Shocking Incidents during Radiofrequency for Facet Joint Pain in Patients with Permanent Pacemakers and Defibrillators

Radiofrequency neurotomy (RFN) has emerged as a valuable intervention in the field of pain management. It is widely employed for the treatment of facet joint pain, which is a common cause of chronic low back pain. RFN involves the use of thermal energy to selectively ablate the nerves transmitting pain signals from the affected facet joints. The procedure offers a minimally invasive alternative to surgical interventions, providing durable pain relief for an extended duration. RFN has demonstrated efficacy in reducing pain, improving functional outcomes, and enhancing the quality of life for patients suffering from facet joint pain. Its role in interventional pain management continues to evolve, with ongoing research and technological advancements aimed at optimizing patient outcomes.


Purpose/Objectives: The goal of this research is to further inform recommendations and procedures for RFN in patient with ICD and PPM devices in place. Radiofrequency neurotomy (RFN) is commonly used for the treatment of facet joint pain. However, patients with implanted permanent pacemakers (PPM) or implantable cardiac defibrillators (ICD) may experience device dysfunction during RFN procedures. patients with implanted permanent pacemakers (PPM) or implantable cardiac defibrillators (ICD) may face the risk of device dysfunction during RFN procedures. This case report aims to discuss a shocking mechanism implication during RFN and suggest preventive measures to enhance patient safety by discussing possible preventive measures.

Method: We present the case of a 52-year-old African American female with a Medtronic ICD in place referred to our clinic for chronic low back pain evaluation. The patient with had a history of radiating pain, failed conservative treatments, and fibromyalgia diagnosis. We performed R-sided L3,4,5 RFN while adhering to the recommendations provided by the American Society of Anesthesiologists (ASA). The grounding electrode was placed >15 cm away from the pacing leads, as per ASA guidelines. Grounding lead was placed on RUE. Additionally, after clearance from the patient's established cardiology physician, the procedure was performed on the contralateral side with adjusted placement of grounding pad.

Results: During the procedure, the patient experienced two shocking incidents within 30 seconds of the burning session. The process was immediately stopped, and the patient woke up without any sequelae. Subsequent evaluation by the cardiologist confirmed no device malfunction, but reprogramming or magnet use was recommended, which posed challenges in a small private facility. After clearance from cardiology, left-sided RFN of L3,4,5 was performed adhering to guidelines, but with grounding lead placed on RLE without incident.

Conclusions: While there are no reported cases of RFN causing serious injury or death in patients with PPMs or ICDs, precautions should be taken. We recommend placing the grounding pad over the lower extremity instead of the upper extremity and consider coordination with device manufacturers and cardiologists/electrophysiologists. There is some concern of electrical current flow traveling through patient tissues in manners not explicitly described and accounted for in ASA recommendations for grounding placement in these RFN procedures. Adjustment of grounding pad placement, patient education, and further study of involved procedure risks are essential to maximize safety during RFN procedures in this population.

References: -Clark Smith, MD, MPH and others, Radiofrequency Neurotomy for Facet Joint Pain in Patients with Permanent Pacemakers and Defibrillators, Pain Medicine, Volume 20, Issue 2, February 2019, Pages 411–412, https://doi.org/10.1093/pm/pny213
-Ng Yuet Tong, Hsieh Jing Ru, Hui Yu Ling, Yu Chun Cheung, Lau Wai Meng, Peter Chi Ho Chung; Extracardiac Radiofrequency Ablation Interferes with Pacemaker Function but Does Not Damage the Device. Anesthesiology 2004; 100:1041 doi: https://doi.org/10.1097/00000542-200404000-00053
-Friedrich J, Itano EM, Lynn RR. Management of Cardiac Implantable Electrical Devices in Patients Undergoing Radiofrequency Ablation for Spine Pain: Physician Survey and Review of Guidelines. Pain Physician. 2020 Jul;23(4):E335-E342. PMID: 32709179.