Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

Steven P Cohen, Arun Bhaskar, Anuj Bhatia, Asokumar Buvanendran, Tim Deer, Shuchita Garg, W Michael Hooten, Robert W Hurley, David J Kennedy, Brian C McLean, Jee Youn Moon, Samer Narouze, Sanjog Pangarkar, David Anthony Provenzano, Richard Rauck, B Todd Sitzman, Matthew Smuck, Jan van Zundert, Kevin Vorenkamp, Mark S Wallace, Zirong Zhao, Steven P Cohen, Arun Bhaskar, Anuj Bhatia, Asokumar Buvanendran, Tim Deer, Shuchita Garg, W Michael Hooten, Robert W Hurley, David J Kennedy, Brian C McLean, Jee Youn Moon, Samer Narouze, Sanjog Pangarkar, David Anthony Provenzano, Richard Rauck, B Todd Sitzman, Matthew Smuck, Jan van Zundert, Kevin Vorenkamp, Mark S Wallace, Zirong Zhao

Abstract

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.

Keywords: chronic pain: back pain; complications; interventional pain management; pain medicine; radiofrequency ablation.

Conflict of interest statement

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.

© American Society of Regional Anesthesia & Pain Medicine 2020. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.

Figures

Figure 1
Figure 1
Representational drawing depicting the lumbosacral facet joints and accompanying neural anatomy. Insets illustrate closeup views of the bony and neural anatomical landmarks and a schematic representation of the effect electrode orientation has on nerve ablation. Artistic renditions by Joe Kanasz (joekanasz@att.net). (A) Parallel insertion of electrodes. Parallel placement may result in a higher likelihood of missing the nerve than with near-parallel orientation. (B) Near-parallel insertion of electrodes. This may result in the highest likelihood of medial branch nerve ablation. (C) Perpendicular insertion of electrodes. This theoretically results in the highest chance of missing the nerve, which may be more likely when the medial branch is entrapped beneath the mammilo-accessory ligament.

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