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

Abstract

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.

Keywords: Low back pain; facet rhizolysis; lumbar facet joints; lumbar zygapophyseal joints; medial branch block; medial branch of the dorsal ramus; radiofrequency denervation.

Conflict of interest statement

Conflict of interest: MU was Chair of the NICE accreditation advisory committee until March 2017 for which he received a fee. He is chief investigator or co-investigator on multiple previous and current research grants from the UK National Institute for Health Research, Arthritis Research UK, and is a co-investigator on grants funded by Arthritis Australia and Australian NHMRC. He has received travel expenses for speaking at conferences from the professional organisations hosting the conferences He is a director and shareholder of Clinvivo Ltd that provides electronic data collection for health services research. He is part of an academic partnership with Serco Ltd related to return to work initiatives. He is an editor of the NIHR journal series for which he receives a fee. He has published multiple papers on Low back pain (LBP) some of which are referenced in this paper. SE uses radiofrequency (RF) only in his NHS practice; he does not have a private practice. SE is investigator on number of NIHR and industry sponsored studies. He received travel expenses for speaking at conferences from the professional organisations organising these conferences. SE attended advisory boards and provided consultancy service for Medtronic, Abbott, Boston Scientific and Mainstay Medical, none in relation to radiofrequency denervation (RFD). SE is chair of the BPS Science and Research Committee. SE’s department has received funding from Medtronic. HA has used RF in private practice in the past. He holds an Honorary contract at Warwick University and has been co-investigator on a NIHR-funded feasibility study of facet joint injections. SN has used RFD in clinical and research context. He is retired from clinical practice and has no other conflicts to declare. MK performs RF procedures in NHS and Private practice regularly. MK takes part as faculty in the Abbott sponsored Cadaver Workshop annually. He receives a fee for the same. He has taken part in Pain Conferences in India as a faculty member, receiving free facilities and accommodation. TF practices RF procedures in the NHS as well as private sector; he has no other conflicts to declare. FH attended advisory boards and provided consultancy service for Medtronic, Abbott, Mainstay and Saluda. FH was one of the two principle investigators (PIs) in the MINT study, which was granted by the minister of healthcare and ZONmw (Dutch government). FH is chair of the 2018 update on the evidence-based interventional pain management guidelines (Dutch Society of Anaesthesiologists). VM uses RF in both his NHS and private practice. VM is investigator on number of NIHR and industry sponsored studies. He has received travel expenses for speaking at conferences from the professional organisations organising these conferences. VM attended advisory boards and provided consultancy service for Boston Scientific and Mainstay Medical, none in relation to RFD. VM is the PI of investigator-initiated study on sham controlled RF trial on sacroiliac joint (SIJ) pain; paper accepted for publication. VM’s department has received funding from Medtronic, Boston Scientific, Mainstay Medical and Abbott. AKF is only practicing in the NHS. She has received an indirect bursary for her neuromodulation and pain research fellowship by Medtronic. She has been sponsored by Nevro to take her FIPP exam and attend NANS 2018. She has completed the neuromodulation fellowship sponsored by Abbott and has attended two sponsored educational events by Boston Scientific. She is currently a PI for a neuromodulation study. None of the above are linked to RF. RT has been using RF treatment regularly in his NHS and private practice. RT is an investigator in an industry sponsored SCS study, with no relation to the above treatment or technique. MB uses RF in his NHS and private practice. He organises an annual course which receives sponsorship funding from Abbot. SS carries out RF denervation in her routine NHS clinical practice; she was the PI of the FACET feasibility study which used diagnostic medial branch blocks to diagnose pain of lumbar facet joint origin. AG uses RF in his NHS and private practice. He is investigator on number of NIHR and industry sponsored studies and received travel expenses for speaking at conferences from the professional organisations as well as industry organising these conferences. AG attended advisory boards and provided consultancy service for Medtronic, Abbott, Nevro, Boston Scientific and Mainstay Medical, none in relation to RFD. His department has received funding from Medtronic, Abbott and Mainstay Medical. NC performs RF procedures in NHS and private practice regularly. NC has taken part as Faculty in the Abbott sponsored Cadaver Workshop. He received a fee for the same. NC was Co-chair of the development group who wrote ‘Standards of good practice for medial branch block injections and radiofrequency’ March 2014 (Reference 10). SM performs RF in both NHS and private practice. He has no other conflicts of interest. SM performs RF in the NHS only. He has no other conflicts of interest. SH performs RFD regularly in his clinical practice. He holds an NHS contract and is an Honorary Senior Lecturer at Imperial College London. He has previously received grants from organisations such as the Wellcome Trust. He has received honoraria from several companies for attending and speaking at meetings and conferences; these include Grunenthal, Pfizer, Astellas, St Jude Medical, Abbot and Boston Scientific. AT has no conflicts of interest. PB uses RFD in his clinical practice. He has no other conflicts to declare.

© The British Pain Society 2019.