Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic Hayes Satellite Unit, Hayes, UK.
Reg Anesth Pain Med. 2020 Jun;45(6):424-467. doi: 10.1136/rapm-2019-101243. Epub 2020 Apr 3.
The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.
After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.
17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).
Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
在过去的二十年中，腰椎关节突关节阻滞和射频消融（RFA）治疗腰痛（LBP）的使用急剧增加，但几乎所有程序都存在争议。
在美国区域麻醉和疼痛医学学会董事会批准后，向十几个疼痛协会以及美国退伍军人事务部和国防部的代表发出了信函。召集了一个指导委员会来选择初步问题，然后由全体委员会对这些问题进行修订。将问题分配给 4-5 人的模块，他们与小组委员会负责人和委员会主席一起研究初步版本，然后将这些版本发送给全体委员会。我们使用了一种改良的 Delphi 方法，即将问题整块发送给委员会，并以非盲方式将意见返回给主席，主席将意见纳入并发送修订版本，直到达成共识。
选择了 17 个问题来制定指南，委员会成员对所有主题均达成了 100%的共识。除一个协会外，所有协会都批准了每项建议，一个协会对两个问题（阻滞的数量和 RFA 前阳性阻滞的截止值）有异议，但批准了该文件。所涉及的具体问题包括病史和体格检查在选择阻滞患者中的价值、影像学在患者选择中的价值、注射前是否应使用保守治疗、注射时是否需要影像学、内侧支阻滞（MBB）和关节内（IA）注射的诊断和预后价值、镇静和注射量对有效性的影响、关节突阻滞是否具有治疗价值、预测性阻滞的理想截止值是多少、在进行 RFA 之前应进行多少次阻滞、电极应如何定向、较大病变的证据、在进行 RFA 之前是否应进行刺激、减轻并发症的方法、是否应在临床实践和临床试验中应用不同的标准、RFA 重复的证据（见表 12 中的总结）。
腰椎内侧支 RFA 可能对精选的个体有益，MBB 比 IA 注射更具预测性。更严格的选择标准可能会改善去神经支配的结果，但代价是更多的假阴性。临床试验应根据目标进行定制，并且一些临床试验的选择标准可能比临床实践中的理想标准更严格。
