Radiofrequency denervation for chronic low back pain - PubMed (original) (raw)
Review
Radiofrequency denervation for chronic low back pain
Esther T Maas et al. Cochrane Database Syst Rev. 2015.
Abstract
Background: Radiofrequency (RF) denervation, an invasive treatment for chronic low back pain (CLBP), is used most often for pain suspected to arise from facet joints, sacroiliac (SI) joints or discs. Many (uncontrolled) studies have shown substantial variation in its use between countries and continued uncertainty regarding its effectiveness.
Objectives: The objective of this review is to assess the effectiveness of RF denervation procedures for the treatment of patients with CLBP. The current review is an update of the review conducted in 2003.
Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, three other databases, two clinical trials registries and the reference lists of included studies from inception to May 2014 for randomised controlled trials (RCTs) fulfilling the inclusion criteria. We updated this search in June 2015, but we have not yet incorporated these results.
Selection criteria: We included RCTs of RF denervation for patients with CLBP who had a positive response to a diagnostic block or discography. We applied no language or date restrictions.
Data collection and analysis: Pairs of review authors independently selected RCTs, extracted data and assessed risk of bias (RoB) and clinical relevance using standardised forms. We performed meta-analyses with clinically homogeneous studies and assessed the quality of evidence for each outcome using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.
Main results: In total, we included 23 RCTs (N = 1309), 13 of which (56%) had low RoB. We included both men and women with a mean age of 50.6 years. We assessed the overall quality of the evidence as very low to moderate. Twelve studies examined suspected facet joint pain, five studies disc pain, two studies SI joint pain, two studies radicular CLBP, one study suspected radiating low back pain and one study CLBP with or without suspected radiation. Overall, moderate evidence suggests that facet joint RF denervation has a greater effect on pain compared with placebo over the short term (mean difference (MD) -1.47, 95% confidence interval (CI) -2.28 to -0.67). Low-quality evidence indicates that facet joint RF denervation is more effective than placebo for function over the short term (MD -5.53, 95% CI -8.66 to -2.40) and over the long term (MD -3.70, 95% CI -6.94 to -0.47). Evidence of very low to low quality shows that facet joint RF denervation is more effective for pain than steroid injections over the short (MD -2.23, 95% CI -2.38 to -2.08), intermediate (MD -2.13, 95% CI -3.45 to -0.81), and long term (MD -2.65, 95% CI -3.43 to -1.88). RF denervation used for disc pain produces conflicting results, with no effects for RF denervation compared with placebo over the short and intermediate term, and small effects for RF denervation over the long term for pain relief (MD -1.63, 95% CI -2.58 to -0.68) and improved function (MD -6.75, 95% CI -13.42 to -0.09). Lack of evidence of short-term effectiveness undermines the clinical plausibility of intermediate-term or long-term effectiveness. When RF denervation is used for SI joint pain, low-quality evidence reveals no differences from placebo in effects on pain (MD -2.12, 95% CI -5.45 to 1.21) and function (MD -14.06, 95% CI -30.42 to 2.30) over the short term, and one study shows a small effect on both pain and function over the intermediate term. RF denervation is an invasive procedure that can cause a variety of complications. The quality and size of original studies were inadequate to permit assessment of how often complications occur.
Authors' conclusions: The review authors found no high-quality evidence suggesting that RF denervation provides pain relief for patients with CLBP. Similarly, we identified no convincing evidence to show that this treatment improves function. Overall, the current evidence for RF denervation for CLBP is very low to moderate in quality; high-quality evidence is lacking. High-quality RCTs with larger patient samples are needed, as are data on long-term effects.
Conflict of interest statement
ET Maas: none.
RWJG Ostelo: none.
L Niemisto: none.
J Jousimaa: none.
H Hurri: working for and leading the Rehabilitation Unit and Hospital of Orton, where radiofrequency is applied as well.
A Malmivaara: working as a scientific expert in the Research Unit of Orton.
MW van Tulder: none.
Figures
1
Study flow diagram.
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1. Analysis
Comparison 1 Facet joint: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 month.
1.2. Analysis
Comparison 1 Facet joint: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 2 VAS 1 to 6 months.
1.3. Analysis
Comparison 1 Facet joint: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 3 VAS > 6 months.
2.1. Analysis
Comparison 2 Facet joint: radiofrequency denervation versus placebo, functional status (ODI), Outcome 1 ODI 1 month.
2.2. Analysis
Comparison 2 Facet joint: radiofrequency denervation versus placebo, functional status (ODI), Outcome 2 ODI > 6 months.
3.1. Analysis
Comparison 3 Facet joint: continuous radiofrequency denervation versus pulsed radiofrequency denervation, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 to 6 months.
4.1. Analysis
Comparison 4 Facet joint: percutaneous intra‐articular denervation versus percutaneous extra‐articular denervation, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 to 6 months.
5.1. Analysis
Comparison 5 Facet joint: radiofrequency denervation distal approach versus tunnel vision approach, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 month.
5.2. Analysis
Comparison 5 Facet joint: radiofrequency denervation distal approach versus tunnel vision approach, pain intensity (VAS 0 to 10), Outcome 2 VAS > 6 months.
6.1. Analysis
Comparison 6 Facet joint: radiofrequency denervation distal approach versus tunnel vision approach, functional status (ODI), Outcome 1 ODI 1 month.
6.2. Analysis
Comparison 6 Facet joint: radiofrequency denervation distal approach versus tunnel vision approach, functional status (ODI), Outcome 2 ODI 6 months.
7.1. Analysis
Comparison 7 Facet joint: radiofrequency denervation versus steroid injections, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 month.
7.2. Analysis
Comparison 7 Facet joint: radiofrequency denervation versus steroid injections, pain intensity (VAS 0 to 10), Outcome 2 VAS 6 months.
7.3. Analysis
Comparison 7 Facet joint: radiofrequency denervation versus steroid injections, pain intensity (VAS 0 to 10), Outcome 3 VAS 12 months.
8.1. Analysis
Comparison 8 Facet joint: radiofrequency denervation versus steroid injections, functional status (ODI), Outcome 1 ODI 6 months.
9.1. Analysis
Comparison 9 Facet joint: radiofrequency denervation versus steroid injections, participant satisfaction (scale 1 to 4), Outcome 1 Participant satisfaction 1 month.
9.2. Analysis
Comparison 9 Facet joint: radiofrequency denervation versus steroid injections, participant satisfaction (scale 1 to 4), Outcome 2 Participant satisfaction 6 months.
9.3. Analysis
Comparison 9 Facet joint: radiofrequency denervation versus steroid injections, participant satisfaction (scale 1 to 4), Outcome 3 Participant satisfaction 12 months.
10.1. Analysis
Comparison 10 Discs: 120‐second radiofrequency denervation versus 360‐second radiofrequency, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 month.
10.2. Analysis
Comparison 10 Discs: 120‐second radiofrequency denervation versus 360‐second radiofrequency, pain intensity (VAS 0 to 10), Outcome 2 VAS 1 to 6 months.
10.3. Analysis
Comparison 10 Discs: 120‐second radiofrequency denervation versus 360‐second radiofrequency, pain intensity (VAS 0 to 10), Outcome 3 VAS 6 months.
11.1. Analysis
Comparison 11 Discs: 120‐second radiofrequency denervation versus 360‐second radiofrequency, functional status (ODI), Outcome 1 ODI < 1 month.
11.2. Analysis
Comparison 11 Discs: 120‐second radiofrequency denervation versus 360‐second radiofrequency, functional status (ODI), Outcome 2 ODI > 6 months.
12.1. Analysis
Comparison 12 Discs: radiofrequency denervation versus lidocaine, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 to 6 months.
13.1. Analysis
Comparison 13 Discs: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 month.
13.2. Analysis
Comparison 13 Discs: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 2 VAS 1 to 6 months.
13.3. Analysis
Comparison 13 Discs: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 3 VAS 6 months.
14.1. Analysis
Comparison 14 Discs: radiofrequency denervation versus placebo, functional status (ODI), Outcome 1 ODI 1 month.
14.2. Analysis
Comparison 14 Discs: radiofrequency denervation versus placebo, functional status (ODI), Outcome 2 ODI 1 to 6 months.
14.3. Analysis
Comparison 14 Discs: radiofrequency denervation versus placebo, functional status (ODI), Outcome 3 ODI 6 months.
15.1. Analysis
Comparison 15 SI joint: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 month.
15.2. Analysis
Comparison 15 SI joint: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 2 VAS 1 to 6 months.
16.1. Analysis
Comparison 16 SI joint: radiofrequency denervation versus placebo, functional status (ODI), Outcome 1 ODI 1 month.
16.2. Analysis
Comparison 16 SI joint: radiofrequency denervation versus placebo, functional status (ODI), Outcome 2 ODI 1 to 6 months.
17.1. Analysis
Comparison 17 Radiating LBP: pulsed radiofrequency denervation versus pulsed radiofrequency denervation and continuous radiofrequency denervation, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 to 6 months.
18.1. Analysis
Comparison 18 Dorsal root ganglion: radiofrequency denervation versus placebo, pain intensity (VAS 0 to 10), Outcome 1 VAS 1 to 6 months.
19.1. Analysis
Comparison 19 Dorsal root ganglion: pulsed radiofrequency versus placebo (number of participants with > 50% reduction in VAS 0 to 10), Outcome 1 VAS 1 month.
Comment in
- Cochrane Review Identifies Safe and Effective Treatment for Z-Joint Pain.
Schneider BJ, Miller DC, Martinez KR, Cota AG, Maes MK; Standards Division of the Spine Intervention Society. Schneider BJ, et al. Pain Med. 2017 Dec 1;18(12):2509-2510. doi: 10.1093/pm/pnx095. Pain Med. 2017. PMID: 28444244 No abstract available.
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