Radiofrequency Ablation as an Effective Long-Term Treatment for Chronic Sacroiliac Joint Pain: A Systematic Review of Randomized Controlled Trials

Abstract

Radiofrequency ablation (RFA) has emerged as a popular intervention for chronic pain management, including pain originating in the sacroiliac joint. It offers a less invasive option than surgery but with better results than the previous standard treatment with steroid and anesthetic injections. Procedure volumes have enjoyed significant growth in the market in recent years. The evidence supporting this intervention, in the form of randomized controlled trials, however, is both thin and mixed. The purpose of this systematic review is to evaluate the body of randomized controlled trials (RCTs) to determine the quality of support for and against the use of radiofrequency ablation to treat sacroiliac joint (SIJ) pain. Several important new papers have emerged since previous systematic reviews with similar objectives were published. The review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and three databases were used: PubMed, Google Scholar, and Scopus. Only RCTs were sought, and no other filters, such as a historical timeline cut-off, were used. Among 95 publications that returned in response to the query, 16 were ultimately accepted as meeting the inclusion/exclusion criteria. The Cochrane risk-of-bias tool was utilized as a quality assessment measure, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was used to assess the certainty of the evidence. Among the included publications, 15 out of 16 publications featured positive results and conclusions that supported the use of RFA in treating chronic sacroiliac joint pain. The single negative study was also the largest trial (n=681), but it was identified as "High Risk" using the Cochrane risk-of-bias tool. It included several design flaws including neither operator nor patient blinding, missing information, use of inconsistent treatment modalities across groups, and disproportionate drop-out rates. Despite its flaws, we have included this study in the present review because of its sheer size. Taken in aggregate, the total body of research included in this review supports this intervention. Questions continue to exist around whether there are clinically significant benefits associated with different RFA modalities (for example, unipolar vs. bipolar), with convincing evidence supporting each of them. Finally, it can be concluded that while the benefits are reasonably and justifiably supported in this patient population for up to one year, there is a dearth of evidence beyond a 12-month post-intervention follow-up.

Radiofrequency Neurotomy for Sacroiliac Joint Pain: Twelve Month Outcomes and Comparison Between Two Techniques

“…Our findings corroborate and extend previous results in patients with SIJ pain showing clinically significant and sustained symptom palliation for a duration of 12 months following RFN. 6 Clinical improvements after RFN have also been found to be more robust and durable than intraarticular steroid injection for the same patient population. 13 We noted moderately better improvement in clinical efficacy among patients who received supplementary ablation of the L4 medial branch and the L5 dorsal ramus as part of their treatment protocol.…”

“…Targeted RFN of specific SIJ innervation segments has been shown to produce clinically significant and durable improvements in pain severity, physical functioning, and a reduction in the need for opioid analgesics. [4][5][6][7][8][9] In the recently published best practice guidelines issued by the American Society of Pain and Neuroscience (ASPN), lateral sacral branch RFN for the treatment of posterior sacral ligament and joint pain received a grade of II-1 B based on the compilation of published clinical findings reflecting moderate to substantial clinical benefit as demonstrated in well-designed clinical trials. 10 The SIJ is innervated from several sources including the ventral rami of L4 and L5, the dorsal rami of L5, S1, S2, and S3, as well as the superior gluteal nerve.…”

Presentation, Diagnosis, and Treatment of Sacroiliac Joint Dysfunction

“…Radiofrequency ablation is similarly used for both diagnostic and therapeutic for SIJ dysfunction 24. Typically, radiofrequency ablation is used after initial SIJ injection 35,36. Radiofrequency ablation uses radio waves to denervate the sacral dorsal rami and lateral sacral branches 7.…”

Presentation, Diagnosis, and Treatment of Sacroiliac Joint Dysfunction

“…24 Typically, radiofrequency ablation is used after initial SIJ injection. 35,36 Radiofrequency ablation uses radio waves to denervate the sacral dorsal rami and lateral sacral branches. 7 Although the L5 dorsal ramus and the lateral S1-3 dorsal rami primarily provide sensory innervation to the SIJ, significant anatomical variation courses through these nerve branches.…”