Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline

STUDY DESIGN

Systematic review of the literature and subsequent meta-analysis for the development of a new guideline.

OBJECTIVES

This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure.

METHODS

A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications.

CONCLUSION

Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.

Comparative Evaluation of Intraarticular Facet Joint Injection Versus Medial Branch Block in Patients With Low Back Pain: A Randomised Controlled Study

INTRODUCTION

Lumbar facet joint pain may refer to the back, buttocks, and proximal parts of the lower extremities. Intraarticular facet joint injections, facet joint nerve blocks, or facet joint neurolytic procedures are popular for the management of facet joint pain.

MATERIAL AND METHODS

In this prospective, randomised study, 60 patients with a medical evaluation and pain pattern consistent with lumbar facet joint pain were randomly allocated to two groups. Group Ⅰ (n=30) patients were administered fluoroscope-guided lumbar facet joint injection, and group Ⅱ (n=30) patients were administered fluoroscope-guided lumbar facet joint nerve block. The primary objective is to compare the efficacy of both in managing facet joint pain in terms of pain and disability improvement. Secondary objectives were to compare the requirement for repeat injections and parameters related to the block, such as ease of administering the block, and to note the side effects pertaining to either of the blocks.

RESULTS

There was a statistically significant improvement in pain score after injection in both groups (p>0.05). The mean pain score in both groups remained less than two at all time intervals throughout the study period (p>0.05) Excellent patient satisfaction was reported by the majority of the patients at different time intervals in both groups.

CONCLUSION

Both lumbar facet joint injection and lumbar facet joint nerve block are safe and effective techniques for managing lower back pain patients. Both techniques provide adequate pain relief and disability improvement.

Comparative outcome of lidocaine versus bupivacaine for cervical medial branch block (CMBB) in chronic cervical facet arthropathy: a randomized double-blind study

OBJECTIVE

This study evaluated the effect of prolonged concordant response and functional clinical improvement between lidocaine and bupivacaine for cervical medial branch block (CMBB) in chronic cervical facet syndrome.

METHODS

Sixty-two patients diagnosed with chronic cervical facet syndrome were randomized into either lidocaine or bupivacaine groups. The therapeutic CMBB was performed under ultrasound guidance. Either 2% lidocaine or 0.5% bupivacaine with a volume of 0.5-1 ml per level, according to the patient's pain symptoms. The patients, pain assessor, and pain specialist were blinded. The primary outcome was the duration of pain reduction by at least 50%. The numerical rating scale (NRS) of 0-10 and the Neck Disability Index (NDI) questionnaire were recorded.

RESULTS

There was no significant difference in the duration of 50% and 75% pain reduction and NDI between the lidocaine and bupivacaine groups. Lidocaine provided significant pain reduction up to 16 weeks (P<0.05) and significant improvement in neck functional outcomes up to 8 weeks (P<0.01) compared to the baseline. Whist bupivacaine yielded significant pain alleviation for up to 8 weeks for pain upon neck mobilization (P<0.05) and demonstrated notable improvement in neck function up to 4 weeks (P<0.01) compared to the baseline.

CONCLUSION

CMBB using lidocaine or bupivacaine provided clinical benefits in prolonged analgesic effect and improving neck functions for chronic cervical facet syndrome. Lidocaine illustrated better performance and could be considered a local anesthetic of choice regarding the prolonged concordance response.

Is Preexisting Cervical Degeneration a Risk Factor for Poor Prognosis in Whiplash-Associated Disorder?

BACKGROUND

The term whiplash describes the acceleration-deceleration mechanism of injury to the cervical spine. Whiplash injuries present with a variety of clinical and psychological manifestations, collectively termed as whiplash-associated disorders (WADs). Although largely self-limiting, some patients may experience long-lasting symptoms. This review aimed to summarize the current literature regarding the predictive value of cervical degeneration in the prognosis of patients with WAD.

METHODS

A comprehensive search of the literature was performed. Nine studies were identified, including 894 patients, with an age range between 16 and 76 years.

RESULTS

A statistically significant association was found between moderate facet joint degeneration and nonrecovery. Although no association was established between isolated disc degeneration and nonrecovery, total cervical degeneration (facet joint + disc degeneration) was shown to correlate with nonrecovery.All included studies demonstrated the lack of correlation between preexisting disc degeneration and clinical outcomes. Four studies showed a significant correlation between cervical degeneration and poor prognosis following whiplash injury. A significantly higher proportion of patients who remained symptomatic at 2 years following a whiplash injury had preexisting degenerative changes.

CONCLUSIONS

This review highlights the presence of significant variability in the existing literature concerning WAD in terms of study methodology, definitions of cervical degeneration, and outcome measures. Degenerative changes of the facet joint lead to alterations in its biomechanics. Several cadaveric, biomechanical, and clinical studies have demonstrated facet joints as a source of pain in patients with chronic WAD. We present moderate evidence to suggest that preexisting facet joint degeneration is a negative prognostic indicator for long-lasting symptoms in WAD. Conversely, preexisting disc degeneration is not associated with chronicity of WAD symptoms. We propose facet joint instability due to facet joint capsule rupture as a potential mechanism for nonrecovery. Further studies are needed to inform our knowledge of the long-term sequelae of WAD among patients with preexisting cervicalspine degeneration.

Clinical Efficacy of Pulsed Radiofrequency Treatment Targeting the Mid-cervical Medial Branches for Intractable Cervicogenic Headache

OBJECTIVE

Cervicogenic headache has been known to originate from the convergence of the upper 3 cervical and trigeminal afferents. The administration of conservative treatments, interventional procedures, and more recently, pulsed radiofrequency, has been used to relieve cervicogenic headache. In this study, the authors evaluated the clinical efficacy and safety of pulsed radiofrequency targeting the mid-cervical medial branches.

MATERIALS AND METHODS

From September 2012 until December 2017, 395 patients were diagnosed with cervicogenic headache based on the third edition of the International Classification of Headache Disorders. The authors treated them conservatively at first, and those patients with nonresolution of pain were treated with mid-cervical medial branches block applied from C3 to C5 twice. Subsequently, if any patient continued to experience persistent pain, the authors classified them as having intractable cervicogenic headache and performed pulsed radiofrequency treatment targeting the mid-cervical medial branches from C3 to C5 bilaterally. The authors analyzed their demographics and used a Visual Analogue Scale to assess their pain for 12 months.

RESULTS

Fifty-seven patients were enrolled in this study. The mean age was 49.8 years, and the mean duration of symptoms was 47.7 months. The mean Visual Analogue Scale score was 6.21 before pulsed radiofrequency treatment, and it improved to 1.54 immediately after the procedure without the symptoms recurring for a minimum of 12 months. There were no severe complications, such as vascular or nerve injuries.

CONCLUSIONS

In patients with intractable cervicogenic headache, pulsed radiofrequency treatment targeting the mid-cervical medial branches resulted in a satisfactory, long-lasting outcome without serious complications.

Predictors of response to medial branch block, radiofrequency ablation or facet joint injections: a retrospective study

Aim: Low back pain is a leading cause of patient disability in the USA. Our goal was to determine association between patient characteristics and their response to lumbar medial branch block, radiofrequency ablation of medial nerves or lumbar facet joint injections. Materials & methods: Medical records for the first 100 patients who underwent lumbar medial branch block, radiofrequency ablation of lumbar medial nerves or lumbar facet joint injections between 1 September 2019 and 31 March 2020 were reviewed and demographic data were recorded. Results: At the 3-month post-procedure visit, positive responders were significantly more likely to be non obese patients (BMI <30) and those with pain <5-years. Conclusion: Obesity and chronicity of pain certainly are found to be predictors of response to the above mentioned procedures.

Interventional Pain Treatments in the Management of Oncologic Patients With Thoracic Spinal Tumor-Related Pain: A Case Series

BACKGROUND

Advanced tumors of the thoracic spine are difficult to treat and can lead to complex pain syndromes. Following conventional oncologic treatments, pharmacologic therapy may be insufficient to manage pain. Minimally invasive interventional procedures offer alternatives to treat malignant thoracic spinal pain.

METHODS

Thirteen patients with metastatic disease and poorly controlled thoracic axial and/or radicular pain were identified via a retrospective chart review. Patients were either treated with radiation, surgery, chemotherapy, or a combination of these. Then, the patients were organized into groups based on their diagnoses, anatomical disease locations, symptoms, prior treatments, and interventional pain procedures offered.

RESULTS

All cases of intercostal nerve, costotransverse junction, erector spinae plane, and paravertebral blocks resulted in pain relief without any reported complications. A patient who received a thoracic epidural injection had a complete resolution of pain when combined with radiation therapy 2 weeks after the injection. One patient who underwent repeat thoracic epidural injections eventually had an intrathecal pump placement, resulting in reduced opioid usage. Finally, 1 patient who received a thoracic medial branch block with a relief of thoracic axial pain reported greater pain relief with a medial branch nerve cryoablation.

CONCLUSION

We propose a treatment algorithm to manage patients with thoracic spinal tumor-related pain. Interventional thoracic axial procedures may be safe and efficacious pain treatments for patients with cancer.

Predictors of Response to a Medial Branch Block: MRI Analysis of the Lumbar Spine

The aim of this study was to determine the association between radiologic spinal pathology and the response to medial branches block (MBB). This retrospective observational study compared 165 patients. A successful response was defined as ≥30% or a 2-point reduction in the numeric rating scale (NRS) compared with the baseline at the 1-month follow-up. The facet angle, facet angle difference, facet joint degeneration, disc height and spondylolisthesis grade were analyzed from an MRI at the L3 to S1 levels. Univariate and multivariate logistic regression analyses were used to evaluate independent factors associated with a successful response of MBB. In the univariate analysis, the disc height at L5-S1 and facet angle difference at L3-4 were lower in the positive responders (p = 0.022 and p = 0.087, respectively). In the multivariate analysis, the facet angle difference at L3-4 and disc height at L5-S1 were independent factors associated with a successful response (odds ratio = 0.948; p = 0.038 and odds ratio = 0.864; p = 0.038, respectively). In patients with a degenerative disc at L5-S1, MBB can lead to a good response for at least one month. In patients with facet tropism at L3-4 level, the response to MBB after one month is likely to be poor.

Best practice in radiofrequency denervation of the lumbar facet joints: a consensus technique

Background

Radiofrequency denervation is used to treat selected people with low back pain. Recent trials have been criticised for using a sub-optimal intervention technique.

Objectives

To achieve consensus on a best practice technique for administering radiofrequency denervation of the lumbar facet joints to selected people with low back pain.

Study design

A consensus of expert professionals in the area of radiofrequency denervation of the lumbar facet joints.

Methods

We invited a clinical member from the 30 most active UK departments in radiofrequency pain procedures and two overseas clinicians with specific expertise to a 1 day consensus meeting. Drawing on the known anatomy of the medial branch, the theoretical basis of radiofrequency procedures, a survey of current practice and collective expertise, delegates were facilitated to reach consensus on the best practice technique.

Results

The day was attended by 24 UK and international clinical experts. Attendees agreed a best practice technique for the conduct of radiofrequency denervation of the lumbar facet joints.

Limitations

This consensus was based on a 1 day meeting of 24 clinical experts who attended and took part in the discussions. The agreed technique has not been subject to input from a wider community of experts.

Conclusions

Current best practice for radiofrequency denervation has been agreed for use in a UK trial. Group members intend immediate implementation in their respective trusts. We propose using this in a planned Randomised Controlled Trial (RCT) of radiofrequency denervation for selected people with low back pain.

Clinical Diagnostic Tests versus Medial Branch Blocks for Adults with Persisting Cervical Zygapophyseal Joint Pain: A Systematic Review and Meta-Analysis

Purpose: A systematic review and meta-analysis were performed to identify clinical tests for diagnosing cervical zygapophyseal joint pain (CZP) and to determine their diagnostic accuracy. Method: A search strategy was carried out to find relevant evidence published in CINAHL, Embase, MEDLINE, and PEDro from 1980 to January 1, 2015, pertaining to the clinical diagnosis of CZP. Quality assessment was completed using the Quality Assessment of Diagnostic Accuracy Studies-2. Results were analyzed to pool sensitivity and specificity and clarify diagnostic value. Results: Seven articles (n=463) were included for data synthesis and review. Intersegmental mobility tests were found to have the highest diagnostic accuracy, with pooled sensitivity of 0.91 (95% CI: 0.85, 0.94) and specificity of 0.74 (95% CI: 0.65, 0.81). The pooled sensitivity for mechanical sensitivity (palpation) was 0.88 (95% CI: 0.78, 0.95), and specificity was 0.61 (95% CI: 0.50, 0.71). Conclusion: Limited studies are available that discuss the clinical diagnosis of CZP, and significant heterogeneity is present in the available data. In this review, intersegmental mobility tests were found to be the most accurate. Clustering of tests, agreement on a reference standard, and further exploration of CZP referral patterns are recommended.

Technique for CT Fluoroscopy-Guided Lumbar Medial Branch Blocks and Radiofrequency Ablation

OBJECTIVE

The purpose of this study is to describe the procedure for CT fluoroscopy-guided lumbar medial branch blocks and facet radiofrequency ablation.

CONCLUSION

CT fluoroscopic guidance allows more-precise needle tip positioning and is an alternative method for performing medial branch blocks and facet radiofrequency ablation.

Interventional spine procedures for management of chronic low back pain-a primer

Chronic low back pain is a common clinical condition. Percutaneous fluoroscopic-guided interventions are safe and effective procedures for the management of chronic low back pain, which can be performed in an outpatient setting. Interventional radiologists already possess the technical skills necessary to perform these interventions effectively so that they may be incorporated into a busy outpatient practice. This article provides a basic approach to the evaluation of patients with low back pain, as well as a review of techniques used to perform the most common interventions using fluoroscopic guidance.

Radiofrequency treatment of facet-related pain: evidence and controversies

Pain originating from the lumbar facet joints is estimated to represent about 15% of all low back pain complaints. The diagnostic block is considered to be a valuable tool for confirming facetogenic pain. It was demonstrated that a block of the ramus medialis of the ramus dorsalis is preferred over an intra-articular injection. The outcome of the consequent radiofrequency treatment is not different in patients reporting over 80% pain relief after the diagnostic block than in those who have between 50% and 79% pain relief. There is one well-conducted comparative trial assessing the value of one or two controlled diagnostic blocks to none. The results of the seven randomized trials on the use of radiofrequency treatment of facet joint pain demonstrate that good patient selection is imperative for good clinical outcome. Therefore, we suggest one block of the ramus medialis of the ramus dorsalis before radiofrequency treatment.

Value of Bone Scintigraphy and Single Photon Emission Computed Tomography (SPECT) in Lumbar Facet Disease and Prediction of Short-term Outcome of Ultrasound Guided Medial Branch Block with Bone SPECT

Background

Facet joint disease plays a major role in axial low-back pain. Few diagnostic tests and imaging methods for identifying this condition exist. Single photon emission computed tomography (SPECT) is reported that it has a high sensitivity and specificity in diagnosing facet disease. We prospectively evaluated the use of bone scintigraphy with SPECT for the identification of patients with low back pain who would benefit from medial branch block.

Methods

SPECT was performed on 33 patients clinically suspected of facet joint disease. After SPECT, an ultrasound guided medial branch block was performed on all patients. On 28 SPECT-positive patients, medial branch block was performed based on the SPECT findings. On 5 negative patients, medial branch block was performed based on clinical findings. For one month, we evaluated the patients using the visual analogue scale (VAS) and Oswestry disability index. SigmaStat and paired t-tests were used to analyze patient data and compare results.

Results

Of the 33 patients, the ones who showed more than 50% reduction in VAS score were assigned 'responders'. SPECT positive patients showed a better response to medial branch blocks than negative patients, but no changes in the Oswestry disability index were seen.

Conclusions

SPECT is a sensitive tool for the identification of facet joint disease and predicting the response to medial branch block.