R E V I E W A R T I C L E

Genicular nerve ablation: a systematic review of

procedure outcomes for chronic knee pain
Lauren Zeitlinger, DO, Judith Kopinski, MD and Thomas DiPasquale, DO

Department of Orthopedics, WellSpan York Hospital, York, PA

number of individuals over the age of 65 from 35 million in

ABSTRACT 2000 to 49.2 million by 2016.2 Consequently, osteoarthritis
Background: of the hip and knee has become one of the leading causes of
Chronic pain caused by knee osteoarthritis is becoming more global disability.3 To raise further concern, the incidence of
common among the elderly. Furthermore, patients who would medical comorbidities increases as the population ages,
otherwise benefit from total joint arthroplasty are not candi-
which can complicate operative management of osteoarthri-
dates for surgery due to increasingly high rates of obesity and
diabetes. Genicular nerve ablation has become an attractive
tis. Most notably, over 40% of individuals over the age of 60
alternative to arthroplasty in these patients. This systematic are obese, and 26.3 million individuals over the age of 45
review sought to assess the effectiveness and safety of genicular have diabetes.4,5 For individuals with a body mass index
nerve ablation. (BMI) greater than 35, there is an increased risk of superficial
and deep infections, implant removal, and revision for
Methods: polyethylene wear and aseptic loosening.6 Jämsen et al.7
A literature search of PubMed, Medline, clinicaltrials.gov, and reported an increase in infection rates by 4.29% in individ-
Google Scholar was conducted for studies performing genicular uals with morbid obesity. Furthermore, diabetes (independ-
nerve ablation with radiofrequency. Clinical and patient-centric ent of obesity) more than doubled the risk of total joint
outcomes were obtained.
infection. Thus, the risks associated with total knee arthro-
Results: plasty for individuals with an elevated BMI and poor blood
Eleven studies and 194 knees were included in this analysis. Our sugar control drives the need for an effective, nonoperative
review revealed that visual analog pain scores decreased from an strategy to manage symptomatic OA.
average score of 8/10 to 1.9/10, 2.3/10, 2/10, and 4/10 at 3, 6, While oral nonsteroidal antiinflammatory agents (NSAID),
and 12 mo after genicular ablation, respectively. Additionally, corticosteroid injections and debatably, viscosupplementa-
Oxford Knee Scores and scores on the Western Ontario and tion are effective modalities for symptomatic relief, they are
McMaster Universities Arthritis Index showed improvements that often nonsustainable alternatives. NSAIDs are frequently
were sustained at least up to 12 wk and 1 yr, respectively. There contraindicated in geriatric individuals, (especially those
were very few procedural complications.
with congestive heart failure and kidney disease) and are
Conclusions: associated with gastrointestinal bleeding.8 Intraarticular
Genicular nerve ablation with radiofrequency has demonstrated corticosteroids are only indicated for 3-month intervals and
favorable outcomes with low complication rates. can be associated with increased systemic blood sugars, fat
necrosis, sepsis, and long-term deterioration of articular
Key Words cartilage.9,10 Thus, the nonoperative management of
knee pain, genicular nerve ablation, osteoarthritis symptomatic knee osteoarthritis is preferable, and imperative
to global survivorship.
In light of the aforementioned concerns, genicular nerve
ablation has emerged as a treatment option for symptomatic
INTRODUCTION management of chronic knee pain. Nerve ablation has been
used as early as 1931 for trigeminal neuralgia. Since that

C
hronic pain due to knee osteoarthritis (OA) is a
mounting problem affecting roughly 10% of men time, its use has evolved for treatment of chronic pain.11 The
and 13% of women over the age of 60.1 The first of genicular nerves have been identified as the sensory
the “Baby Boomers” began turning 65 in 2011, increasing the innervation of the knee, and are relatively consistent in
anatomic orientation.12,13 According to a study by Franco
et al.,12 positioning a 5.5-mm radiofrequency probe that
Financial Disclosure: The authors report no conflicts of produces a 12-mm lesion at 60% depth of the femoral and
interest.
tibial shafts is capable of 100% disruption of vastus medialis
Correspondence to Lauren Zeitlinger, DO, WellSpan York Hospital,
Department of Orthopedics, 1001 S. George St, York, PA 17403 and saphenous nerve branches and 86% of the vastus
Tel: (+305) 968-2878; fax: (+717) 851-3142; lateralis contributions of the genicular nerves.
e-mail: [email protected]. It is hypothesized that genicular nerve ablation is an
1941-7551 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. effective, low-risk strategy to manage symptomatic knee

Volume 30  Number 5  September/October 2019 Current Orthopaedic Practice 477

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478 | www.c-orthopaedicpractice.com Volume 30  Number 5  September/October 2019

pain, reduce narcotic demands, and improve function. This summarized to provide consolidated information about the
systematic review seeks to evaluate treatment outcomes in effectiveness and safety of genicular nerve ablation. Incon-
patients who have undergone genicular nerve ablation. sistences between study outcome measures, protocols, and
follow-up did not allow for statistical comparison of outcomes
between studies; however, descriptive statistics were reported
MATERIALS AND METHODS as applicable.
An extensive literature search was performed to identify all
English-language publications regarding genicular nerve
ablations, including case reports, case series, retrospective RESULTS
reviews, and prospective trials. PubMed, Medline, clinical- Eleven studies qualified for inclusion in this analysis.
trials.gov, and Google Scholar were searched using “genicular Included papers were published between 2011 and 2017.
nerve”, “ablation”, “osteoarthritis”, and “knee pain” as key Each paper was characterized by study type. The majority
words. Only papers that specifically utilized genicular nerve were case series,15–19 three studies were observational,20–22
ablation with radiofrequency were included. Papers were not two studies were randomized controlled trials,13,23 and one
excluded based on year of publication. was a prospective “pre-post” study.24 Each study was scored
Through this search, 11 studies were identified for utilizing the appropriate NHLBI scoring tool. Tables 1–4
inclusion. The papers were scored using the criteria devised provide the details of the scoring criteria addressed for each
by the National Heart Lung and Blood Institute (NHLBI) in study type, and the resulting score for each individual study.
the Quality Assessments for controlled intervention studies, Our analysis included a total of 194 knees. The patient
case series, before-and-after studies, and observational/cross- demographic was mostly female. The total number of study
sectional studies.14 The type of study, number of participants, participants in each study ranged from case reports of one
and participants who completed the study (if appropriate) individual to 76 participants (some of whom were random-
were recorded. Additionally, patient demographics were ized to a nongenicular ablation control group). For random-
recorded, including age, body mass index (BMI), gender, ized trials, only patients who were allocated to the genicular
and duration of pain. Study variables that were collected (if nerve ablation treatment group were included in this
available) were initial pain scores on a 0-10 or 0-100 analysis. The average BMI was 29.9. The average age of
(converted to 0-10 scale), pain scales on follow-up, mean included patients was 74 yr.
reduction in medication quantification scale III, Knee Injury Upon review of each study, treatment protocols showed
and Osteoarthritis Outcome score, and Western Ontario and substantial variability with respect to criteria necessitating
McMaster Universities Arthritis Index (WOMAC) scores. Last, genicular nerve ablation, and the protocols for the genicular
any additional study remarks, complications, or adverse nerve ablation procedure itself. Criteria for ablation ranged
reactions were recorded. The data were organized and from a response to diagnostic lidocaine nerve block from 50%

TABLE 1. NHLBI quality assessment of controlled intervention studies

Criteria Yes No Other (CD, NR, NA)*
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
2. Was the method of randomization adequate (i.e. use of a randomly generated assignment)?
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
4. Were study participants and providers blinded to treatment group assignment?
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g.
demographics, risk factors, co-morbid conditions)?
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to
treatment?
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or
lower?
9. Was there high adherence to the intervention protocols for each treatment group?
10. Were other interventions avoided or similar in the groups (e.g. similar background treatments)?
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all
study participants?
12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in
the main outcome between groups with at least 80% power?
13. Were outcomes reported or subgroups analyzed prespecified (i.e. identified before analyses were
conducted)?
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e.,
did they use an intention-to-treat analysis?
Manuscript 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Score
Choi13 X X X X X X X X X – X X X X 13
Davis23 X X – – – X X X X X X X X X 11
Upper table shows study evaluation criteria. Lower table shows scores for individual studies.
*CD, cannot determine; NA, not applicable; NR, not reported.
NHLBI, National Heart Lung and Blood Institute.

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Current Orthopaedic Practice www.c-orthopaedicpractice.com | 479

TABLE 2. NHLBI quality assessment for before-after (pre-post) studies with no control group
Criteria Yes No Other (CD, NR, NA)*
1. Was the study question or objective clearly stated?
2. Were eligibility/selection criteria for the study population prespecified and clearly described?
3. Were the participants in the study representative of those who would be eligible for the test/service/
intervention in the general or clinical population of interest?
4. Were all eligible participants that met the prespecified entry criteria enrolled?
5. Was the sample large enough to provide confidence in the findings?
6. Was the test/service/intervention clearly described and delivered consistently across the study
population?
7. Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently
across all study participants?
8. Were the people assessing the outcomes blinded to the participants’ exposures/interventions?
9. Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the
analysis?
10. Did the statistical methods examine changes in outcome measures from before to after the
intervention? Were statistical tests done that provided P values for the pre-to-post changes?
11. Were outcome measures of interest taken multiple times before the intervention and multiple times
after the intervention (i.e., did they use an interrupted time-series design)?
12. If the intervention was conducted at a group level (e.g. a whole hospital, a community, etc.) did the
statistical analysis taken into account the use of individual-level data to determine effects at the
group level?
Manuscript 1 2 3 4 5 6 7 8 9 10 11 12 Score
Kesikburun et al.24 X X X X – X X – – X X X 9
Upper table shows evaluation criteria. Lower table shows scores for individual studies.
*CD, cannot determine; NA, not applicable; NR, not reported.
NHLBI, National Heart Lung and Blood Institute.

to 80% relief. Subsequently, the ablation procedure differed in ablation for 2 min or longer in duration. The most common
both duration of the radiofrequency administered and the temperature settings used for radiofrequency ablation (RFA) were
temperature of the probe. Five of the 11 papers performed the 60 degrees C and 80 degrees C.

TABLE 3. NHLBI assessment tool for observational cohort and cross-sectional studies
Criteria Yes No Other (CD, NR, NA)*
1. Was the research question or objective in this paper clearly stated?
2. Was the study population clearly specified and defined?
3. Was the participation rate of eligible persons at least 50%?
4. Were all the subjects selected or recruited from the same or similar populations (including the same
time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied
uniformly to all participants?
5. Was a sample size justification, power description, or variance and effect estimates provided?
6. For the analysis in this paper, were the exposure(s) of interest measured prior to the outcome(s)
being measured?
7. Was the timeframe sufficient so that one could reasonably expect to see an association between
exposure and outcome if it existed?
8. For exposures that can vary in amount or level, did the study examine different levels of the exposure
as related to the outcome (e.g., categories of exposure, or exposure measured as continuous
variable)?
9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and
implemented consistently across all study participants?
10. Was the exposure(s) assessed more than once over time?
11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented
consistently across all study participants?
12. Were the outcome assessors blinded to the exposure status of participants?
13. Was loss to follow-up after baseline 20% or less?
14. Were key potential confounding variables measured and adjusted statistically for their impact on
the relationship between exposure(s) and outcome(s)?
Manuscript 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Score
McCormick20 X X X X – X X – X – X – X X 10
Iannaccone21 X X X X – X X – X X X – – – 9
Santana Pineda22 X X – X – X X – X X X – X – 9
Upper table shows evaluation criteria. Lower table shows scores for individual studies.
*CD, cannot determine; NA, not applicable; NR, not reported.
NHLBI, National Heart Lung and Blood Institute.

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480 | www.c-orthopaedicpractice.com Volume 30  Number 5  September/October 2019

TABLE 4. NHLBI assessment tool for case series studies

Criteria Yes No Other (CD, NR, NA)*
1. Was the study question or objective clearly stated?
2. Was the study population clearly and fully described. Including a case definition?
3. Were the cases consecutive?
4. Were the subjects comparable?
5. Was the intervention clearly described?
6. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all
study participants?
7. Was the length of follow-up adequate?
8. Were the statistical methods well-described?
9. Were the results well-described?
Manuscript 1 2 3 4 5 6 7 8 9 Score
Protzman15 X X – – X X – – X 5
Reddy16 X X – X X X X – X 7
Wong17 X X – – X X X – X 6
Bellini18 X X X X X X X X X 9
Rojhani19 X X – – X – X – X 5
Upper table shows evaluation criteria. Lower table shows scores for individual studies.
*CD, cannot determine; NA, not applicable; NR, not reported.
NHLBI, National Heart Lung and Blood Institute.

As seen in Tables 5 and 6, the average initial starting visual techniques, average VAS showed improvement regardless of
analog pain score (VAS) was 8/10. The most commonly reported the protocol used. Additionally, for studies that reported
time frame for repeat scores was at 1, 3, and 6 mo, which WOMAC scores, there is a sustained improvement in func-
revealed an average VAS decrease to 1.9, 2.3, and 2, respectively. tional scores regardless of the protocol used. This implies that
Two studies obtained Oxford Knee Scores that revealed clinically genicular nerve ablation may not just improve pain scores
meaningful improvements (Table 7) (an improvement of 5 but may improve an individual’s quality of life and function
points or greater) at 1 mo and 3 mo, and up to 6 mo in one when his/her limitations are related to knee pain.
study. Four studies reported Western Ontario and McMaster We noted variability between RFA treatment protocols. At
Universities Arthritis Index (WOMAC) scores, which showed present, there are no randomized studies that assess the
improvements that were sustained out to 12 mo. The average efficacy of different criteria for RFA or the technique for RFA.
initial WOMAC score was 72.5, which decreased to 46, 20, 30, The criteria to move forward from a genicular nerve block with
and 30 at the 1-month, 3-months, 6-month, and 12-month time lidocaine ranged from 50% to 80% relief to undergo RFA.
frames, respectively (Table 7). Of note, however, was that follow- Additionally, there was wide variety in the temperature and
up duration was not uniform across studies. duration of ablation. Although there is insufficient evidence to
Table 8 annotates pertinent patient-centric outcomes from assess, it appears that the time duration of ablation may
the reviewed studies, including patient perceptions, overall impact VAS pain scores. Because of the variation in temper-
patient outcomes, and complications. Interestingly, most ature, time, and method of ablation, statistical analyses were
studies reported that the majority of patients treated with not performed to compare outcomes of genicular nerve
genicular nerve ablation had favorable outcomes. One study ablation among studies.
reported that 74% of patients would recommend this procedure Additionally, the effect of nerve ablation on narcotic use is
to a friend or family member, one study found that 84% of inconclusive based on this review, as two papers identified a
patients reported a good or very good outcome at 6 mo, and reduction in narcotic consumption, while one reported
another reported 68% of individuals with at least 50% overall improved Oxford Knee Scores without associated significant
improvement in VAS. In the case report by Wong et al.,17 the change in opioid use. There is insufficient evidence to infer an
patient was able to walk to the store without limitations and no effect on narcotic use; however, randomized controlled studies
longer suffered functional limitations from knee pain by 6 mo in the future may better assess this outcome parameter.
post-procedure. The most commonly reported adverse reactions The main limitations of assessing outcomes related to
were intraprocedure discomfort and transient numbness. genicular nerve ablation are the lack of standardized protocol
However, these symptoms eventually resolved. No other long- for the procedure and the variation in study type, con-
term adverse complications were reported in any of the studies. sequently making data pooling and interpretation difficult.
However, because genicular nerve ablation for the treatment
of chronic knee pain in patients with osteoarthritis is
DISCUSSION controversial, we believe we are able to draw the most
Overall, 11 studies were identified for inclusion in our accurate conclusions possible given the scarcity of existing
systematic review of genicular nerve ablation. The results of information. Authors that required an 80% improvement in
this review indicate that patient outcomes were advanta- symptoms after a genicular nerve block appear to have
geous with relatively low complication rates. Although the improved sustainability of outcomes compared to 50%
included RFA procedures were performed with differing threshold for ablation; however, there was still meaningful

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 Current Orthopaedic Practice
TABLE 5. Study characteristics
#
Included Native/ BMI Age
Author Study Type Year Published # Participants Knees Arthroplasty (avg) (avg) Gender

A Basic demographic and study data from reviewed studies

1 Protzman15 Case report 2014 1 1 TKA – 48 100%M
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2 McCormick20 Cross sectional survey 2017 33 44 Native 31 66 30%M

70%F
3 Iannaccone21 Retrospective review + 2017 23 23 Native 28.5 72 42% M
Prospective follow- 58% F
up
4 Kesikburun24 Prospective 2016 28 9 Native 31 67 18%M
82%F
5 Reddy16 Case series 2016 4 6 Native 35 64 66%M
33%F
6 Wong17 Case report 2016 1 1 Native – 88 100% F
7 Bellini18 Case series 2015 8 8 3 TKA: 5 – 72 25%M
Native 75%F
8 Santana Prospective 2017 25 25 Native 29 75 13%M
Pineda22 87%F
9 Rojhani19 Case report 2015 1 2 Native 34 81 100%F
10 Choi13 Randomized double 2017 38 randomized 17 Native 26 67 11%M
blind 89%F
11 Davis23 Randomized 2011 76 randomized trial vs. 58 Native 30.6 63 21%M
controlled intra-articular steroid 79%F
B Basic study design from reviewed studies
Author Study type Criteria for ablation (lidocaine),
temperature and duration of
ablation
1 Protzman15 Case report Diagnostic lidocaine; 80C×90 sec
2 McCormick20 Cross sectional survey Diagnostic lidocaine, 60C×2.5 min
3 Iannaccone21 Retrospective review + Diagnostic lidocaine (80% relief),
Prospective follow- 60C×120 sec
up
4 Kesikburun24 Prospective Diagnostic lidocaine (50% relief),

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42C×120s×2 cycles
5 Reddy16 Case series Diagnostic lidocaine (80% relief),
60C×2.5min
17
6 Wong Case report Diagnostic lidocaine (80% relief)
80C×90 sec
7 Bellini18 Case series Not reported
8 Santana Prospective 80C×90 sec
Pineda22
9 Rojhani19 Case report 60C×150 sec
10 Choi13 Randomized double 70C×90 sec
blind
11 Davis23 Randomized Diagnostic lidocaine (50% relief),
controlled 60C×150 sec
Criteria for ablation based on response to lidocaine test if reported and subsequent method radiofrequency ablation (temperature and duration of ablation).
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TABLE 6. Reported visual analog pain scores (VAS) on a scale of 1-10

VAS pain scores Pain score: Pain score: Pain scores: Pain scores: Pain score:
Author (Initial) 1 wk 1 mo 3 mo 6 mo 12 mo
1 Protzman15 9 – – 0 – –
2 McCormick20 7.5 – – – 4.2 –
3 Iannaccone21 7 – – 3.7 3.3 –
4 Kesikburun24 6.3 3.9 3.9 4.7 – –
5 Reddy16 5 – – 0.85 0.55 –
6 Wong17 8 – 0 – 0 –
7 Bellini18 8 – – 2.3 2.1 2.2
8 Santana 8.5 – 2.5 – 3.9 5.8
Pineda22
9 Rojhani19 8 – – 0 – –
10 Choi13 7.8 3.7 3.3 4.2 – –
11 Davis23 7.3 – 3 2.8 2.5 –
Pain scores: Pain score: Pain score: Pain scores: Pain scores: Pain score:
initial 1 wk 1 mo 3 mo 6 mo 12 mo
8.01 3.7 1.9 2.3 2 4
Dashes indicating no reported VAS score for that specific time point interval. Lower table with average pain scores averaged only from the studies that reported on that
time interval.

TABLE 7. Reported WOMAC and Oxford Knee scores and averages based on reported data
Author Initial 1 mo 3 mo 6 mo 12 mo
WOMAC scores
4 Kesikburun24 65 53 14.8 – –
7 Bellini18 88 – 22 21 20
8 Santana Pineda22 65 39 – 40 49
9 Rojhani19 72 – 26 – –
Average scores 75 46 24 30.5 34.5
Oxford knee score
Author Initial 1 wk 1 mo 3 mo 6 mo
10 Choi13 39 23 25 27 –
11 Davis23 76 – 67 65 58
WOMAC scores averaged below showing improvements that appear to be sustained at 12 mo. Lower table with Oxford Knee Scores, not averaged due to limited data
points but also showing a trend towards improvement in symptoms. WOMAC, Western Ontario and mcMaster Universities Arthritis Index.

TABLE 8. Long term outcomes/reported success and complications after the procedure, impressions from patients
and overall remarks from reported studies
Author Long term success? Complications Notes
1 Protzman15 1 patient with 100% relief at 3 mo No reported events -
2 McCormick20 36% with > 50% relief 19% with 100% No reported events Pain for <2 yr associated with clinical success; BMI age and gender
relief on numeric rating scale nonpredictive
3 Iannaccone21 At 3 mo, 61% with 67% relief, at 6 mo 1 patient with transient 74% said they would recommend RFA to others
95% with 64% relief numbness. No weakness,
neuralgia, paresthesias.
4 Kesikburun24 67% of patients with > 50% relief at No adverse event or 68% with at least 50% improvement on VAS
3 mo complication
16
5 Reddy All 4 patients with 80-100% relief at No complications -
6 and 12 mo
17
6 Wong 100% pain free at 6 mo No complications -
7 Bellini18 100% patients with > 50% pain relief at No Complications Genicular Nerve ablation improved pain and restored function in
12 mo 2/3 patients with painful TKA.
8 Santana 88% of patients with > 50% relief at Intra-procedure touch pain; no Patient satisfaction scores: 2/25 said poor, 1/25 said average, 5/25
Pineda22 1 mo 64% with > 50% relief at 6 mo adverse events at follow up said good, 16/25 said very good outcome at 6 mo
32% with > 50% relief at 12 mo
9 Rojhani19 100% relief at 6 wk and 3 mo No reported events -
10 Choi13 59% patients with > 50% relief at 12 Temporary periosteum touch Patient satisfaction much higher at 1 wk, 4 wk and 12 wk compared
wk verses 0% relief in the control pain, gone at follow up; no to no-ablation control group. Improvements became statistically
group adverse events at follow up significant at 4 and 12 wk for VAS and OKS
11 Davis23 74% of patients with > 50% relief at No reported events OKS were significantly improved compared to intra-articular
6 mo verses only 16% of patients in injection at 1/3/6 mo. No significant change in opioid use
the control group

BMI, body mass index; OKS, Oxford Knee Score; RFA, radiofrequency ablation; TKA, total knee arthroplasty; VAS, visual analog scale.

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Current Orthopaedic Practice www.c-orthopaedicpractice.com | 483

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