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Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group
  1. Steven P Cohen1,
  2. Arun Bhaskar2,
  3. Anuj Bhatia3,
  4. Asokumar Buvanendran4,
  5. Tim Deer5,
  6. Shuchita Garg6,
  7. W Michael Hooten7,
  8. Robert W Hurley8,
  9. David J Kennedy9,
  10. Brian C McLean10,
  11. Jee Youn Moon11,
  12. Samer Narouze12,
  13. Sanjog Pangarkar13,
  14. David Anthony Provenzano14,
  15. Richard Rauck15,
  16. B Todd Sitzman16,
  17. Matthew Smuck17,
  18. Jan van Zundert18,19,
  19. Kevin Vorenkamp20,
  20. Mark S Wallace21 and
  21. Zirong Zhao22
  1. 1 Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  2. 2 Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic Hayes Satellite Unit, Hayes, UK
  3. 3 Anesthesia and Pain Management, University of Toronto and University Health Network—Toronto Western Hospital, Toronto, Ontario, Canada
  4. 4 Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
  5. 5 Spine & Nerve Centers, Charleston, West Virginia, USA
  6. 6 Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
  7. 7 Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
  8. 8 Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  9. 9 Physical Medicine & Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
  10. 10 Anesthesiology, Tripler Army Medical Center, Tripler Army Medical Center, Hawaii, USA
  11. 11 Dept of Anesthesiology, Seoul National University College of Medicine, Seoul, The Republic of Korea
  12. 12 Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
  13. 13 Dept of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
  14. 14 Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
  15. 15 Carolinas Pain Institute, Winston Salem, North Carolina, USA
  16. 16 Advanced Pain Therapy, Hattiesburg, Mississippi, USA
  17. 17 Dept.of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford Medicine, Stanford, California, USA
  18. 18 Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Lanaken, Belgium
  19. 19 Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
  20. 20 Anesthesiology, Duke Medicine, Durham, North Carolina, USA
  21. 21 Anesthesiology, UCSD Medical Center—Thornton Hospital, San Diego, California, USA
  22. 22 Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
  1. Correspondence to Dr Steven P Cohen, Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; scohen40{at}


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
  • complications

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, an indication of whether changes were made, and the use is non-commercial. See:

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  • Twitter @Kumar_ASRA, @doctdeer, @NarouzeMD

  • 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.

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