Bipolar Pulsed Radiofrequency for Pain: Clinical Applications, Mechanistic Rationale and Technical Considerations - A Narrative Review

Pulsed radiofrequency (PRF) has gained recognition as a minimally neurodestructive modality for the management of diverse chronic pain syndromes. A notable advancement of this technique is bipolar pulsed radiofrequency (BPRF), which employs two active electrodes to generate a more concentrated and potentially more efficacious electric field compared to its monopolar counterpart. This review presents a comprehensive evaluation of BPRF as an interventional pain management technique. The biophysical distinctions between BPRF and monopolar PRF are delineated, with particular emphasis on the generation of denser and spatially broader electric fields. The proposed mechanisms of action encompassing neuromodulatory effects, anti-inflammatory activity mediated by cytokine suppression, and ultrastructural alterations in neural tissue are constructed from both preclinical and clinical evidence. An in-depth analysis of clinical applications indicates that BPRF demonstrates superior or at least comparable efficacy in the treatment of chronic pain conditions, including lumbosacral and cervical radiculopathy, knee osteoarthritis, and postherpetic neuralgia, especially in patients who are refractory to monopolar RF or conservative therapies. Evidence regarding procedural parameters, including voltage, duration, and inter-electrode distance, highlighting the trend towards high-voltage, extended-duration protocols are consolidated. The safety profile of BPRF, including its application in patients with cardiac implantable electronic devices, is critically evaluated. Finally, limitations in the current literature are addressed and future research directions, underscoring the need for standardized treatment protocols and further exploration of potential synergistic applications with orthobiologic therapies are proposed. Collectively, this review seeks to provide pain physicians with a rigorous, evidence-based framework to inform clinical practice and stimulate ongoing investigation in this evolving field.