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

BACKGROUND

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

METHODS

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

RESULTS

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

CONCLUSIONS

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Informations de copyright

© American Society of Regional Anesthesia & Pain Medicine 2022. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.

Déclaration de conflit d'intérêts

Competing interests: SPC has served as a consultant for Avanos, SPR, Releviate, Persica and Scilex in the past 3 years. ZLM receives research funding from Avanos. Anuj Bhatia receives research funding from Medtronic and consults for Bioventus. DAP has consulted for Avanos, Boston Scientific, Heron, Medtronic, Wise and Nevro. He has received research support from Avanos, Medtronic, Nevro, Stimgenics, and Abbott. DWL has served as a member of the Abbott speaker’s bureau. WMH receives funding from US WorldMeds. BJS is a consultant for State Farm and AIM Specialty Health. NK served on an advisory board for Bright Minds Biosciences, received research funding from Nevro Corporation, and received royalties from UpToDate. TD is a consultant for Abbott, Vertos, Axonics, Flowonix, SpineThera, Saluda Medical, Nalu, Medtronic, Nevro, SI Bone, Stimgenics, SPR Therapeutics, Cornerloc, Boston Scientific, PainTeq, Ethos, and Vertiflex; is a member of the advisory board for Abbott, Vertos, Flowonix, Nalu, SPR Therapeutics and Vertiflex; has stock options in Bioness, Vertiflex, Axonic, Vertos, SpineThera, Nalu, Cornerloc, PainTeq and SPR Therapeutics, and has common stock in Saluda Medical. He is a research consultant for Abbott, Vertos, Mainstay Medical, Saluda Medical, SPR Therapeutics, Boston Scientific and Vertiflex, and has a patent pending for the dorsal root ganglion paddle lead with Abbott.