Dr. John O’Neil, DPT meets with Dr. Chirag Sanghvi, MD to discuss a less invasion option for arthritic knee pain
Dr. Sanghvi is a board certified Anesthesiologist and Pain Management physician that practices out of Newbridge Spine & Pain Center in Leesburg, VA. Dr. Sanghvi completed his fellowship in Pain Management at the Cleveland Clinic in Cleveland, Ohio, after fulfilling his residency at Loma Linda University, in Loma Linda, California, where he served as an anesthesia and trauma clinical research specialist. I had the opportunity to sit down with him and talk about the ins and outs of this physician’s view of the genicular nerve block and ablation procedures.
What is a Genicular nerve ablation, and who could benefit from this?
A genicular nerve ablation is a procedure in which the nerves that give pain signals to the brain from the knee are made temporarily (4-9 months, with an average of 6) unable to send a pain signal. The genicular nerves are a group of six sensory nerves, of which, three are able to be treated with this procedure. Fortunately, 70-80% of the pain due to osteoarthritis of the knee is due to these three nerves. If this procedure is found effective, and deemed appropriate, genicular nerve ablations are able to be repeated indefinitely without ill effect.
Conditions treated: chronic knee pain, degenerative joint disease of the knee, osteoarthritis of the knee, or prior to or after a total or partial knee replacement. Also, it can be very effective for individuals who are either not able or wish to avoid a knee replacement. For example, if someone is too young for a knee replacement, or has comorbidities that would prevent a knee replacement.
This procedure is performed in two steps:
- Diagnostic: Genicular Nerve Block – Not all knee pain is due to the genicular nerves, so before Dr. Sanghvi ablates the nerve, he tests the genicular nerve to see if it is the pain generator. This procedure consists of placing a small amount of a very short acting (6-8 hour) local anesthetic on the genicular nerves. If there is at least a 50% decrease in pain from this procedure, performed at two separate times to double check, the patient is deemed likely to benefit from ablation of these nerves.
- Treatment: Genicular Nerve Ablation – in this process, the genicular nerve is cauterized by heating a very small area around the nerve for 90-120 seconds. This heat is usually not felt by the patient. After this, the nerve will be unable to transmit sensory information to the brain, and thus the individual will not feel pain if the genicular nerve was the source of the pain.
Questions with Dr. Chirag Sanghvi, MD
When do you recommend a Genicular Nerve Ablation over other procedures?
Although a genicular nerve ablation is an effective procedure for reducing knee pain due to degeneration of the knee, it is not a first line treatment. If someone has advanced arthritis of the knee, and is a candidate for a total knee replacement, this should be considered first. A genicular nerve ablation is best utilized when a person is either too young/too old to benefit from a knee replacement, or has comorbidities that would prevent a knee replacement from taking place. Of particular benefit is when someone has pain on the inside, or medial aspect, of the knee.
It can also be effectively utilized if a patient has to wait for a period of time prior to receiving a knee replacement. Sometimes an orthopedic physician will want an individual to lose weight prior to a performing a knee replacement, and this procedure can greatly help with pain while the individual is becoming a candidate for a knee replacement. Or, sometimes an individual has to wait to get a knee replacement for other reasons, such as wanting to go on a scheduled vacation or prefers a certain time of year to have the replacement done. This procedure can help with pain during this waiting period as well.
After a knee replacement, many individuals still struggle with some pain in the knee, and this procedure can be performed then as well.
Are there any serious complications associated with this procedure?
As with any medical procedure, there are risks, but for this procedure, the risks are quite low. It is possible that you can injure the blood vessels around the knee during the procedure, but if proper utilization of imaging techniques are used during the procedure, it is very uncommon for this to occur. Also, there is a rare complication of irritating the nerve, which could cause 3-6 months of nerve pain that can be treated with nerve pain medications.
Does a Genicular Nerve Ablation hurt?
Most of the pain is from the placement of the needles, with the procedure itself not causing much pain. If the individual is concerned with this, they can be sedated during the procedure.
Are there other ways to treat the nerves in the knee?
There is ongoing research on dorsal root ganglion stimulators to affect the nerve at the spinal level. Nerves from the spine control sensory and motor information to the legs, and most of the sensory and motor information for the knee is from the third and fourth lumbar vertebrae. In this procedure, the sensory nerves are selectivity stimulated to not cause pain in this individual.
Preliminary results are showing good promise, although more research needs to be performed before this technique becomes more mainstream.
Time to Take a Stand!
Physical therapists use sound, scientifically proven principles of human anatomy, physiology, movement and psychology to help patients lead healthy, pain-free lives.
The therapist will conduct an initial evaluation followed by several progress notes to document progress over time. A comprehensive analysis establishes a ‘clinical baseline’ and identifies muscle imbalances, causes of pain and joint alignments. This is the foundation for short and long-term goals designed to help individuals recover completely. In fact, physical therapy can address every aspect of recovery including:
- Biomechanical aspects like spine/hip/foot alignments
- Lower back strength
- Pain levels
- Functional capability