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

Abstract

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 b...

Dropped head syndrome: report of a rare complication after multilevel bilateral cervical radiofrequency neurotomy

“…9,11,15 Although catastrophic complications such as injury to spinal nerves, ventral rami, and other unintended neuronal structures can theoretically occur, these are extremely rare if practitioners use appropriate fluoroscopic imaging guidance and avoid heavy intravenous sedation during procedures. 4,9,17 Here, we report a case of dropped head syndrome after radiofrequency neurotomy of the bilateral C3, C4, and C5 medial branches. The patient provided HIPAA-compliant permission for the inclusion of their clinical information in this report.…”

“…Transient postprocedural pain or dysesthesia is the most commonly reported complication and is usually self-limited. 9,11,15 Although catastrophic complications such as injury to spinal nerves, ventral rami, and other unintended neuronal structures can theoretically occur, these are extremely rare if practitioners use appropriate fluoroscopic imaging guidance and avoid heavy intravenous sedation during procedures. 4,9,17 Here, we report a case of dropped head syndrome after radiofrequency neurotomy of the bilateral C3, C4, and C5 medial branches.…”

Molecular and Genetic Mechanisms of Spinal Stenosis Formation: Systematic Review

“…Treatment with corticosteroid intra-articular injections has long been utilized to relieve facet joint osteoarthritis-related pain. However, a recent management guidance consensus article questions their use due to the small beneficial effect [ 74 ]. The discovery of drugs that selectively affect Wnt/β-catenin signaling may help determine the specific roles of this pathway in cartilage degeneration and repair [ 63 , 73 ].…”

Bipolar radiofrequency ablation of the superomedial (SM), superolateral (SL) and inferomedial (IM) genicular nerves for chronic osteoarthritis knee pain: a randomized double-blind placebo-controlled trial with 12-month follow-up

“…Sensory stimulation at 50 Hz was performed to confirm sufficient electrode proximity to the nerves, with concordant stimulation ideally obtained at less than 0.6 V. To avoid motor nerve damage, the absence of distal leg movement was verified using stimulation of 2 Hz at up to 2.0 V. Prior to activating the bipolar RF generator, 2 mL of lidocaine 2% mixed with 2.5 mg dexamethasone was injected at each of three target nerves, with steroid added to prevent neuritis 20 21. After waiting for 2 min, RF lesioning was initiated at 90°C for 180 s, simultaneously generating three large contiguous lesions (URF-3AP, Diros technologies, Toronto, Canada).…”