Background The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.
Methods After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4–5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.
Results 17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).
Conclusions Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
- interventional pain management
- radiofrequency ablation
- chronic pain: back pain
- pain medicine
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Contributors SPC’s institution has received research funding from Avanos, and in the past 3 years he has served as a consultant for Abbott and Medtronic. SPC: concept design, committee chair, developed initial list of questions and outline, participated in writing and editing manuscript. Other authors: assisted with refinement of questions, participated in writing and editing manuscript.
Funding This work was supported in part by the Uniformed Services University, Department of Physical Medicine & Rehabilitation, Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) (HU00011920011). The American Society of Regional Anesthesia and Pain Medicine contracted with Sarah Staples, MA, ELS, for assistance with manuscript preparation. Dr Cohen received funding for his role from MIRROR, Uniformed Services University of the Health Sciences, US Department of Defense.
Disclaimer Since the document has neither been presented to nor approved by either the ASA Board of Directors or House of Delegates, it is not an official or approved statement or policy of the Society. Variances from the recommendations contained in the document may be acceptable based on the judgment of the responsible anesthesiologist. The views expressed do not reflect the official policy or position of the Department of Defense, the Department of Veterans Affairs or the US Government.
Competing interests TD: consultant for Abbott, Axonics, Nalu, Saluda, Medtronic, Vertiflex (Boston Scientific), Nevro, Vertos, Vertiflex, SPR. Funded research: Vertiflex, Vertos, Abbott, Saluda, SPR. Minor Equity: Bioness, Vertiflex, Vertos, Saluda, SPR. SPC: funded research: Avanos Consultant: Abbott, Medtronic, Boston Scientific David Provenzano: consultant for Avanos, Boston Scientific, Medtronic, Nevro, Esteve and Salix Research support: Medtronic, Nevro, Stimgenics and Abbott.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.