Radiofrequency denervation for chronic back pain stemming from the facet joints

Chronic backpain is very common and can often be traced to the facet joints. Facet joints are located between the protruding portions of adjacent vertebrae and serve to guide and stabilise the backbone, especially when extending or twisting. Radiofrequency ablation aims to alleviate back pain by disrupting the transmission of pain signals carried by the spinal nerves associated with the facet joints.

Reading time approx. 7 minutes Published: March 19, 2020 Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: March 19, 2020 Report no: ut202013 Registration no: SBU 2019/709

Question

What systematic reviews have been published that assess the efficacity of radiofrequency denervation in treating chronic back pain stemming from the facet joints.

Identified literature

Table 1 Systematic reviews with low/medium risk of bias
Included studies	Population/Intervention (Relevant studies, study population)	Outcome (Relevant studies)
Chen 2019 [1]
14 RCTs	Participants with chronic lumbar facet joint pain (9) or sacroiliac joint pain¹ (5). Authors do not report if nerve target was confirmed with a diagnostic block before randomization. Any radiofrequency denervation method compared to sham (10, n=598), Celecoxib (1, n=155), steroid mediated medial branch block (3, n=232). Follow-up: 1 month to 3 years, analysis of 3- to 6-month follow-up data	Effect: Pain (14) Oswestry Disability Index (6) Quality of Life (6)
Authors' conclusion: “Patients treated with RF neurotomy for chronic lumbar and sacroiliac joint pain had significantly greater improvement in pain and functional outcomes compared with those who received conservative treatment or sham therapy.” “Larger, more directly comparable studies will be needed to confirm the current findings.”
National Institute for Health and Care Excellence 2016 [2]
7 RCTs	Participants over age 16 with chronic lower back pain, without sciatica, who did not respond to conservative treatment. Diagnosis confirmed with nerve block or intra-articular joint injection. Conventional radiofrequency denervation compared to sham (6, n=322), or steroid mediated medial branch block (1, n=100) Lesions induced at 80 °C to 85 °C for 60 to 90 seconds Follow-up: 1 to 12 months, assessed as short term 4 months (4), or long term >4 months (4)	Effect: Pain (7) Response to treatment (2) Quality of Life (2) Function (3) Healthcare utilization (4) Adverse effects: 2 studies reported adverse events: moderate or severe treatment related pain, reported or evident tactile perception, reported or evident loss of motor function
Authors' conclusion: “Evidence from 4 studies demonstrated clinical benefit in pain for radiofrequency denervation compared to placebo/sham at both the short and long term follow-ups of less than and greater than 4 months (low to moderate quality, n=160). In contrast there was no difference in function between treatments at any time point.” “a benefit for radiofrequency denervation in responders to pain reduction measured by global perceived effect was demonstrated by 2 studies” at both the short- and long-term follow-ups… (low quality, n=111)” “Evidence from a single study reporting adverse events at less than 4 months follow-up demonstrated an increase in adverse effects….in terms of the number of patients with moderate or severe treatment related pain (low quality, n=79). There was no difference in other adverse events (change of sensibility and loss of motor function) at short term follow-up… (very low quality).”
Manchikanti 2016 [3]
14 studies, of which 9 RCTs are relevant to this report	Participants were adults with chronic lumbar facet joint pain, who did not respond to conservative treatment and who responded positively to a diagnostic nerve block Conventional radiofrequency denervation compared to sham (4, n=212), or steroid mediated medial branch block (2, n=156), or comparing two conventional radiofrequency denervation methods (3, n=278). Follow-up: assessed as short-term 6 months (2), long-term >6 months (7)	Effect: Pain (9)
Authors' conclusion: “This review provides … moderate evidence for therapeutic radiofrequency neurotomy … in managing chronic low back pain.”
Maas 2015 [4]
23 RCTs, of which 12 are relevant to this report	Participants with chronic lower back pain (minimum 3 months) confirmed by nerve blocks or discography. Radiofrequency denervation of the facet joints compared to sham (6, n=286), or steroid mediated medial branch block (3, n=232), or comparing different radiofrequency denervation methods (3, n=142). Follow-up: 1 to 12 months, defined short-term as <1 month (3), intermediate-term as between 1 and 6 months (3), and long-term as >6 months (3)	Effect: Pain (12) Function (3) Global improvement QoL Adverse effects (9): 5 studies report no adverse effects, 3 reported transient pain or numbness, 1 reported no statistically significant difference in transient pain
Authors' conclusion: “Reviewed studies provided evidence of low to moderate quality suggesting that RF denervation of the facet joint could offer greater pain relief (visual analogue scale (VAS)) (short term) and small improvement in function (Oswestry Disability Index (ODI)) (short and long term) when compared with placebo and steroid injections.” “RF denervation is an invasive procedure that can cause a variety of complications. The quality and size of original studies were inadequate to permit assessment of how often complications occur.”
Manchikanti 2015 [5]
26 studies, of which 11 RCTs and 3 non-controlled trials (NCT) are relevant to this report	Participants had chronic pain (minimum 3 months) in neck (1 RCT, n=24 och 3 NCT, n=305) mid- to upper-back (1 RCT, n=40), or lower back (9 RCTs, n=646) confirmed as originating from facet joints. Conventional radiofrequency denervation (appropriately performed with proper technique under image guidance) compared to sham (5), or steroid mediated medial branch block (2), alcohol nerve ablation (1 thoracic RF) or comparing two radiofrequency denervation methods (3). Follow-up: 3 to 12 months, assessed as short-term 6 months, long-term >6 months	Effect: Pain (14) Function (10)
Authors' conclusion: “Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II² for lumbar and cervical radiofrequency neurotomy…; and Level IV for … thoracic radiofrequency neurotomy.” “Overall, the results appear to be somewhat superior in patients who receive conventional radiofrequency neurotomy after undergoing controlled diagnostic blocks.”
Nagar 2015 [6]
9 studies, of which 3 RCTs and 2 non-controlled trials (NCT) are relevant to this report	Participants with cervicogenic headaches (3 RCTs, n=64 and 2 NCT, n=45) Continuous radiofrequency denervation compared to sham (2), steroid mediated medial branch block (1) Longest follow-up: 3 to 17 months	Effect: Pain (5) Quality of life (1 RCT)
Authors' conclusion: “There is limited evidence to support RF ablation for management of CHA as there are no high quality RCTs and/ or multiple consistent non-RCTs without methodological flaws.” “There is a need for high quality RCTs and/or multiple consistent non-RCTs without methodological flaws to evaluate the efficacy of RF and pulsed RFA therapies for CHA.”
¹ Nerves that innervate the facet joints (L4/L5) were ablated in addition to nerves associated with the sacroiliac joint. ² Levels of evidence are defined as follows: Level I, Evidence obtained from multiple relevant high quality RCTs; Level II, Evidence obtained from at least one relevant high quality RCT or multiple relevant moderate or low quality RCTs; Level III, Evidence obtained from at least one relevant moderate or low quality RCT with multiple relevant observational studies, or Evidence obtained from at least one relevant high quality NRCT or observational study with multiple moderate or low quality observational studies; Level IV, Evidence obtained from multiple moderate or low quality relevant observational studies; Level V, Opinion or consensus of a large group of clinicians and/or scientists.

References

Chen CH, Weng PW, Wu LC, Chiang YF, Chiang CJ. Radiofrequency neurotomy in chronic lumbar and sacroiliac joint pain: A meta-analysis. Medicine (Baltimore) 2019;98:e16230.
NICE. (National Institute for Health and Care Excellence). Low back pain and sciatica in over 16s: assessment and management - Invasive treatments. Section 23. NICE guideline NG59 Methods, evidence and recommendations. November 2016.
Manchikanti L, Hirsch JA, Falco FJ, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World J Orthop 2016;7:315-37.
Maas ET, Ostelo RW, Niemisto L, Jousimaa J, Hurri H, Malmivaara A, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev 2015;2015:CD008572.
Manchikanti L, Kaye AD, Boswell MV, Bakshi S, Gharibo CG, Grami V, et al. A Systematic Review and Best Evidence Synthesis of the Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. Pain Physician 2015;18:E535-82.
Nagar VR, Birthi P, Grider JS, Asopa A. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician 2015;18:109-30.

Page published March 19, 2020

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