Radiofrequency Denervation Ineffective for Chronic Low Back Pain

Radiofrequency denervation may be ineffective in alleviating chronic low back pain (cLBP), according to results from 3 multicenter clinical trials reported in the Journal of the American Medical Association.¹

Chronic low back pain is the leading cause of disability and the third most costly healthcare expenditure in the United States; an estimated $87.6 billion was spent for the management of cLBP and neck pain between 1996 and 2013 and spending shows no signs of abating.² Between 2000 and 2014, facet and sacroiliac joint interventions far outpaced the overall Medicare population, with an annual increase of 10.7%. A meta-analysis on the effectiveness of radiofrequency for cLBP published in 2015 that included 23 randomized controlled trials failed to identify high-quality studies indicating the effectiveness of this technique in cLBP.⁴

The nonblinded randomized clinical trials were conducted across 16 pain clinics in The Netherlands. A total of 681 patients with cLBP (mean age 52.2; 61.8% women) were randomly assigned to receive radiofrequency denervation plus a standard 3-month exercise program or the exercise program alone (trialregister.nl identifier: NTR3531). Eligible patients had chronic low back pain and were assigned to trial groups according a positive nerve block at the facet joints (n=251), sacroiliac joints (n=228), or a combination of joints (n=202).

The primary outcome was pain intensity measured on a 0 to 10 scale at 3 and 12 months. The predetermined improvement was a difference of ≥2 points. The secondary outcomes included functioning scores and global perceived recovery.

At 3 months, the mean difference in pain intensity scores between the radiofrequency denervation group and the control group were −0.18 (95% CI, −0.76 to 0.40; P =.55) in the facet joint trial, −0.71 (95% CI, −1.35 to −0.06; P =.03) in the sacroiliac joint trial, and −0.99 (95% CI, −1.73 to −0.25; P =.01) in the combination trial. At the 12-month follow-up, the mean difference in pain intensity scores between the radiofrequency denervation group and the control group was 0.47 (95% CI, −0.14 to 1.07; P =.13) in the facet joint trial, −0.07 (95% CI, −0.74 to 0.60; P =.83) in the sacroiliac joint trial, and 0.69 (−0.10 to 1.49; P =.09) in the combination trial.

The secondary outcomes in all 3 trials yielded small or no therapeutic benefit.

“[Radiofrequency denervation] should be performed in a research setting only. The role of [radiofrequency denervation] in the treatment of a subgroup of patients with cLBP resulting from anatomical structures such as facet joints, sacroiliac joints, and intervertebral discs remains questionable,” explained study co-author Esther T. Maas, PhD, from Vrije University, Amsterdam, The Netherlands, in an interview with Clinical Pain Advisor. “Future research on the diagnosis and treatment for this subset of patients with cLBP is necessary and should focus on better patient selection and improvement of treatment techniques and tools for outcome measurement.”

Summary and Clinical Applicability

Despite its common use, radiofrequency denervation may not be effective in reducing cLBP intensity in the facet joints, sacroiliac joints, or a combination of both joints.

Limitations and Disclosures

• The participants were not blinded to the radiofrequency denervation procedure
• Trial participants were excluded if they presented with psychological comorbidities, which may decrease the generalizability of the study
• Some patients in the control group received radiofrequency denervation after the 3-month treatment period
• A higher dropout rate in the control group in the sacroiliac joint trial might have introduced bias

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References

1. Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the mint randomized clinical trials. JAMA. 2017;318(1):68-81. doi:10.1001/jama.2017.7918
2. Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996-2013. JAMA. 2016;316(24):2627-2646. doi:10.1001/jama.2016.16885
3. Manchikanti L, Hirsch JA, Pampati V, Boswell MV. Utilization of facet joint and sacroiliac joint interventions in Medicare population from 2000 to 2014: explosive growth continues! Curr Pain Headache Rep. 2016;20(10):58. doi:10.1007/s11916-016-0588-2
4. Maas ET, Ostelo RWJG, Niemisto L, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev. 2015;(10):CD008572. doi:10.1002/14651858.CD008572.pub2