Efficacy and Long-term Effect of Radiofrequency Denervation in Patients with Clinically Diagnosed Cervical Facet Joint Pain

Abstract

Study Design. Multicenter double-blind randomized sham-controlled trial. Objective. To assess the efficacy of radiofrequency (RF) denervation of the cervical facet joints in chronic cervical facet joint pain. Summary of Background Data. One randomized controlled trial showed efficacy of RF denervation in whiplash-associated disease. There are no randomized controlled trials on RF denervation in patients with chronic cervical facet joint pain. Methods. Patients were randomized to receive RF denervation combined with bupivacaine (intervention group) or bupivacaine alone (control group). In the intervention group, an RF thermal lesion was made at the cervical medial branches after the injection of bupivacaine. The primary outcome was measured at 6 months and consisted of pain intensity, self-reported treatment effect, improvement on the Neck Disability Index, and the use of pain medication. Duration of effect was determined using telephone interviews. Results. We included 76 patients. In the intervention group, 55.6% showed > 30% pain decrease versus 51.3% in the control group (P = 0.711); 50.0% reported success on the Patients’ Global Impression of Change in the intervention group versus 41.0% (P = 0.435); the Neck Disability Index was 15.0 ± 8.7 in the intervention group compared with 16.5 ± 7.2 (P = 0.432), the need for pain medication did not differ significantly between groups (P = 0.461). The median time to end of treatment success for patients in the RF group was 42 months, compared with 12 months in the bupivacaine group (P = 0.014). Conclusions. We did not observe significant differences between RF denervation combined with injection of local anesthesia compared with local anesthesia only at 6 months follow-up. We found a difference in the long-term effect after 6 months follow-up in favor of the RF treatment. Level of Evidence: 2

The Diagnostic Value of an X‐ray‐based Scoring System for Degeneration of the Cervical Spine: A Reproducibility and Validation Study

“…In the absence of a reference standard for degenerative CFJ pain, we defined in a study on interventions for degenerative CFJ pain that at least three of the five described degenerative features had to be present assuming an interdependent association between CFJ degeneration and other radiographic cervical degenerative abnormalities. 45 This assumption has to be substantiated with future research.…”

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

“…The Spine Intervention Society (SIS) and the American Society of Interventional Pain Physicians (ASIPP) have published guidelines on the performance of cervical facet blocks and RFA, 18 27 but these rigorous criteria have not been followed in recent randomized controlled and uncontrolled trials (RCTs). 19 28 Whereas stringent selection criteria have been associated with high medial branch RFA success rates, 21 the increased false-negative rate that inevitably accompanies strict diagnostic criteria and a host of other factors have resulted in an urgent need for guidelines to inform cervical joint interventions in clinical practice and trials. These factors include the absence of safer and more effective alternatives for neck pain (ie, spinal fusion and chronic opioid therapy were less scrutinized when many of the previous cervical facet studies were published), the publication of few high-quality clinical trials, rising utilization which alters the risk to benefit ratio, and questions surrounding the cost-effectiveness of diagnostic paradigms, which vary from country to country.…”

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

“…There have been three double-blind trials that evaluated outcomes of cervical MBB in the context of a ‘sham-controlled’ study. Van Eerd and colleagues [ 28 ] randomized 76 patients with presumptive facetogenic pain based on historical and physical examination findings to receive cervical MBB at three contiguous levels with 0.5 mL bupivacaine and sham RFA, or the same volume of bupivacaine and true RFA. In the RFA group, the mean average neck pain score decreased from 6.8 to 3.6 and 3.8 at 3- and 6-month follow-ups, respectively.…”

“…In describing their results using a new posterior oblique approach for cervical facet RFA, van Eerd et al [ 298 ] reported that 51% of 65 patients were much or very much improved at 2 months. A later double-blind randomized trial performed in 76 patients with axial neck pain reported ≥50% success rates based on meaningful reduction in pain scores in both the RFA group (56%) and the LA block-sham RFA group (51%) at 6-month follow-up [ 28 ] Earlier, in a randomized trial by Stovner et al [ 103 ] that failed to enroll their intended sample size, 12 patients were allocated to true and sham denervation of the medial branches innervating the C2–6 facet joints. Although patients underwent medial branch and occipital nerve blocks before treatment, the results were not used to select participants.…”

“…One of the most recent comprehensive systematic reviews of cervical medial branch RFA included both comparative and cohort studies [ 21 ] There were no exclusion criteria pertinent to electrode orientation, although four studies were excluded since the technique was deemed outdated and inconsistent with current practice. Twenty-one manuscripts were considered, all of which used some variation of parallel electrode placement [ 21 ] One randomized sham-controlled study demonstrating the efficacy of cervical medial branch RFA for the treatment of neck pain described a rigorous technique including both a posterior pass and an posterior oblique pass of the electrode [ 68 ] Two other sham-controlled trials that yielded equivocal results (ie, some benefit favoring RFA but failure to meet the primary endpoint) described posterior oblique approaches [ 28 103 ] No published peer-reviewed studies supporting the use of cervical medial branch RFA for the treatment of neck pain have described using a perpendicular approach. As noted above, a single non-peer-reviewed abstract retrospectively comparing the perpendicular versus parallel approach in 82 patients concluded that “a statistically significant interaction between RFA treatment and post-procedural time indicated that the lateral RFA group experienced higher pain reduction at 6 months and 12 months (p=0.004), while the differences in mean percent pain reduction were not statistically significant at 1 and 3 months (p=0.05 and 0.06, respectively)” [ 309 ] No actual data were reported, including the type of electrode used, the magnitude of relief, or the responder rate.…”