- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04534829
Fluoroscopic vs Ultrasound Guided Sacroiliac (SI) Joint Radiofrequency Ablation
Efficacy of Fluoroscopic Versus Ultrasound Guided Sacroiliac Joint Radiofrequency Ablation: A Randomized Control Trial
Study Overview
Status
Conditions
Detailed Description
Current practice for SIJ pain that is refractory to conservative treatment, is the use of RFA of the posterior sacral network under fluoroscopic-guidance. There is high variability regarding the long-term benefits of this procedure. To date, there have been no clinical studies evaluating the effectiveness of US-guided RFA procedures for SIJ pain. A study performed in 2017 attempted to determine the effectiveness of US-guided sacral LBBs compared to fluoroscopic-guidance (gold standard in current practice). The results were in favour of an US-guided approach. Compared with fluoroscopy, US-guided sacral lateral branch blocks required a shorter performance time, fewer needle passes, and was associated with a lower incidence of vascular breach. Furthermore, with an US-guided procedure, the patient is no longer exposed to ionizing radiation.With an improved understanding of SIJ sensory innervation, as well as technical improvements in RFA electrodes, it is postulated that RFA under ultrasound-guidance will lead to non-inferior clinical outcomes, as well as shorter performance time and reduced costs compared with the current practice of fluoroscopic-guidance.
The objectives of the current study are the following:
- To evaluate the efficacy of US-guided posterior sacral network SIJ RFA compared to fluoroscopy-guided SIJ RFA.
- To compare the post-procedure pain/flare-up and duration required to achieve full recovery for each approach.
- To perform a cost effectiveness analysis comparing ultrasound and fluoroscopy-guided SIJ RFA.
- To determine the safety of US-guided SIJ RFA by tracking intra-operative and post-procedure complications.
Research Method/Procedures:
The proposed study is a single-blind, single-center randomized controlled trial. Patients who present with pain thought to be originating from the SIJ will be screened for study participation with fluoroscopy-guided sacral LBBs. If a patient has an initial successful sacral LBB (defined as 70% reduction in pain), or has prior successful SIJ RFA, they will be approached for consent to be contacted for study participation by a member of the HealthPointe team; specifically, patients who consent to be contacted for study participation, will have their charts reviewed by independent assessors for inclusion and exclusion criteria. If a patient meets the inclusion criteria (listed below), they will be contacted by a HealthPointe team member, specifically a nurse or care manager, for study participation. If the patient expresses an interest with the initial contact, they will be subsequently contacted by a study sub-investigator.
Upon obtaining written consent for study participation, patients will be randomized into one of two groups; US-guided SIJ RFA or fluoroscopy-guided SIJ RFA (current gold-standard). Upon being randomized to either group they will then undergo a second confirmatory sacral LBB under their respective image guidance to confirm candidacy for RFA. If this second, confirmatory LBB is successful (70% pain relief or more) the patient qualifies for RFA. Then, SIJ RFA will be performed under each respective imaging modality and patients will be followed to document pain improvement, functional outcomes, quality of life and medication use for 18 months. Study participants will be asked to perform a daily VAS pain diary for the first 6 weeks post-procedure in order to document post-procedure pain flare. Questionnaires will be administered either in person (if appropriate), or by email or over the phone, at 6 weeks, 12 weeks, 6 months, 12 months and 18 months post-RFA procedure.
The primary endpoint is 12 months post-procedure, however the investigators plan to follow for 18 months to determine long-term effectiveness. The investigators will perform an interim-analysis at the 6-month follow-up time period.
In further analyses, the effect of the intervention groups on secondary outcomes listed below will be evaluated:
The average time (in days) for post-procedure pain flare. Pain medication use post-procedure (% increase or decrease from baseline). Participation in physiotherapy and exercise programs (as a binary variable: yes or no) Cost effectiveness analysis comparing procedures based on the following mean data: performance time, radiation time, number of thermal lesions performed, number of RFA needle passes, volume of local anesthetic used. Cost will be compared based on mean data for fluoroscopy- and ultrasound-guided procedures, as well as the cost of monopolar vs. bipolar RFA.
Safety: this will include intra-operative complications related directly to the intervention, as well as post-operative complications and adverse events over the study duration.
Study Type
Phase
- Phase 3
Contacts and Locations
Study Locations
-
-
Alberta
-
Edmonton, Alberta, Canada, T6X 0S8
- HealthPointe
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-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Age ≥ 18
- Body Mass Index (BMI) ≤35
- Clinical presentation must be in keeping with SIJ pain based on both history (pain below L5 vertebrae, localized to the SIJ area, back pain greater than leg pain) and/or physical examination (≥2/5 SIJ provocative tests).
- Diagnosis confirmed by having >70% index pain relief with fluoroscopy-guided SIJ lateral branch blocks (with local anesthetic). Participants will require confirmatory lateral branch block under their respective image modality once randomized, requiring >70% pain relief for diagnosis, prior to completing the randomized SIJ RFA procedure.
Exclusion Criteria:
- Age <18
- Pregnant or inadequate birth control methods (to prevent the exposure of a pregnant female and/or fetus to radiation).
- Inflammatory spondyloarthropathy
- Fibromyalgia
- Radiculopathy (will require an electromyography study to rule out radiculopathy if clinically suspected in patients with primarily buttock pain)
- Discogenic low mechanical back pain
- Symptomatic spinal stenosis
- Generalized or local infection
- Coagulopathy
- Allergy to local anesthetic
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Ultrasound-Guided SIJ RFA
Utilizing short axis views, the S1, S2 and S3 foramen and tubercles would be localized and marked by a surgical skin marker. Then, the ultrasound transducer will be moved laterally to achieve a long axis view between the S1 and S2 tubercle. Local skin and subcutaneous tissue freezing would be performed with Lidocaine 1% utilizing a 30-gauge needle. An 18-gauge radiofrequency (RF) cannula will be directed utilizing an in-plane approach toward the S2 and S3 lateral branches between the S2 and S3 tubercles. A small amount of 1% lidocaine will be injected in order to provide comfort. The RF generator will be set to continuous monopolar RF ablation and the needle will be heated to 80 degrees Celsius for 90 seconds. The needle will then be repositioned proximally to obtain a slightly larger burn in a similar fashion previously described. A similar approach will be utilized for the S1 lateral branch RF ablation between the S1 and S2 tubercles. |
Radiofrequency ablation of the posterior SIJ complex under ultrasound-guidance
|
Active Comparator: Fluoroscopic-Guided SIJ RFA
An anterior-posterior approach is used to identify the S1-S3 foramen.
A 3-inch spinal needle would be used for marking.
Local tissue freezing would be accomplished with Lidocaine 1% and a 30-G needle.
An 18-G RF cannula will be positioned over the 12 o'clock position of the S1 foramen and a second cannula placed in the 2 o'clock or 10 o'clock position for the right and left respectively (4-5 mm distance between the cannula).
A small amount of 1% lidocaine will be injected for comfort.
A lateral projection is taken to ensure the needles are not placed into the foramen.
The RF generator will be set to continuous bipolar RF ablation and heated to 80 degrees Celsius for 90 seconds.
Then another 18-G RF cannula will be positioned at the 4 o'clock or 8 o'clock position (4-5 mm distance between the cannula) to achieve the second RF ablation.
The third RF ablation will be performed with the RF cannula at the 6 o'clock position.
An identical fashion is utilized at the S2 and S3 foramen.
|
Radiofrequency ablation of the posterior SIJ complex under fluoroscopic-guidance
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Pain reduction: change from baseline pain scores
Time Frame: 6 weeks to 18 months post-procedure.
|
Visual analog scale (VAS) for pain at the various follow-up time periods.
The visual analog scale is a numerical scale from 0 to 10; with 0 representing no pain and 10 representing the worst pain imaginable.
|
6 weeks to 18 months post-procedure.
|
Function and quality of life
Time Frame: 6 weeks to 18 months post-procedure.
|
Pain, Disability and Quality of Life Questionnaire- Spine (PDQQ-S)
|
6 weeks to 18 months post-procedure.
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Post-procedure pain flare
Time Frame: Daily visual analog scale (VAS) for pain for the first 6 weeks.
|
Daily visual analog scale (VAS) for pain for the first 6 weeks post-procedure to document post-procedure pain flare.
The visual analog scale is a numerical scale from 0 to 10; with 0 representing no pain and 10 representing the worst pain imaginable.
|
Daily visual analog scale (VAS) for pain for the first 6 weeks.
|
Pain medication usage
Time Frame: 6 weeks to 18 months post-procedure.
|
Percentage increase or decrease from patients baseline.
|
6 weeks to 18 months post-procedure.
|
Cost effectiveness
Time Frame: Costs compared based on procedural data upon study completion, an average of 18 months.
|
Compare study arms based on the following mean data; performance time, radiation time, number of thermal lesions performed, number of RFA needle passes, volume of local anesthetic used.
Cost will be compared based on mean data for fluoroscopy- and ultrasound-guided procedures, as well as the cost of monopolar vs. bipolar RFA
|
Costs compared based on procedural data upon study completion, an average of 18 months.
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Participation in physical therapy
Time Frame: 6 weeks to 18 months post-procedure.
|
Binary variable (yes/no) to document confounding data.
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6 weeks to 18 months post-procedure.
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Shane Hoeber, M.D., University of Alberta
Publications and helpful links
General Publications
- Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother. 2013 Jan;13(1):99-116. doi: 10.1586/ern.12.148.
- Roberts SL, Burnham RS, Ravichandiran K, Agur AM, Loh EY. Cadaveric study of sacroiliac joint innervation: implications for diagnostic blocks and radiofrequency ablation. Reg Anesth Pain Med. 2014 Nov-Dec;39(6):456-64. doi: 10.1097/AAP.0000000000000156.
- Roberts SL, Stout A, Loh EY, Swain N, Dreyfuss P, Agur AM. Anatomical Comparison of Radiofrequency Ablation Techniques for Sacroiliac Joint Pain. Pain Med. 2018 Oct 1;19(10):1924-1943. doi: 10.1093/pm/pnx329.
- Finlayson RJ, Etheridge JB, Elgueta MF, Thonnagith A, De Villiers F, Nelems B, Tran DQ. A Randomized Comparison Between Ultrasound- and Fluoroscopy-Guided Sacral Lateral Branch Blocks. Reg Anesth Pain Med. 2017 May/Jun;42(3):400-406. doi: 10.1097/AAP.0000000000000569.
- Aydin SM, Gharibo CG, Mehnert M, Stitik TP. The role of radiofrequency ablation for sacroiliac joint pain: a meta-analysis. PM R. 2010 Sep;2(9):842-51. doi: 10.1016/j.pmrj.2010.03.035.
- Dreyfuss P, Henning T, Malladi N, Goldstein B, Bogduk N. The ability of multi-site, multi-depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex. Pain Med. 2009 May-Jun;10(4):679-88. doi: 10.1111/j.1526-4637.2009.00631.x.
- Roberts SL, Burnham RS, Agur AM, Loh EY. A Cadaveric Study Evaluating the Feasibility of an Ultrasound-Guided Diagnostic Block and Radiofrequency Ablation Technique for Sacroiliac Joint Pain. Reg Anesth Pain Med. 2017 Jan/Feb;42(1):69-74. doi: 10.1097/AAP.0000000000000515.
Study record dates
Study Major Dates
Study Start (Anticipated)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Other Study ID Numbers
- Pro00102343
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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