Table 23.
Summary of recommendations
| Question | Recommendation |
|---|---|
| Use of history and physical examination to identify painful AO or AA joints or to select patients for injections | History and physical examination cannot reliably identify painful AO or AA joints, but can guide injection decisions which could confirm the AO and AA joints as pain generators; Grade C, low level of certainty. |
| Use of history and physical examination to identify painful cervical facet joints and select patients for blocks | No pathognomonic historical or examination signs can reliably predict response to facet joint blocks in individuals with chronic neck pain; Grade C, low level of certainty |
| Correlation between radiological findings and prognostic block or RFA outcomes | The evidence is insufficient to assess the utility of radiological imaging for diagnosing cervical facet joint pain and as a prognostic indicator for the success of cervical facet blocks or RFA; Grade I. For procedural planning, radiological imaging should be considered when indicated; Grade C, low level of certainty |
| Conservative treatment requirement before cervical facet blocks | Conservative therapy should be used before prognostic blocks in those with chronic neck pain; Grade B, moderate level of certainty. The trial should be for 6 weeks, although this may vary based on a personalized approach; Grade C, low level of certainty. Grade I for concomitant use of conservative measures to accompany prognostic blocks |
| Image guidance for cervical facet blocks and RFA | Fluoroscopy or US should be used for cervical MBB; Grade A recommendation, moderate level of certainty. Fluoroscopy (vs. CT) should be used for IA injections; Grade C, low level of certainty. Fluoroscopy should be used before RFA; Grade A, high level of certainty for imaging, Grade B, moderate level of certainty for use of fluoroscopy |
| Optimal technique for AO and AA joint injections and risk mitigation | Advanced imaging should be obtained before injections; Grade C, low level of certainty. Posterior approach with real-time fluoroscopy or DSA in multiple views; Grade B, moderate level of certainty. Grade C, low level of certainty for steroid use; if steroids are injected, <1 mL non-particulate steroids should be used |
| Approach for cervical MBB | A fluoroscopically-guided lateral approach should be considered for TON and C3–C7 MBB, but a posterior or posterior oblique approach should be used for C8 MBB. The smallest needles possible should be used; Grade I. |
| Volumes for cervical MBB and IA injections | Volumes ≤0.3 mL should be used for cervical MBB and ≤1 mL for IA injections; Grade C, low level of certainty for MBB, grade C, low level of certainty for IA injections |
| Therapeutic value of cervical MBB and IA injections | Therapeutic IA injections should not be routinely used; Grade C, low-to-moderate level of certainty. Grade D recommendation, moderate level of certainty against use of steroids during MBB |
| Performing bilateral cervical MBB and RFA, and limits on the number of levels treated | Bilateral MBB may be performed at one session, but bilateral RFA should be avoided. Treating >2 spinal levels (>3 nerves) during one session should not be done routinely; Grade C recommendation, low level of certainty. |
| Diagnostic and prognostic utility of cervical injections | Cervical MBB meet most criteria for a diagnostic intervention, while IA injections meet full criteria but carry a high technical failure rate; Grade C, low-to-moderate level of certainty. MBB may be more predictive of RFA outcomes than IA injections; Grade C, low level of certainty. AO and AA local anesthetic injections may be diagnostic and predictive for steroid injections; grade C, low level of certainty |
| Use of sedation | Sedation should not routinely be given for diagnostic procedures; Grade B, moderate level of certainty |
| Cut-off for designating a MBB as positive and use of non-pain measures | ≥50% pain relief should be used as the cut-off to maximize access to care; Grade C, low-to-moderate level of certainty. Non-pain measures can be used in conjunction with pain relief, but not as the sole criterion for designating a block as positive; grade B recommendation, moderate level of certainty |
| Number of blocks before RFA | A single block should be used to select patients for RFA in the absence of extenuating circumstances; Grade B, low-to-moderate level of certainty |
| Orientation of electrodes for RFA | A near-parallel approach should be used; Grade B, low-to-moderate level of certainty. For surgeries involving the articular pillars, a modified (posterior oblique or lateral) approach with advanced imaging and multiple lesions may be necessary; Grade C, low level of certainty |
| Sensory and motor stimulation before RFA | Sensory stimulation should be considered when single lesions are planned and with C2–3 denervation; Grade C, low level of certainty. Motor stimulation may be beneficial for safety and efficacy; Grade B, low-to-moderate level of certainty |
| Evidence for larger lesions | There is indirect evidence that larger lesions may improve RFA results; Grade C, low-to-moderate level of certainty. Grade C, low level of certainty for larger lesions to increase duration of pain relief |
| Risk mitigation | Aspirate and use real-time fluoroscopy or DSA to prevent vascular uptake; Grade B, moderate level of certainty. Position electrode in the posterior two-thirds of C2–3 facet joint to avoid vascular damage; Grade C, low level of certainty. Discontinue anticoagulants only after a careful risk: benefit assessment; Grade I. Non-particulate steroids can be injected post-RFA when there is a high risk for post-procedure neuritis, and a short course of NSAIDs may reduce post-RFA pain; Grade C, low level of certainty. There is inconsistent evidence supporting the peri-procedural use of gabapentin; Grade I. Discussion with relevant healthcare teams and device manufacturers should be undertaken before performing RFA in a person with an implanted device and their guidance considered; Grade C, low level of certainty. RFA can be performed in individuals with hardware, but may require a modified technique; Grade C, low level of certainty. |
| Repeating RFA | RFA can be repeated in patients who obtain meaningful relief lasting ≥3 months when their baseline pain returns; Grade B, moderate level of certainty. For pain that returns in a similar quality and location as the baseline pain, repeat MBBs are not necessary; Grade C, low level of certainty |
| Differences between clinical trials and practice | Because of different objectives, differences in patient selection (more rigorous for trials) and minor differences in performance (eg. for quality assurance in studies, to increase study power) may be indicated |
AA, atlanto–axial; AO, atlanto–occipital; DSA, digital subtraction angiography; IA, intra-arterial; MBB, medial branch block; NSAID, non-steroidal anti-inflammatory drug; RFA, radiofrequency ablation; TON, third occipital nerve.