Ep. 44 Pain Procedures: Sacroiliac Joint Radiofrequency
Episode Summary:
In this episode of 'It's Not In Your Head' podcast, hosts Justine Feitelson and Dr. Dan Bates delve into radiofrequency ablation as a treatment for sacroiliac joint (SIJ) dysfunction. This procedural-focused episode covers the nature of SIJ pain, the diagnostic process, and the specifics of radiofrequency ablation, including its applications, risks, and outcomes. Dr. Bates elaborates on different approaches and techniques used in the procedure, while sharing insights from his practice and recent research developments. Give this episode a listen to learn more about how RFA is performed and who it is best for.
Episode Overview:
Radiofrequency ablation (RFA) in this episode is explained as a targeted nerve-burning procedure used mainly for sacroiliac (SI) joint osteoarthritis when other treatments, including injections and rehab, have not provided lasting relief.
The episode continues the “procedures” series, zooming in on RFA for SI joint–related low back pain, especially sacroiliac joint osteoarthritis rather than SI joint dysfunction.
Dan reminds listeners of the five major lower back pain sources (facets, SI joints, hips, discs, and nerves) and how pain location (above vs below the belt line; back vs legs) helps narrow down the likely cause.
When RFA is considered
For suspected SI joint osteoarthritis, the first step is usually a diagnostic and therapeutic injection into the joint with local anesthetic plus cortisone, after rehab has already been tried.
If the local anesthetic gives short-term relief and cortisone only helps for about 4–6 days before pain climbs back, this is seen as a failure of the first treatment option and a cue to consider RFA.
How RFA works for the SI joint
RFA “potato/potahto” or radiofrequency neurotomy involves heating the nerves that supply the SI joint to reduce their ability to transmit pain.
Although newer research suggested L4 might not contribute much to SI joint innervation, Dan finds including nerves from L4 down to S3 gives better results, likely because it also treats nearby facet joint pain that often coexists.
Procedure technique and variations
The first two treated nerves (L4 and L5 medial branches) are targeted with a technique that ideally runs the needle parallel to the nerve, or uses special larger tips if the needle is perpendicular.
Across S1–S3, Dan uses a “palisade” approach: four needles spaced about a centimeter apart with bipolar burns between them to catch nerve branches that may sit up to a centimeter off the bone.
Risks, flares, and managing side effects
General risks mirror other spine procedures: infection, bleeding, bruising, and a temporary flare of burning or “nervy” pain after the procedure.
Around 20% of people get this flare, usually lasting up to two weeks; a smaller portion may have symptoms up to six weeks, and historically about 1 in 1000 might have pain up to six months, though Dan feels newer techniques make that long duration much less likely.
Using extra injections to reduce flares
Dan often adds paravertebral injections or an epidural at the same time as RFA to reduce early post-procedure pain, noting that this is controversial but has clearly reduced “my phone is ringing because this is really sore” calls in his practice.
He emphasizes that if pain after RFA goes beyond six weeks, patients should speak up, as there are now better options to get on top of prolonged nerve pain.
How long relief lasts and what “success” looks like
In Dan’s experience, many people get about 9–18 months of relief, and he is comfortable repeating the procedure every two to three years if it remains effective.
Published research often reports that about 50–60% of patients achieve at least 50% pain reduction for 3–6 months, but data usually stop at 6–12 months, so longer-term outcomes are less clearly captured in studies.
When results are disappointing
If RFA only gives around three months of relief despite strong initial benefit, Dan suspects underlying SI joint dysfunction rather than “pure” osteoarthritis and changes his management plan.
A poor response after a clearly positive diagnostic block might mean either a false-positive block or a technical RFA failure; repeating the diagnostic block helps distinguish between misdiagnosis (block now negative) and a need to change RFA technique (block still positive).
Other RFA technologies and cost issues
Alternative systems (like “Simplicity”) and cooled RF can create larger burn areas; cooled RF still uses high heat but cools the needle tip to widen the lesion.
Justine highlights that people with conditions like CRPS should be cautious about nerve-burning procedures, and Dan notes that in Australia, higher consumable costs with no extra rebate make cooled RF less commonly used despite its effectiveness.
Take-home messages for listeners
RFA is not a first-line treatment but a next-step option when SI joint osteoarthritis is strongly suspected, injections have given only short-lived benefit, and rehab has been fully tried.
Listeners are encouraged to discuss with clinicians: accurate diagnosis (including blocks), realistic expectations about duration of benefit, what happens if relief is short-lived, and how flares or prolonged pain after RFA will be managed.