The Effectiveness of Radiofrequency Ablation of Medial Branch Nerves for Chronic Lumbar Facet Joint Syndrome in Patients Selected by Guideline-Concordant Dual Comparative Medial Branch Blocks

Abstract

Objectives Although the effectiveness of lumbar medial branch radiofrequency ablation (RFA) for the treatment of zygapophyseal joint (z-joint)–mediated low back pain has been characterized, few studies have described outcomes in patients selected using a guideline-concordant paradigm of ≥80% pain relief with dual comparative medial branch blocks (MBBs). We investigated long-term treatment outcomes of patients selected according to this paradigm. Design Cross-sectional cohort study. Methods The medical records of 111 consecutive patients were reviewed; 85 met inclusion criteria. A standardized telephone survey was used to capture current numerical rating scale (NRS) and Patient Global Impression of Change (PGIC) scores. The primary outcome was the proportion of patients reporting ≥50% reduction of index pain. Binary logistic regression analysis was performed to explore associations between the primary outcome and covariates, including age, duration of pain, presence of scoliosis, degenerative spondylolisthesis, and >75% disc height loss. Results At six to 12, 12–24, and >24 months, 63.2% (95% confidence interval [CI] = 41–85%), 65.6% (95% CI = 49–82%), and 44.1% (95% CI = 27–61%) of patients reported a ≥50% pain reduction (P = 0.170), respectively. At a minimum of six months, 70.6% of patients reported a pain reduction of two or more points (minimally clinically important change), and 54.1% reported a PGIC score consistent with “much improved” or better. Older age and a smaller Cobb angle were associated with a ≥50% pain reduction (P < 0.05). Conclusion Lumbar medial branch RFA is an effective, durable treatment for a significant proportion of patients with recalcitrant lumbar z-joint pain when candidacy is determined by the guideline-concordant paradigm of ≥80% pain relief with dual comparative MBBs.

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

“…More recently, a retrospective review performed in 111 patients who responded with ≥80% concordant pain relief after comparative LA MBB found that older age and a smaller Cobb angle were associated with > 50% pain reduction 6 months after RFA. 56 Finally, in a large, prospective study that sought to determine factors associated with interventional treatment outcomes in 318 patients with LBP (63 with suspected facetogenic pain), Cohen et al found that 51.1% of individual with 0 Waddell signs, 34.1% with one or two signs, 26.1% with three or four signs and only 16.7% of people with five of five Waddell signs experienced a positive treatment outcome. Other variables associated with treatment success included older age, shorter duration of pain, lower baseline pain scores and better function, absence of secondary gain and not having concomitant pain and psychiatric comorbidities.…”

Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN)

“…43 Hence, the literature illustrates that there are no pathognomonic signs with both clinical history and physical examination to reliably diagnose patients with facet-mediated pain or predict the success of LRFN. [43][44][45] Moreover, both MRI and CT scans have no specific findings that help diagnose lumbar facet mediated pathology as the exclusive source of pain. 46,47 As such, the present standard in the diagnosis of lumbar facet mediated pain is diagnostic facet blocks, including both the use of intra-articular facet joint injections and medial branch nerve blocks.…”

“…LRFN has been studied extensively with consensus guidelines indicating moderate to strong evidence. [43][44][45] The efficacy of the lumbar medial branch RFN has been described in observational and RCT. Out of the six RCTs, three contained technical flaws in both patient selection and procedural technique, which yielded less reliable and therefore, non-generalizable findings.…”

Evaluation of an Ultrasound-Assisted Longitudinal Axis Lateral Crest Approach to Radiofrequency Ablation of the Sacroiliac Joint

“…13 Although we observed positive clinical outcomes in a substantial proportion of patients after L-SIJRFA, the present results are inferior to RFA for the treatment of lumbar and cervical facet-mediated pain. [20][21][22][23][24] Selection criteria may be an explanation for outcome discrepancies, despite likely complete ablation of neural tissue. Participants in the current study were selected based on 50% or more pain relief after dual blocks (intraarticular and LBB or LBB and LBB).…”