BrochureCosman & Gonzalez 2011 Ablation Study Technique Guide from Gauci CA. Manual of RF Techniques. 2011Request Information
Treat SIJ Pain with Improved Speed, Ease, Targetry, and Expense
Developed with Dr. Jianguo Cheng of the Cleveland Clinic, the sterile-packed Palisade guide block simplifies bipolar RF treatment of sacroiliac (SI) joint pain by setting 10 mm parallel cannula spacing, and can reduce procedure time, x-ray exposure, and cost.1-4 In less than 10 minutes, the Cosman G4 can generate an elongated ablation that conforms to the individual’s sacral curvature, and interrupts the L5-S3 dorsal innervation of a painful joint. Bipolar radiofrequency (RF) technology creates larger ablations, using smaller, less expensive RF cannulae and electrodes.1-3 Scientific evaluation of the technique predicts a more complete SI Joint lesion zone that conforms to patient anatomy and is less likely to leave gaps between adjacent lesions that could allow painful nerves to remain.3
Bipolar RF Creates Large Overlapping Ablations
The Palisade approach employs overlapping bipolar RF lesions to create an aggregate lesion zone that traverses the entire region that sacral lateral branch nerves travel to the SI Joint.1-4 Since bipolar lesions have an elongated “brick like” rectangular shape that is robust to parallel cannulae spacings of 8-12 mm (Figure 2), a lesion zone with substantially consistent thickness and height can be created using by lowering relatively few standard cannulae straight to the sacral surface.3 In contrast, monopolar RF methods use multiple, smaller spherical lesions that produce a total lesion zone with variable height and thickness, and which will have gaps that could spare painful nerves (see Figure 1).3,6
Figure 1 (A) Cooled monopolar lesion geometry for 10 and 12 mm tip-to-tip spacings, 2 mm tip-to-sacrum distance, 60°C set temperature, and 3.25-minute lesion time (0.75 pre-cooling + 2.5 heating).5-7 Gaps between and around adjacent lesions situated near the sacral surface can arise from small increases in tip-to-tip and tip-to-sacrum distances. (B) Bipolar lesion geometry for 10 mm and 12 mm tip-to-tip spacings, 0 mm tip-to-sacrum distance, 90°C set temperature, and 3-minute lesion time. Individually, bipolar lesions can be larger than both cooled and noncooled monopolar lesions. When arranged in a palisade on the sacral surface, bipolar lesions can collectively produce a lesion zone of consistent height, width, and depth that has fewer gaps than the lesion zone produced by the reported cooled RF SIJ method. (C) Three monopolar lesions, created using 90°C set temperature and 3-minute lesion time, are required to approximate a single bipolar lesion for 10 mm tip spacing and the same RF parameters (shown by the dotted outline). (A–C) Each panel shows a set of thermal lesions in both lateral (top) and needle (bottom) views.3
Straight-Line Ease and Efficiency
In the Palisade procedure, cannulae are placed in a straight line between the sacral foramina and the ipsilateral SIJ line.1-4 The line can be chosen using an AP x-ray image using the Palisade guide block’s radiopaque markers.1,2 The most superior cannula can be placed at the sacral ala so that the L5 dorsal ramus is targeted using the same bipolar RF technique and generator settings as the sacral lateral branch nerves.1,2 In contrast, for periforaminal techniques like that used with cooled RF, each sacral foramina must be accurately identified and electrodes placed at specific positions and distances relative to each foramina.5-7 Use of additional reference needles5,6 and an epsilon ruler6 are advocated by some for these periforaminal placements.
Multi-Bipolar for Even Faster Procedures
With standard reusable electrodes, the Palisade procedure can be performed efficiently and at very low cost using as few as two standard disposable RF cannulae. Using 4-7 cannulae and the G4 four-electrode generator reduces procedure time even more, since multiple bipolar lesions are generated at the same time. The Palisade Kit includes disposable cannulae and disposable electrodes to perform the Palisade procedure as described in the literature.1-4
The Confidence of Bony Contact
Since Palisade cannulae remain in contact with the sacral surface through placement and lesioning, the physician can ensure that placements conform to patient anatomy over the length of the sacrum. And, the physician can avoid placements within the sacral foramina which could pose a risk to the sacral nerve roots.3
Bipolar RF is a Powerful New Tool for Pain Management
Recent scientific discoveries demonstrate that Bipolar RF is a powerful tool for creating large RF heat lesions, with dimensions that can even exceed 20 mm (see Figure 2).3,4 When employing radiofrequency ablation of any size, a physician must always excise his own independent clinical judgement in selecting an ablation size that is appropriate to the target anatomy to avoid undesired damage to sensitive structures.4
Figure 2. Cross-sectional photographs of bipolar lesions in ex vivo adult bovine liver show the lesion lengths L and widths W produced by different parallel tip spacing s, tip diameters, and tip lengths, for 90°C tip temperature and 3-minute lesion time. The “Depth Cross Section” photograph shows two bipolar lesions in the lower liver slab, revealed by cutting the lower liver slab in a plane perpendicular to the tip lengths. Half of their midline depth dimension D can be measured in this manner.3
References and Footnotes:
- Cheng J, inventor. The Cleveland Clinic Foundation, assignee. US Appl No 14/564,309. 2014.
- Cheng J, Chin SL, Zimmerman N, Dalton JE, LaSalle G, Rosenquist RW. A new method of radiofrequency ablation to treat sacroiliac joint pain. Submitted 2015.
- Cosman ER Jr, Gonzalez CD. Bipolar Radiofrequency Lesion Geometry: Implications for Palisade Treatment of Sacroiliac Joint Pain. Pain Practice 2011; 11(1): 3-22.
- Cosman ER Jr, Dolensky JR, Hoffman RA. Factors That Affect Radiofrequency Heat Lesion Size. Pain Medicine 2014; 15(2):2020-36.
- Wright RF, Wolfson LF, DiMuro JM, Peragine JM, Bainbridge SA. In vivo temperature measurement during neurotomy for SIJ pain using the Baylis SInergy probe. International Spine Intervention Society 15th Annual Scientific Meeting; 2007: 82–84. This reference notes that the maximum tissue temperature is not measured by the SInergy probe.
- Kapural L, Nageeb F, Kapural M, Cata JP, Narouze S, Mekhail N. Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series. Pain Pract. 2008;8:348–354.
- Cohen SP, Hurley RW, Buckenmaier III CC, Kurihara C, Morlando B, Dragovich A. Randomized placebocontrolled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008; 109:279–288. This reference notes that an 9th lesion is placed at S4 if it is suspected to be involved in the pain syndrome.
The procedure steps on this webpage summarize the clinical methods reported by the authors of referenced articles. They are not intended to be used as a medical guide, instruction, or comprehensive report on referenced articles. Refer to the original articles and their authors for further information. The treatment of any patient is the sole responsibility of the administering physician. Refer to the instructions for use for all devices before treatment. Cosman Medical does not advise on use of products for a particular patient.