Radiofrequency neurotomy for low back pain: evidence-based procedural guidelines.
OBJECTIVE
This review was undertaken to outline the procedural limitations of the randomized controlled trials (RCTs) of radiofrequency (RF) neurotomy for low back pain. Second, the literature related to patient selection, diagnostic testing, and the technique of performing lumbar spine RF neurotomy will be critically reviewed and analyzed. Based on these analyses, diagnostic and procedural guidelines will be proposed.


METHODS
A Medline and EMBASE search identified three RCTs and two systematic reviews of RF neurotomy for low back pain. A similar search identified pertinent literature related to the method of patient selection for a diagnostic block, the medial branch and L5 dorsal ramus comparative block, and the anatomical and technical parameters of lumbar spine RF neurotomy.


RESULTS
Substantial procedural shortcomings were identified in all three RCTs. In the systematic reviews, these procedural limitations were not accounted for by the quality assessment of study design which resulted in an inaccurate estimate of clinical effectiveness. Analysis using likelihood ratios showed that screening criteria could increase the probability of zygapophysial joint pain before performing diagnostic blocks. Similar analysis showed that comparative medial branch blocks, rather than single blocks, must be used before RF neurotomy. Anatomical studies demonstrated that the shorter distal compared with the circumferential radius of the RF lesion necessitates placement of the electrode parallel to the course of the nerve along the base of the superior articular process.


CONCLUSIONS
The evidence-based procedural guidelines provide consistent criteria for multisite studies that could enroll a sufficiently large homogenous study cohort.
Hooten
W Michael
WM
Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA. hooten.william@mayo.edu
Martin
David P
DP
Huntoon
Marc A
MA
D017115:Catheter Ablation / Q000379:methods*; D003714:Denervation / Q000379:methods*; D019317:Evidence-Based Medicine; D006801:Humans; D017116:Low Back Pain / Q000209:etiology / Q000517:prevention & control*; D008159:Lumbar Vertebrae / Q000601:surgery; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D016032:Randomized Controlled Trials as Topic; D013127:Spinal Nerves / Q000601:surgery; D016896:Treatment Outcome; D021801:Zygapophyseal Joint / Q000294:innervation* / Q000601:surgery*