. In Ontario, the College of Physicians and Surgeons of Ontario (CPSO) would be the organization to make that decision for each individual case. You can ask your doctor if he or she has been credentialed by the CPSO to do this procedure.
At Bloor Pain Specialists, Dr. Visnjevac, Dr. Catapano, and Dr. Chue are several of the physicians fully credentialed for all procedures. Through his faculty appointment at McMaster’s medical school through the Faculty of Health Sciences in the Department of Anesthesiology, Dr. Visnjevac also teaches these techniques to residents and other physicians.
What Kinds of Pain Problems Can RFA Treat?
Low back pain
Sacroiliac joint (SIJ) pain
Upper back pain
Chest wall pain (aka non-cardiac chest pain)
Abdominal wall pain
Chronic headaches /Migraines
Large joint arthritic pain (knees, hips, shoulders)
Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD)
Ischemic (Vascular) Pain (aka vascular claudication)
Yes. All procedures are covered by OHIP. Only a few clinics/hospitals are approved to perform these procedures, with Bloor Pain Specialists being one of them. Check with your GP, neurologist, chronic pain doctor, or other specialist. You will need a referral from your Family Doctor or specialist before scheduling an appointment. Please bring all MRI/CT/X-ray/EMG reports when you go for your consultation.
What are epidural steroid injections (ESI's)?
The epidural space is a location that surrounds the nerves of the spine. “Epi” means outside and “dura” is the name of the membrane that holds the spinal fluid and the nerves. Hence, the epidural space is by definition the space outside the nerves of the spine.
The epidural space can have a number of different things injected or inserted into it. In labour, women often get an epidural catheter (tube) placed, but this cannot be done with x-ray guidance because x-rays can be bad for developing fetuses and babies.
In the outpatient setting, for management of pain, corticosteroids are sometimes put into the epidural space with x-ray guidance. This x-ray guidance allows for more precise placement of the needle and magnification of the needle, which allows for a smaller needle to be used.
These injected corticosteroids are medications that act as antidotes to inflammation, very potently improving any inflammation around a nerve root or herniated disc for conditions like sciatica.
Unless the patient is pregnant, these procedures should always be performed with a mobile C-Arm X-ray machine (fluoroscopy) in a specially-built procedure suite in a clinic, or an operating room, as a standard of care, to watch the needle go accurately to the correct layer of the spine. The x-ray is used to take pictures as the needle is moved into the correct position to target each nerve root or herniated disc. Bloor Pain Specialists has 4 of these procedure suites and C-Arm machines.
What kind of doctor can perform epidural steroid injections?
Although several specialties perform epidural steroid injections, the most experienced specialists are anesthesiologists. Typically, these will undergo additional sub-specialty training called a “fellowship” or another form of additional education to sub-specialize in doing this form of procedure. In each province, the regulatory body will inspect the physician’s credentials prior to approving the physician to perform these procedures in his or her province. In Ontario, the College of Physicians and Surgeons of Ontario (CPSO) would be the organization to make that decision for each individual case.
What Kinds of Pain Problems Can Epidural Steroid Injections Treat?
Low back pain
Upper back pain
Abdominal wall pain
Rib or chest wall pain (aka non-cardiac chest pain)
Sacral/ Tailbone pain
Surgical planning (typically referred by a surgeon or Rapid Access Clinic for diagnostic Selective Nerve Root Blocks (SNRBs)
Yes. All procedures are covered by OHIP. Only a few clinics/hospitals are approved to perform these procedures, with Bloor Pain Specialists being one of them. Check with your GP, neurologist, chronic pain doctor, or another specialist. You will need a referral from your Family Doctor or specialist before scheduling an appointment. Please bring all MRI/CT/X-ray/EMG reports when you go for your consultation.
What other kinds of procedures do Specialists at BPS perform?
Our specialists are trained to inject every joint and all types of nerve blocks. Some procedures are done with x-ray (fluoroscopic C-Arm) guidance, while others are performed with ultrasound guidance. Our anesthesiologists also perform ketamine and/or lidocaine infusions.