Randomized, controlled blind study comparing sacroiliac intra-articular steroid injection to radiofrequency denervation for sacroiliac joint pain

The effectiveness of sacral lateral branch radiofrequency neurotomy for posterior sacroiliac joint complex pain in patients selected by dual sacral lateral branch blocks; A real-world cohort study

Background

Previous study of spinal neurotomy procedures indicates that stringent block selection improves outcomes. However, this pattern is not established for sacral lateral branch radiofrequency neurotomy (SLBRFN). Few SLBRFN studies have used stringent block selection criteria such as ≥80 % pain reduction following dual sacral lateral branch blocks (SLBB).

Objective

Evaluate the effectiveness of SLBRFN in patients with ≥80 % pain relief following dual SLBBs.

Methods

Retrospective single-arm cohort study of consecutive patients from two Canadian musculoskeletal and pain clinics who underwent first-time SLBRFN after report of ≥80 % pain relief following dual diagnostic SLBBs. Patients were identified by electronic medical record query between 2016 and 2022. The primary outcome was the proportion of individuals with a ≥50 % reduction in the numeric pain rating scale (NPRS) score three months after SLBRFN. Secondary outcomes included the proportion of responders achieving the minimal clinically important difference (MCID) on the pain disability quality-of-life questionnaire (PDQQ), and the duration and mean percentage of pain relief among those with recurrent symptoms after a successful SLBRFN.

Results

Of the 70 participants included, 32 (45.7 %; 95 % CI = 34.6-57.3) reported a ≥50 % reduction in NPRS, and 35 (50.0 %; 95 % CI = 38.6-61.4) achieved the MCID on the PDQQ at 3-months. Among the 17 patients who reported a return of symptoms, the mean duration of relief was 8.0 ± 3.5 months, and the mean percentage of pain relief was 77.9 % ± 16.4 %. Logistic regression models revealed that the use of multi-tined RF probes and lower patient BMI were associated with treatment success.

Discussion/conclusion

SLBRFN reduced pain and disability in approximately 50 % of patients at 3 months when selected using relatively restrictive selection criteria. Treatment success was associated with multi-tined RF probe type and lower patient BMI. Larger prospective studies assessing long-term outcomes are needed to further evaluate the impact of different selection criteria and techniques on SLBRFN effectiveness.

Minimally invasive interventional procedures for osteoarthritis and inflammatory arthritis: A systematic review and meta-analysis

OBJECTIVE

to summarize the evidence on the efficacy of minimally invasive interventional procedures such as radiofrequency ablation (RFA) and transcatheter arterial embolization (TAE) in patients with osteoarthritis or inflammatory arthritis.

METHODS

a literature search was conducted in PubMed and Web of Science databases. Both randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) were included. The results were organized according to the treated anatomical site: knee, hip, foot and ankle, shoulder, hand and wrist, sacroiliac joints. Data about treatment efficacy were extracted. The main outcome was change in pain intensity using the 0-10 visual analog scale (VAS) from baseline to 1 month. Additional timepoints at 3, 6 and 12 months were assessed. Change in functional status was evaluated. Pooled estimates were calculated as the mean difference (MD) and 95 % confidence interval relative to baseline. The meta-analyses of RCTs and NRSI were conducted separately.

RESULTS

of the 4599 retrieved articles, 164 were included in the review and, considering all the established timepoints, 111 (38 RCTs and 73 NRSI) were selected for the meta-analysis. Only one article described patients with inflammatory arthritis. In the meta-analysis of RCTs, one month after the procedure, MD in VAS was -3.98 (-4.41 to -3.55; k = 21) for knee RFA, and -3.18 (-3.96 to -2.39; k = 8) for sacroiliac joints RFA. In the meta-analysis of NRSI, MD in VAS was -4.12 (-4.63 to -3.61; k = 23) for knee RFA, -3.84 (-4.77 to -2.92; k = 7) for knee TAE, -4.34 (-4.96 to -3.71; k = 2) for hip RFA, -3.83 (-4.52 to -3.15; k = 3) for shoulder RFA and -4.93 (-5.58 to -4.28; k = 14) for sacroiliac joints RFA. Significant decrease in pain intensity was found also at 3, 6 and 12 months. Additionally, functional status improved at all the assessed timepoints.

CONCLUSION

minimally invasive interventional procedures can improve pain and functional status of patients affected by OA or chronic sacroiliac pain of degenerative origin. Further research is warranted in the field of inflammatory rheumatic diseases.

Radiofrequency vs Steroid Injections for Spinal Facet and Sacroiliac Joint Pain: A Systematic Review and Meta-Analysis

Purpose

Pain management for spinal facet joint (SFJ) and sacroiliac joint (SIJ) pain is challenging, often requiring interventions like radiofrequency ablation (RFA) or corticosteroid injections (CI). This study aims to assess and compare the effectiveness of CI and RFA in treating SFJ and SIJ pain. We combine these treatments due to their shared pathophysiology, similar therapeutic interventions, and the necessity for an integrated approach to spinal pain management.

Patients and methods

Literature search from PubMed, Scopus, CENTRAL and Google Scholar for published studies upto 31st December 2023, and reporting data of patients who were treated using CI of RFA for SFJ and SIJ pain. Pooled standardized mean difference (SMD) with a 95% Confidence Interval (CI) was calculated.

Results

Our meta-analysis incorporated thirteen studies. Overall, patients, treated with CI had a higher pain intensity score compared to patients treated with RFA (SMD=0.92; 95% CI: 0.19 to 1.65) at 3 months, and at 6 months (SMD=1.53; 95% CI: 0.66 to 2.40) after the treatment. No significant association was reported at 12 months (SMD=1.47; 95% CI: -0.03 to 2.97). Subgroup analysis based on joint types revealed increased pain intensity scores in patients who were treated with CI for SIJ (SMD=1.25; 95% CI: 0.39 to 2.11) and SFJ (SMD=1.33; 95% CI: 0.09 to 2.57) pain. A negative but not significant effect was detected in patients, treated with CI for cervical joint pain (SMD=-0.40; 95% CI: -0.90 to 0.10). Patients treated with CI exhibited higher functional disability score compared to patients treated with RFA at 3 months (SMD=1.28; 95% CI: 0.20 to 2.35) post-treatment.

Conclusion

This study suggests that RFA may offer superior pain relief with longer duration compared to steroid injections for spinal facet and sacroiliac joint pain. Decision regarding specific interventions should be individualized and consider patient preferences, clinical context, and potential risks.

Systematic Review and Meta-Analysis of the Effectiveness of Radiofrequency Ablation of the Sacroiliac Joint

PURPOSE OF REVIEW

To evaluate the effectiveness of radiofrequency neurotomy in managing sacroiliac joint pain utilizing a systematic review with meta-analysis of randomized controlled trials (RCTs) and observational studies.

RECENT FINDINGS

The prevalence of sacroiliac joint pain is estimated at around 25% of low back pain cases, and its diagnosis lacks a gold standard. Treatments include exercise therapy, injections, ablation, and fusion, with variable effectiveness. COVID-19 altered utilization patterns of interventions, including sacroiliac joint procedures, and the evidence for these interventions remains inconclusive. Recently, Medicare has issued its local coverage determinations (LCDs) in the United States, which provides noncoverage of sacroiliac joint radiofrequency neurotomy. Additionally, a recent systematic review of sacroiliac joint injections showed Level III or fair evidence. The sacroiliac joint, a critical axial joint linking the spine and pelvis, contributes to low back pain. Its complex innervation pattern varies among individuals. Sacroiliac joint dysfunction, causing pain and stiffness, arises from diverse factors.The present systematic review and meta-analysis aimed to evaluate radiofrequency neurotomy's effectiveness for sacroiliac joint pain management by applying rigorous methodology, considering both RCTs and observational studies. Despite methodological disparities, the evidence from this review, supported by changes in pain scores and functional improvement, suggests Level III evidence with fair recommendation for radiofrequency neurotomy as a treatment option. The review's strengths include its comprehensive approach and quality assessment. However, limitations persist, including variations in criteria and technical factors, underscoring the need for further high-quality studies in real-world scenarios.

5. Sacroiliac joint pain

INTRODUCTION

Sacroiliac (SI) joint pain is defined as pain localized in the anatomical region of the SI joint. The reported prevalence of SI joint pain among patients with mechanical low back pain varies between 15% and 30%.

METHODS

In this narrative review, the literature on the diagnosis and treatment of SI joint pain was updated and summarized.

RESULTS

Patient's history provides clues on the source of pain. The specificity and sensitivity of provocative maneuvers are relatively high when three or more tests are positive, though recent studies have questioned the predictive value of single or even batteries of provocative tests. Medical imaging is indicated only to rule out red flags for potentially serious conditions. The diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for false-positive and false-negative results. Treatment of SI joint pain ideally consists of a multidisciplinary approach that includes conservative measures as first-line therapies (eg, pharmacological treatment, cognitive-behavioral therapy, manual medicine, exercise therapy and rehabilitation treatment, and if necessary, psychological support). Intra- and extra-articular corticosteroid injections have been documented to produce pain relief for over 3 months in some people. Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 (or 4) lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The reported rate of complications for SI joint treatments is low.

CONCLUSIONS

SI joint pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, corticosteroid injections and radiofrequency treatment can be considered.

Chronic sacroiliac joint dysfunction and CT-guided percutaneous fixation: a 6-year experience

PURPOSE

Reporting the clinical outcomes, patient satisfaction, and complications following an imaging-guided percutaneous screw fixation in the treatment of sacroiliac joint dysfunction and evaluating the safety and effectiveness of this method.

METHODS

We performed a retrospective study on a prospectively gathered cohort of patients with physiotherapy-resistant pain due to sacroiliac joint incompetence that underwent percutaneous screw fixation, between 2016 and 2022 in our center. A minimum of two screws were used in all patients to obtain fixation of the sacroiliac joint, using percutaneous screw insertion under CT guidance, coupled with a C-arm fluoroscopy unit.

RESULTS

The mean visual analog scale significantly improved at 6 months of follow-up (p < 0.05). One hundred percent of the patients reported significant improvement in pain scores at the final follow-up. None of our patients experienced intraoperative or postoperative complications.

CONCLUSION

The use of percutaneous sacroiliac screws provides a safe and effective technique for the treatment of sacroiliac joint dysfunction in patients with chronic resistant pain.

The effectiveness and safety of sacral lateral branch radiofrequency neurotomy (SLBRFN): A systematic review

Objective

To assess the effectiveness and safety of sacral lateral branch radiofrequency neurotomy (SLBRFN) in treating posterior sacroiliac joint complex (PSIJC) pain, stratifying results by patient selection criteria and technique.

Design

Systematic review.

Population

Adults over 18 years old with suspected PSIJC pain.

Intervention

SLBRFN with image guidance (including computed tomography, fluoroscopy, ultrasound).

Comparison

Any other treatment, sham, or no treatment.

Outcomes

The primary outcome was improvement in pain reported as continuous data or the proportion of patients obtaining ≥50% reduction in pain scores on either the visual analog scale (VAS) or numeric rating scale (NRS). Secondary outcomes included functional improvement, reported as continuous data or the proportion of patients obtaining ≥30% in function from baseline, and adverse events.

Methods

Six reviewers independently assessed publications prior to December 2022 in PubMed, EMBASE, Web of Science, and Google Scholar and utilized the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to evaluate the overall quality of evidence.

Results

Of the 415 publications screened, 37 met the inclusion criteria, with 33 providing sufficient data regarding the effectiveness of SLBRFN. Of the included studies, there were four explanatory randomized controlled trials (RCTs), four pragmatic RCTs, 11 prospective cohort studies, 14 retrospective cohort studies, and four case reports describing adverse events. At 6 months, the proportion of patients with ≥50% pain relief ranged from 19 to 89%. Studies providing continuous data reported that patients achieved 40-60% pain relief sustained at 12 months. There was heterogeneity in reporting functional improvement, but most studies noted improvement. While all studies that reported categorical outcomes targeted the S1-3 sacral lateral branches, the majority also included RFN of the L5 dorsal ramus. Successful outcomes were reported in patients selected by the response to intra-articular blocks (single or dual) or sacral lateral branch blocks (single or dual). Twenty-nine total adverse events and three serious adverse events (SAE) were reported across 1367 patients. According to the GRADE system, there is moderate-quality evidence overall that SLBRFN effectively reduces pain and disability in a majority of patients with PSIJC pain at 1, 3, 6, and 12 months. When anatomically validated SLBRFN techniques are assessed, the level of evidence is upgraded to high quality.

Discussion/conclusion

Despite the variability in types of radiofrequency technology, technique, nerve targets, and study methodology, most studies found that substantial proportions of patients achieved ≥50% relief at 1, 3, 6, and 12 months following SLBRFN. When anatomically validated SLBRFN techniques are applied, there is a high level of confidence that the procedure effectively reduces pain and improves function in patients with PSIJC pain. Additional high-quality studies exploring the prognostic value of different block protocols and the relative effectiveness of the various SLBRFN procedure techniques are needed to further optimize the clinical outcomes of SLBRFN.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Radiofrequency Ablation as an Effective Long-Term Treatment for Chronic Sacroiliac Joint Pain: A Systematic Review of Randomized Controlled Trials

Radiofrequency ablation (RFA) has emerged as a popular intervention for chronic pain management, including pain originating in the sacroiliac joint. It offers a less invasive option than surgery but with better results than the previous standard treatment with steroid and anesthetic injections. Procedure volumes have enjoyed significant growth in the market in recent years. The evidence supporting this intervention, in the form of randomized controlled trials, however, is both thin and mixed. The purpose of this systematic review is to evaluate the body of randomized controlled trials (RCTs) to determine the quality of support for and against the use of radiofrequency ablation to treat sacroiliac joint (SIJ) pain. Several important new papers have emerged since previous systematic reviews with similar objectives were published. The review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and three databases were used: PubMed, Google Scholar, and Scopus. Only RCTs were sought, and no other filters, such as a historical timeline cut-off, were used. Among 95 publications that returned in response to the query, 16 were ultimately accepted as meeting the inclusion/exclusion criteria. The Cochrane risk-of-bias tool was utilized as a quality assessment measure, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was used to assess the certainty of the evidence. Among the included publications, 15 out of 16 publications featured positive results and conclusions that supported the use of RFA in treating chronic sacroiliac joint pain. The single negative study was also the largest trial (n=681), but it was identified as “High Risk” using the Cochrane risk-of-bias tool. It included several design flaws including neither operator nor patient blinding, missing information, use of inconsistent treatment modalities across groups, and disproportionate drop-out rates. Despite its flaws, we have included this study in the present review because of its sheer size. Taken in aggregate, the total body of research included in this review supports this intervention. Questions continue to exist around whether there are clinically significant benefits associated with different RFA modalities (for example, unipolar vs. bipolar), with convincing evidence supporting each of them. Finally, it can be concluded that while the benefits are reasonably and justifiably supported in this patient population for up to one year, there is a dearth of evidence beyond a 12-month post-intervention follow-up.

Preliminary Results of Endoscopic Radiofrequency Treatment of the Sacroiliac Joint Syndrome

BACKGROUND AND STUDY

 The sacroiliac joint (SIJ) may be the primary source of pain in 15 to 25% of patients with axial low back pain. Furthermore, 75% of patients who have had fusion surgery develop SIJ pain within 10 years. Treatment options include SIJ blocks, radiofrequency (RF) denervation, and fusion. The RF techniques range from ablation of the nerves supplying the joint, creating lesions to the joint itself, or a combination of both techniques. However, different clinical studies could only identify a limited or, in some cases, no effect in decreasing of pain intensity and duration of the effect.

METHODS

 In this retrospective study, we selected 23 patients with SIJ pain, with a duration of more than 12 months and a 50% pain reduction on the Numeric Rating Scale (NRS) after diagnostic block. All patients received endoscopic ablation of the medial branch L5/S1 and the lateral branches, exiting the sacral foramina on S1/S2 and S2/S3 on both sides while using only one incision on each side. Telephone interviews were conducted with all patients. The outcome was determined with Odom's criteria, percent reduction NRS, subjective assessment of the patient, and duration of the effect.

RESULTS

 According to Odom's criteria, 79% of the patients showed acceptable to excellent results and confirmed that denervation helped them to manage their daily lives better. The average pain reduction in the responder group was 57% with an average duration of 13.4 months.

CONCLUSION

 In this retrospective study, we could demonstrate the practicability and effectiveness of endoscopic SIJ denervation in the treatment of SIJ pain using only one incision for three levels on each side. Further studies should investigate if this procedure is more effective than percutaneous RF.

Radiofrequency Ablation for Chronic Posterior Sacroiliac Joint Complex Pain: A Comprehensive Review

Radiofrequency ablation of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint. These structures are also collectively referred to as the posterior sacroiliac joint complex. This review will discuss current diagnostic block paradigms and selection criteria for sacral lateral branch radiofrequency ablation, varying techniques and technologies utilized for sacral lateral branch radiofrequency ablation, and updates on the clinical outcome literature. The current evidence suggests that sacral lateral branch radiofrequency ablation can provide relief for posterior sacroiliac joint complex pain, but the literature is limited by variability in selection criteria, the specific nerves targeted by radiofrequency ablation, and the types of radiofrequency ablation technology and techniques utilized in clinical outcome studies.

[Interdisciplinary position paper: the value of radiofrequency denervation in the treatment of chronic pain]

Radiofrequency denervation has been established for many years as an important minimally invasive procedure for the treatment of chronic pain conditions. Positive experiences of many users for various indications are contrasted by a nonuniform evidence. With meticulous patient selection and correct assessment of the indications a longer term reduction of pain, a reduced need for analgesics and an improvement in the quality of life can be achieved. The aim of this interdisciplinary position paper is to present the value of radiofrequency denervation in the treatment of chronic pain. The summarized recommendations of the expert group are based on the available evidence and on the clinical experiences of Austrian centers that frequently implement the procedure. The position paper contains recommendations on patient selection and proven indications. We discribe safety aspects, complications, side effects and contraindications.

Use of Ultrasound-Guided Platelet-Rich Plasma Injection of the Sacroiliac Joint as a Treatment for Chronic Low Back Pain

Back pain and its associated complications are of increasing importance among military members. The sacroiliac joint (SIJ) is a common source of chronic low back pain (LBP) and functional disability. Many patients suffering from chronic LBP utilize opioids to help control their symptoms. Platelet-rich plasma (PRP) has been used extensively to treat pain emanating from many different musculoskeletal origins; however, its use in the SIJ has been studied only on a limited basis. The patient in this case report presented with chronic LBP localized to the SIJ and subsequent functional disability managed with high-dose opioids. After failure of traditional treatments, she was given an ultrasound-guided PRP injection of the SIJ which drastically decreased her pain and disability and eventually allowed for complete opioid cessation. Her symptom relief continued 1 year after the injection. This case demonstrates the potential of ultrasound-guided PRP injections as a long-term treatment for chronic LBP caused by SIJ dysfunction in military service members, which can also aid in the weaning of chronic opioid use.

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial

BACKGROUND

The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care.

OBJECTIVES

To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective.

DESIGN

The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation.

SETTING

Five NHS acute trusts in England.

PARTICIPANTS

Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone.

INTERVENTIONS

All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session.

MAIN OUTCOME MEASURES

Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months.

RESULTS

Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84.

LIMITATIONS

Poor recruitment was a limiting factor.

CONCLUSIONS

This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain.

FUTURE WORK

Further work is needed to test recruitment from alternative clinical situations.

TRIAL REGISTRATION

EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.