PONOS · RADIOFREQUENCY PROCEDURES

Sacroiliac radiofrequency denervation

Targeted treatment of the nerve branches transmitting pain from the posterior sacroiliac complex. The decision is based on diagnosis and the response to selection blocks.

Bipolar thermal radiofrequency · Fluoroscopic guidance · Individual care

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What sacroiliac denervation treats

Thermal radiofrequency produces controlled lesions in small nerve branches involved in transmitting pain. For sacroiliac treatment, the main target is the nerve supply to the posterior complex: the joint, capsule and surrounding ligaments.

Common targets include the S1–S3 sacral lateral branches and the L5 dorsal ramus, with adjustments for anatomy and technique. The procedure does not destroy the joint or target the sciatic nerve.

It may reduce pain carried by the treated nerves, but does not correct pelvic instability or deformity and does not replace treatment of an inflammatory disease.

Sacroiliac pain: symptoms and diagnostic pathway

When it may be appropriate

Denervation may be considered for persistent sacroiliac pain restricting daily life when clinical assessment and appropriate tests support involvement of the posterior complex and conservative treatment has not provided sufficient control.

Short-lived relief after an injection may prompt reassessment, but does not automatically establish an indication for radiofrequency. Lumbar, hip, radicular and rheumatological causes also need consideration.

The decision depends on the pain mechanism, functional goals and the individual’s health. Sex alone neither determines the indication nor predicts a success rate.

Joint injections and lateral branch blocks have different roles

A sacroiliac injection can relieve pain and help assess the contribution of the joint or surrounding tissues, depending on the injection site and medication spread.

A prognostic lateral branch block more directly assesses the nerves being considered for posterior denervation. Temporary relief after local anaesthetic, accompanied by improvement in previously painful activities, helps estimate the likely value of treatment.

Pain and function are compared before and after the block using reproducible activities. Protocols differ in the number of blocks and response thresholds. Meaningful relief is interpreted in its clinical context; a single number is not a guarantee.

Ultrasound-guided sacroiliac injections Sacroiliac diagnostic block (Italian)

The PONOS procedure: bipolar thermal radiofrequency

At PONOS, sacroiliac denervation is performed in theatre under fluoroscopic guidance. The technique generally involves 4–6 bipolar thermal lesions along the course of the nerve branches supplying the sacroiliac complex, combined with a monopolar lesion of the L5 dorsal ramus in the L5–S1 region. The number and arrangement of lesions are adapted to the anatomy and target coverage required.

Fluoroscopy checks bony landmarks and needle position using appropriate views. Sterile preparation, local anaesthesia, monitoring and the safety checks required by the technique form part of the procedure. Any sedation is tailored to the individual.

Bipolar radiofrequency creates a lesion between appropriately placed electrodes. It differs from cooled radiofrequency; these techniques have distinct parameters and evidence that should not automatically be treated as interchangeable.

Dr Evangelos Panagiotakos performing a procedure with radiological guidance and a fluoroscopy monitor — Dr Evangelos Panagiotakos during a procedure under radiological guidance. The photograph illustrates the clinical setting and equipment, rather than a specific sacroiliac denervation. Select to enlarge.

Thermal and pulsed radiofrequency

Thermal, or ablative, radiofrequency is used to selectively interrupt pain transmission in the treated branches. Pulsed radiofrequency aims at neuromodulation and does not produce the same type of thermal lesion.

For denervation of the posterior sacroiliac complex, the strongest evidence concerns anatomically appropriate thermal techniques. Pulsed treatment should not be presented as an equivalent replacement simply because it is non-ablative: the choice should follow the clinical indication.

The appropriate technique, with clinical responsibility

Providing care means making decisions and accepting responsibility for them. Expected benefits, procedural risks and the consequences of leaving pain untreated are considered together.

PONOS avoids unnecessary investigations, medication interruptions and delays. When a procedure is indicated, its aims, alternatives and limitations are clearly explained so that the patient can participate in the decision.

What results can be expected?

In selected patients, radiofrequency can reduce pain and improve function for several months. Results vary with diagnosis, selection, technique and other sources of pain. Relief is not necessarily immediate and may develop over the following weeks.

The 2025 consensus guidelines support anatomically valid ablation techniques for posterior sacroiliac complex pain. A 2024 multicentre trial involving 210 patients found better outcomes with cooled radiofrequency than standard medical management at three months. However, that study concerns a specific technique and does not establish a success rate for the PONOS bipolar approach.

Benefit is neither guaranteed nor necessarily permanent. If pain returns after useful relief, its source and the suitability of repeat treatment are reassessed. If there is no benefit, the pathway is reconsidered rather than automatically repeating the procedure.

Safety and effectiveness are distinct

A correctly performed procedure may have a favourable safety profile without necessarily providing sufficient relief. Reducing pain requires a coherent diagnosis, appropriate selection and adequate coverage of the target nerves.

In Dr Evangelos Panagiotakos’s teaching experience, sacroiliac denervation is among the introductory procedures taught in interventional pelvic pain care. This does not mean it can be performed without training: anatomical knowledge, radiological guidance and supervision remain essential.

Safety and possible adverse effects

The treatment targets branches involved in pain sensation, but nearby neural structures make correct positioning and safety checks essential. The risk of neurological injury cannot be described as zero.

Temporary local soreness, bruising, altered sensation or neuritis may occur. Less common complications include infection, bleeding, burns or nerve injury. Risks are discussed in relation to the technique and individual health.

After treatment, fever, rapidly worsening pain, new weakness or bladder or bowel disturbance require prompt assessment; significant neurological symptoms call for urgent medical evaluation.

Preparation and medication management

Bring a medication list, available reports and the results of diagnostic blocks. Report allergies, infection, pregnancy, clotting problems and implanted devices such as pacemakers or neurostimulators.

Anticoagulants and antiplatelet medication are managed individually. Radiofrequency encompasses procedures with different risk profiles. Interruption is not automatic, but advice for joint injections should not be indiscriminately applied to every denervation procedure.

If a change is required, the clinician determines when to stop and restart medication, taking thrombotic risk into account and involving the prescriber when appropriate. Do not change medication yourself. Any investigations, fasting and accompaniment requirements are specified according to the procedure and planned sedation.

Recovery, rehabilitation and combined treatments

Discharge and return to activities follow an individual assessment. Follow-up considers pain, walking, sitting tolerance, sleep and everyday function. Pain relief should support a gradual recovery of movement and activity.

If lumbar facet pain coexists, combined treatment may be considered, including at the same session when appropriate. Facet treatment requires its own indication and relevant tests; nearby joints are not treated automatically.

Surgical stabilisation is a distinct option for selected cases, particularly when appropriate mechanical problems are present. Radiofrequency may form part of a pathway before surgery, but is not a universally mandatory step and does not replace surgical assessment when needed.

Frequently asked questions

Does denervation destroy the joint?

No. It acts on selected nerve branches, not on bone or joint surfaces.

Is it the same as an injection?

No. An injection delivers medication; thermal radiofrequency creates controlled lesions in target nerve branches. Their indications and preparation differ.

Is a positive joint injection enough to decide?

It provides useful evidence, but posterior radiofrequency may require prognostic lateral branch blocks alongside clinical assessment.

Does it work better in men?

Different results should not be promised on the basis of sex alone. Clinical observations must be distinguished from validated comparative evidence.