Before radiofrequency ablation, patients hear about the nerve that gets burned. They are rarely told that the same nerve runs the muscle that holds the spine steady. Francisco M. Torres, an interventional physiatrist who treats spine pain, is not against the procedure. He is against doing it to a 25-year-old with 40 years of back ahead and no idea what was traded away.

⏱️ Chapters:
0:00 Introduction
0:33 A normal MRI does not mean nothing is wrong
1:24 The insurance rule that rerouted his patients
1:58 Why his patients started coming back sooner
2:52 The evidence comes from older spines, not young ones
3:29 Why telling a patient to do core does not work
5:21 What radiofrequency ablation actually burns
6:04 Atrophy and fat where a stabilizer used to be
7:19 Pain with extension and rotation is the tell
9:02 Why insurers steer patients toward ablation
10:41 The snowball effect he sees decades later
13:50 The line he wants added to the consent form
16:08 Why he told his own son not to go down that path
16:52 Questions to ask before you agree to ablation
18:45 Take home messages

About this episode:
Francisco M. Torres is an interventional physiatrist who spent years treating young adults with non-radiating back pain, benign imaging, and a clear pattern on exam: pain with extension and rotation, pointing to the facet joint. For most of his career he injected the joint, sent them to physical therapy, and did not hear from them again for years. That changed when insurers began requiring a medial branch block before approving a facet injection, which routed those patients to physicians who perform ablation, a procedure that is reimbursed well and that permanently cauterizes the medial branch of the dorsal ramus. Torres argues that the same nerve supplies the multifidus, the most powerful stabilizer of the lumbar spine, so pain relief comes with denervation of the muscle the spine depends on. He points to a 2009 study showing atrophy and fatty replacement of the multifidus two years after unilateral ablation, while acknowledging that the study could not correlate those changes with pain or disability and that no long-term longitudinal data exist. His position is that the evidence base sits in patients over 50 who already have degeneration, and does not transfer to a 25-year-old with four decades of spine ahead. He also argues that generic core exercise does not rehabilitate the multifidus, that surface EMG biofeedback is needed to know the muscle is even firing, and that the consent form should state plainly that a muscle is being denervated. The episode ends on his message to clinicians: do not let a payer algorithm dictate the treatment, and if you go that route, tell the patient exactly what is being traded.

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