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) 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.