Perspective

Cryoneurolysis may relieve knee OA pain, reduce opioid use with TKR

Research has shown mild side effects, no adverse effects with the use of cryoneurolysis in patients with OA.

ORLANDO — Use of cryoneurolysis among patients with chronic knee pain, such as due to osteoarthritis, may decrease anterior and anteromedial knee pain in the anterior femoral cutaneous nerve, according to a presenter at the Current Concepts in Joint Replacement Winter Meeting.

However, S. David Stulberg, MD, said there is limited information available about the effects of cryoneurolysis on the knee.

A randomized, prospective multicenter study published in Osteoarthritis and Cartilage showed use of cryoneurolysis in patients with mild to moderate OA produced pain relief for up to 6 months, he said.

“What they found was that pain relief anteriorly occurred at 30, 60 and, in some cases, 90 days, and in those patients who had relief as long as 120 days, they often extended to 150 days,” Stulberg said. “So, this technique is thought to provide relief that could last as long as 4 or 5 months.”

S. David Stulberg, MD
S. David Stulberg

The results of the study also showed patients had mild side effects and no adverse device effects, he said.

“[Cryoneurolysis] seems to be safe and even the discomfort that is associated with the application of the device is minimal,” Stulberg said.

Preliminary studies are now being performed using cryoneurolysis before total knee replacement, as well as after TKR in patients with painful TKR, according to Stulberg. He noted that cryoneurolysis is extra-articular, can be applied a few days before surgery and has been shown to be associated with a shorter length of stay.

“It is used in conjunction with current multimodal pain management, so it is not a substitute for what we are already doing, but it is associated with the use of less opioids in the first few weeks following surgery and significant pain reduction,” Stulberg said. – by Casey Tingle

Disclosure: Stulberg reports he receives consulting fees from Consensus Orthopedics, Stryker and Zimmer and receives royalties as a device developer from Innomed.

ORLANDO — Use of cryoneurolysis among patients with chronic knee pain, such as due to osteoarthritis, may decrease anterior and anteromedial knee pain in the anterior femoral cutaneous nerve, according to a presenter at the Current Concepts in Joint Replacement Winter Meeting.

However, S. David Stulberg, MD, said there is limited information available about the effects of cryoneurolysis on the knee.

A randomized, prospective multicenter study published in Osteoarthritis and Cartilage showed use of cryoneurolysis in patients with mild to moderate OA produced pain relief for up to 6 months, he said.

“What they found was that pain relief anteriorly occurred at 30, 60 and, in some cases, 90 days, and in those patients who had relief as long as 120 days, they often extended to 150 days,” Stulberg said. “So, this technique is thought to provide relief that could last as long as 4 or 5 months.”

S. David Stulberg, MD
S. David Stulberg

The results of the study also showed patients had mild side effects and no adverse device effects, he said.

“[Cryoneurolysis] seems to be safe and even the discomfort that is associated with the application of the device is minimal,” Stulberg said.

Preliminary studies are now being performed using cryoneurolysis before total knee replacement, as well as after TKR in patients with painful TKR, according to Stulberg. He noted that cryoneurolysis is extra-articular, can be applied a few days before surgery and has been shown to be associated with a shorter length of stay.

“It is used in conjunction with current multimodal pain management, so it is not a substitute for what we are already doing, but it is associated with the use of less opioids in the first few weeks following surgery and significant pain reduction,” Stulberg said. – by Casey Tingle

Disclosure: Stulberg reports he receives consulting fees from Consensus Orthopedics, Stryker and Zimmer and receives royalties as a device developer from Innomed.

    Perspective
    Andrea M. Trescot

    Andrea M. Trescot

    Recognition of the innervation of the knee has been slow in entering medical use. Just like we denervate the nerves going to facets for pain relief of spondylitic facet joints, denervation of the knee can provide pain relief from osteoarthritis, as well as postoperative pain relief. However, radiofrequency lesioning would be expected to have a high rate of neuroma formation because of the destruction of the architecture. Cryoneuroablation, because the myelin sheath is maintained, does not have the neuroma formation issue and is uniquely positioned as a non-opioid pain relief option.

    • Andrea M. Trescot, MD, DABIPP, FIPP, CIPS
    • Past president, American Society of Interventional Pain Physicians; Past president, Florida Society of Interventional Pain Physicians; Past president, Alaska Society of Interventional Pain Physicians; Eagle River, Alaska

    Disclosures: Trescot reports no relevant financial disclosures.

    Perspective

    As one of the principle investigators and authors of the study reviewed by Dr. Stulberg, I would like to share my perspective. Although each site was fully blinded, in some cases it was fairly obvious at our site which patients received treatment and which patients received the sham.

    The multicenter clinical results support this single-site anecdotal experience and are quite impressive with statistically significant improvements in WOMAC scores, including the pain sub-score, across the board, up to, and in some cases beyond, 90 days post-treatment. While this study demonstrated efficacy with the absence of significant morbidity in a knee OA model, the question remains whether this treatment option will be cost-effective and whether repeat treatments will be as efficacious. Although I am not sure where it fits into the treatment of knee OA, further study of cryoneurolysis in a perioperative knee arthroplasty model is clearly warranted. Any non-pharmaceutical intervention, especially one with seemingly little morbidity, is attractive, and could further enhance the state of the art in multimodal pathways for perioperative pain management in TKR.

    • David F. Scott, MD
    • Orthopaedic Specialty Clinic of Spokane; Spokane, Washington

    Disclosures: Scott reports he receives research support from Myoscience, which manufactures a cryoneurolysis device.