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Pain originating from the lumbar facet jointsRecommendationsDescriptionStrength of recommendationLevel of evidenceIntra articular injection of local anesthetic with or without corticosteroid could be considered for the treatment of pain originating from the lumbar facet joints.Very weakLowDescriptionStrength of recommendationLevel of evidenceIf a standardized exercise program fails, a radiofrequency treatment of the ramus medialis of the ramus dorsalis could be used for the treatment of pain originating from the lumbar facet joints.WeakLowDescriptionStrength of recommendationLevel of evidencePulsed radiofrequency of the ramus medialis of the ramus dorsalis could not be considered for the treatment of pain originating from the lumbar facet joints.Very weak againstlowClinical questions:What is the place for interventional pain treatments in the management of pain originating from the lumbar facet joints?Researched treatment optionsFor patients suffering pain originating from the lumbar facet joints, we studied the following treatments:Intraarticular corticosteroid injectionsRadiofrequency treatmentsPulsed radiofrequency treatmentsAny comparators including sham, no treatment or other active treatment techniques were eligible. Inclusion was not restricted based on outcomeMethodsFor the search strategy and the methodology, we refer to the introductionResults of literature searchExisting systematic reviews were assessed but were not fully up to date. They were used asa source of trials to supplement searches. After deduplication 10,333 records were screenedfor inclusion in the study and 38 studies were finally included in the review (22 lumbar facetpain, six sacroiliac pain and 10 discogenic pain).Intraarticular corticosteroid injections (IAC)Literature overviewAll comparators assessing IAC were different so a meta-analysis could not be conducted. One trial compared an IAC to physiotherapy in a total of 18 patients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXd1PC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 1. This trial found that reduction in pain (VAS 0-10), at three and six months was significantly larger in the IAC group. Disability measured, using the Oswestry Disability Index (ODI), was also significantly better in the IAC group. Adverse events were not reported. This trial was rated as unclear or high risk of bias in virtually all domains of the Cochrane Risk of Bias checklist. Methodological problems included unclear procedures for randomization, allocation concealment and blinding of outcome assessors. One trial compared intra-articular injection with local anesthetic to intra-articular injection with local anesthetic and corticosteroid PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYW5jaGlrYW50aTwvQXV0aG9yPjxZZWFyPjIwMTA8L1ll

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ADDIN EN.CITE.DATA 3 in 60 patients (31 in the IAC group and 29 in the IM group). No significant difference in pain (VAS 0-10) between the treatment groups was found at three and six months; significant reductions in pain over time were observed in both groups. All participants had a history of continuous or intermittent low back pain for at least three months, but no objective method of confirming the diagnosis of lumbar facet joint syndrome was reported. There were no statistically significant differences in adverse event rates between the treatment groups. This study was rated as high risk of bias according to the Cochrane Risk of Bias Tool, as it was considered unlikely that caregivers could have been blinded to treatment group. Intra-articular corticosteroid and local anesthetic injection was compared to injection of the same mixture at the ramus medialis of the ramus dorsalis ADDIN EN.CITE <EndNote><Cite><Author>Ackerman</Author><Year>2008</Year><RecNum>11752</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>11752</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1454667699">11752</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ackerman, W. E., 3rd</author><author>Ahmad, M.</author></authors></contributors><auth-address>United Pain Care, Sherwood, AR 72120, USA. epmo@</auth-address><titles><title>Pain relief with intraarticular or medial branch nerve blocks in patients with positive lumbar facet joint SPECT imaging: a 12-week outcome study</title><secondary-title>South Med J</secondary-title></titles><periodical><full-title>South Med J</full-title></periodical><pages>931-4</pages><volume>101</volume><number>9</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Chi-Square Distribution</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Low Back Pain/*drug therapy/etiology/physiopathology/*radionuclide imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain Measurement</keyword><keyword>Prospective Studies</keyword><keyword>Statistics, Nonparametric</keyword><keyword>Survival Analysis</keyword><keyword>*Tomography, Emission-Computed, Single-Photon</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2008</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1541-8243 (Electronic)&#xD;0038-4348 (Linking)</isbn><accession-num>18708988</accession-num><urls><related-urls><url> in 46 patients (23 in each treatment group) found that patients in the IAC group had significantly less pain (NRS 0-10) and lower disability scores (ODI 0-50) at three months than those in the medial branch block group. Similarly, 61% of patients in the IAC group had significant pain relief (≥50%) at three months, compared with 26% in the medial branch block group. Patients had non-radicular low back pain (mean duration of symptoms <2 months) and were lumbar facet joint SPECT-positive. No information on adverse events was reported. This study was rated as high risk of bias and imprecision according to the Cochrane Risk of Bias Tool, due to incomplete outcome data for study participants. ConclusionsQuality of the evidence DescriptionLowThere is evidence of low quality that intra-articular corticosteroid injection provides better pain relief at 3 and 6 months than physiotherapyKawu et al. 2011Quality of the evidence DescriptionModerateThere is evidence of moderate quality that there is no significant difference in pain (numeric rating scale 0-10), at three, six and 12 months, between an intra articular injection with local anesthetic combined with steroids and an intra articular injection with local anesthetic alone.Manchikanti et al. 2010Quality of the evidence DescriptionModerateThere is evidence of moderate quality that there is no difference in pain relief (visual analogue scale 0-10), with intra articular corticosteroid injection compared to intra muscular corticosteroid injection at three and six months.Ribeiro et al. 2013Quality of the evidence DescriptionlowThere is evidence of low quality that patients in the intra articular corticosteroid injection group had significantly less pain (numeric rating scale 0-10) and lower disability scores (Oswestry Disability Index 0-50) at three months than those in the medial branch nerve block group.Ackerman et al 2008Considerations Intra-articular corticosteroid injections for the treatment of pain originating from the lumbar facet joint was compared with a wide variety of treatments, thus not allowing to make a meta-analysis. In general patients experienced pain relief and improvement of disability for 3 to 6 months. No difference between treatments. The added value of corticosteroid added to local anesthetic versus local anesthetic alone could not be demonstrated. The effect size was not consistently reported. Where reported ≥ 50% pain reduction in over half of the patients in the intra-articular corticosteroid group was observed.In the majority of studies adverse effects were not reported. Just one study (IAC versus ramus medialis of the ramus dorsalis) reported adverse events as rare complaints of superficial burns with RF and a burning sensation at the injection site for IAC. Multiple RCT’s with methodological weaknesses yield contradictory results. Weighing the potential benefits against the potential risks and burden for the patients suggests a close balance .RecommendationsDescriptionStrength of recommendationLevel of evidenceIntra articular injection of local anesthetic with or without corticosteroid could be considered for the treatment of pain originating from the lumbar facet joints. Very weakLowRadiofrequency treatmentLiterature overviewWe identified 5 RCT’s PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gV2lqazwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+

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ADDIN EN.CITE.DATA 5-9 that studied RF lesion versus sham procedures. It seems not appropriate to pool the trials of RF versus sham, because the trials were considered to be too heterogeneous. There are differences, for example, in pain scales and outcome time points amongst others. Three of the trials were of high quality and did not appear to suffer from bias, , 33, 40. One trial was rated unclear on several domains of the Cochrane Risk of Bias Tool27 and one was at high risk of bias ADDIN EN.CITE <EndNote><Cite><Author>Gallagher</Author><Year>1994</Year><RecNum>103</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">103</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>J. Gallagher </author><author>P.L.P. Vadi </author><author>J.R. Wesley</author></authors></contributors><titles><title>Radiofrequency facet joint denervation in the treatment of low back pain-a prospective controlled double-blind study in assess to efficacy</title><secondary-title>Pain Clinic</secondary-title></titles><periodical><full-title>Pain Clinic</full-title></periodical><pages>193-198</pages><volume>7</volume><number>1</number><dates><year>1994</year></dates><urls></urls></record></Cite></EndNote>8Gallagher ADDIN EN.CITE <EndNote><Cite><Author>Gallagher</Author><Year>1994</Year><RecNum>103</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">103</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>J. Gallagher </author><author>P.L.P. Vadi </author><author>J.R. Wesley</author></authors></contributors><titles><title>Radiofrequency facet joint denervation in the treatment of low back pain-a prospective controlled double-blind study in assess to efficacy</title><secondary-title>Pain Clinic</secondary-title></titles><periodical><full-title>Pain Clinic</full-title></periodical><pages>193-198</pages><volume>7</volume><number>1</number><dates><year>1994</year></dates><urls></urls></record></Cite></EndNote>8 reported better pain relief (McGill pain questionnaire at 3 month and VAS at 6 months) in patients who received active treatment after a positive diagnostic block. Van Kleef ADDIN EN.CITE <EndNote><Cite><Author>van Kleef</Author><Year>1999</Year><RecNum>12147</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>12147</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1478449081">12147</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van Kleef, M.</author><author>Barendse, G. A.</author><author>Kessels, A.</author><author>Voets, H. M.</author><author>Weber, W. E.</author><author>de Lange, S.</author></authors></contributors><auth-address>Department of Anaesthesiology, Pain Management and Research Centre, Maastricht, The Netherlands. mvk@sane.azm.nl</auth-address><titles><title>Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1937-42</pages><volume>24</volume><number>18</number><keywords><keyword>Adult</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Low Back Pain/diagnosis/*surgery</keyword><keyword>Lumbar Vertebrae/*innervation/radiography</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Odds Ratio</keyword><keyword>Pain Measurement</keyword><keyword>Prospective Studies</keyword><keyword>Quality of Life</keyword><keyword>Spinal Nerve Roots/radiography/*surgery</keyword><keyword>*Transcutaneous Electric Nerve Stimulation</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1999</year><pub-dates><date>Sep 15</date></pub-dates></dates><isbn>0362-2436 (Print)&#xD;0362-2436 (Linking)</isbn><accession-num>10515020</accession-num><urls><related-urls><url> found significant better pain reduction and improvement in disability 8 weeks after the intervention group compared to sham treatment.Nath ADDIN EN.CITE <EndNote><Cite><Author>Nath</Author><Year>2008</Year><RecNum>2248</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>2248</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">2248</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nath, S.</author><author>Nath, C. A.</author><author>Pettersson, K.</author></authors></contributors><auth-address>Smartkliniken (The Pain Clinic), Umea, Sweden. sherdil@</auth-address><titles><title>Percutaneous lumbar zygapophysial (Facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial</title><secondary-title>Spine</secondary-title></titles><periodical><full-title>Spine</full-title></periodical><pages>1291-7; discussion 1298</pages><volume>33</volume><number>12</number><dates><year>2008</year><pub-dates><date>May 20</date></pub-dates></dates><accession-num>18496338</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>7 randomized 40 patients to receive RF treatment or sham intervention. The active treatment group showed statistically significant improvement not only in back and leg pain but also back and hip movement as well as the sacro-iliac joint test. Pre-operative sensory deficit and weak or absent ankle reflex normalized (P < 0.01) and (P < 0.05), respectively. There was significant improvement in quality of life variables, global perception of improvement, and generalized pain. The improvement seen in the active group was significantly greater than that seen in the placebo group.Van Wijck PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gV2lqazwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+

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ADDIN EN.CITE.DATA 5 used a combined primary outcome measure comprising VAS, physical activities, and analgesic intake, from a twice-weekly recorded diary to assess the effect of RF facet denervation and sham intervention. The combined outcome measure showed no differences between radiofrequency facet joint denervation (n=40; success 27.5%) and sham (n=41; success 29.3%) (P=0.86). The VAS in both groups improved (P<0.001). Global perceived effect improved after radiofrequency facet joint denervation (P<0.05). The other secondary outcome parameters showed no significant difference.Leclaire ADDIN EN.CITE <EndNote><Cite><Author>Leclaire</Author><Year>2001</Year><RecNum>1672</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>1672</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1672</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Leclaire, R.</author><author>Fortin, L.</author><author>Lambert, R.</author><author>Bergeron, Y. M.</author><author>Rossignol, M.</author></authors></contributors><auth-address>Center for Clinical Epidemiology and Community Studies, Sir Mortimer B. Davis, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. laf.lec@sympatico.ca</auth-address><titles><title>Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy</title><secondary-title>Spine</secondary-title></titles><periodical><full-title>Spine</full-title></periodical><pages>1411-6; discussion 1417</pages><volume>26</volume><number>13</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Catheter Ablation/*methods</keyword><keyword>Denervation/*methods</keyword><keyword>Disabled Persons</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Low Back Pain/*therapy</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Placebos</keyword><keyword>Prospective Studies</keyword><keyword>Severity of Illness Index</keyword><keyword>Treatment Outcome</keyword><keyword>Zygapophyseal Joint/*innervation</keyword></keywords><dates><year>2001</year><pub-dates><date>Jul 1</date></pub-dates></dates><accession-num>11458140</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>9 randomized 70 patients into a RF facet denervation group and sham intervention. At four weeks the improvement of the Roland-Morris score was higher in the active group. At 12 weeks there was no difference in disability and pain scores between the two groups. Serious adverse events were not identified and where adverse events were mentioned they did not appear to differ by treatment group. One study compared RF treatment of the ramus dorsalis of the segmental nerve with intra articular corticosteroid injection PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYWtlbWVpZXI8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA 11. This study found no differences in ODI between groups. There are methodological weaknesses of this study.No major adverse events were reported during the observation period of 6 months.ConclusionQuality of the evidence DescriptionLowThere is evidence of low quality that radiofrequency facet denervation (ramus medialis of the ramus dorsalis) provides better pain relief and improved disability than sham intervention for 2 to 3 monthsGallagher et al. 1994, van Kleef et al. 1999, Nath et al. 2008, van Wijck et al. 2005, Leclaire et al. 2001Quality of the evidence DescriptionVery lowThere is evidence of very low quality that radiofrequency facet denervation (ramus medialis of the ramus dorsalis) provides no better pain relief and improvement in disability than intra articular corticosteroid injection for 6 months follow upLakemeier 2013ConsiderationsThe RCTs are heterogeneous and subject to discussion frequently yielding contradictory conclusions of systematic reviews. A systematic review by Chou et al. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaG91PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 12 included also the comparative trial of RF, PRF and placebo ADDIN EN.CITE <EndNote><Cite><Author>Tekin</Author><Year>2007</Year><RecNum>1623</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>1623</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1623</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tekin, I.</author><author>Mirzai, H.</author><author>Ok, G.</author><author>Erbuyun, K.</author><author>Vatansever, D.</author></authors></contributors><auth-address>Departments of Anesthesiology, Medical Faculty of Celal Bayar University, Manisa, Turkey. idiltekin@</auth-address><titles><title>A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain</title><secondary-title>Clin J Pain</secondary-title><short-title>facet pain </short-title></titles><periodical><full-title>Clin J Pain</full-title></periodical><pages>524-9</pages><volume>23</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Arthralgia/*therapy</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Radiosurgery/*methods</keyword><keyword>*Zygapophyseal Joint</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><orig-pub>RCT PRF vs RF</orig-pub><accession-num>17575493</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>13Leclaire et al. ADDIN EN.CITE <EndNote><Cite><Author>Leclaire</Author><Year>2001</Year><RecNum>1672</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>1672</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1672</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Leclaire, R.</author><author>Fortin, L.</author><author>Lambert, R.</author><author>Bergeron, Y. M.</author><author>Rossignol, M.</author></authors></contributors><auth-address>Center for Clinical Epidemiology and Community Studies, Sir Mortimer B. Davis, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. laf.lec@sympatico.ca</auth-address><titles><title>Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy</title><secondary-title>Spine</secondary-title></titles><periodical><full-title>Spine</full-title></periodical><pages>1411-6; discussion 1417</pages><volume>26</volume><number>13</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Catheter Ablation/*methods</keyword><keyword>Denervation/*methods</keyword><keyword>Disabled Persons</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Low Back Pain/*therapy</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Placebos</keyword><keyword>Prospective Studies</keyword><keyword>Severity of Illness Index</keyword><keyword>Treatment Outcome</keyword><keyword>Zygapophyseal Joint/*innervation</keyword></keywords><dates><year>2001</year><pub-dates><date>Jul 1</date></pub-dates></dates><accession-num>11458140</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>9? did not establish a therapeutic effect for RF treatment in a placebo controlled trial, but this study has been criticized because the criterion for a positive “diagnostic” block was > 24 hours of pain relief after lidocaine infiltration, which is inconsistent with the drug’s pharmacokinetics. In addition, 94% of the screened patients with back pain were selected for participation, which is much greater than the presumed prevalence for lumbar facetogenic pain (17% to 30%) in this cohort. For this reason, this study is judged to have major methodological flaws. van Wijk et al.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gV2lqazwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+

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ADDIN EN.CITE.DATA 5, 8, 13 One study did not do an intention-to treat analysis, ADDIN EN.CITE <EndNote><Cite><Author>Gallagher</Author><Year>1994</Year><RecNum>103</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">103</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>J. Gallagher </author><author>P.L.P. Vadi </author><author>J.R. Wesley</author></authors></contributors><titles><title>Radiofrequency facet joint denervation in the treatment of low back pain-a prospective controlled double-blind study in assess to efficacy</title><secondary-title>Pain Clinic</secondary-title></titles><periodical><full-title>Pain Clinic</full-title></periodical><pages>193-198</pages><volume>7</volume><number>1</number><dates><year>1994</year></dates><urls></urls></record></Cite></EndNote>8 and in another study flaws were detected in the assessment of the diagnostic block. ADDIN EN.CITE <EndNote><Cite><Author>Leclaire</Author><Year>2001</Year><RecNum>1672</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>1672</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1672</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Leclaire, R.</author><author>Fortin, L.</author><author>Lambert, R.</author><author>Bergeron, Y. M.</author><author>Rossignol, M.</author></authors></contributors><auth-address>Center for Clinical Epidemiology and Community Studies, Sir Mortimer B. Davis, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. laf.lec@sympatico.ca</auth-address><titles><title>Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy</title><secondary-title>Spine</secondary-title></titles><periodical><full-title>Spine</full-title></periodical><pages>1411-6; discussion 1417</pages><volume>26</volume><number>13</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Catheter Ablation/*methods</keyword><keyword>Denervation/*methods</keyword><keyword>Disabled Persons</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Low Back Pain/*therapy</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Placebos</keyword><keyword>Prospective Studies</keyword><keyword>Severity of Illness Index</keyword><keyword>Treatment Outcome</keyword><keyword>Zygapophyseal Joint/*innervation</keyword></keywords><dates><year>2001</year><pub-dates><date>Jul 1</date></pub-dates></dates><accession-num>11458140</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>9 To analyze the effect of the intervention, a meta-analysis including all these 6 trials was performed, it showed a significantly better effect of radiofrequency compared with placebo: 95% confidence interval was 0.6 to 1.5 on a 10-point scale, P < 0.001. Furthermore, if only the trials without shortcomings were included,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gS2xlZWY8L0F1dGhvcj48WWVhcj4xOTk5PC9ZZWFy

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ADDIN EN.CITE.DATA 7, 10? the analysis even showed a significantly better result for radiofrequency: 95% confidence interval was 0.7 to 3.1 on a 10-point scale, P = 0.002. The results of these 2 different analyses indicate that radiofrequency treatment of the facet joint is significantly more effective than placebo. ADDIN EN.CITE <EndNote><Cite><Author>Van Zundert</Author><Year>2010</Year><RecNum>6652</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>6652</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">6652</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Van Zundert, J.</author><author>Vanelderen, P.</author><author>Kessels, A. G.</author></authors></contributors><titles><title>Re: Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009;34: 1078-93</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>841; author reply 841-2</pages><volume>35</volume><number>7</number><keywords><keyword>Clinical Trials as Topic</keyword><keyword>Humans</keyword><keyword>Low Back Pain/*therapy</keyword><keyword>Meta-Analysis as Topic</keyword></keywords><dates><year>2010</year><pub-dates><date>Apr 1</date></pub-dates></dates><accession-num>20357643</accession-num><urls><related-urls><url> National Institute for Health and Care Excellence (NICE) formulated updated recommendations for the treatment of low back pain and sciatica.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJuc3RlaW48L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy

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ADDIN EN.CITE.DATA 15, 16Non-surgical treatment has not worked The main source of pain is thought to come from structures supplied by the medial branch nerveThey have moderate or severe levels of localized pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referralOnly perform radiofrequency treatment in patients with chronic low back pain after a positive response to a diagnostic block of the ramus medialis.Do not offer imaging for people with low back pain with specific facet joint pain as a prerequisite for radiofrequency treatment.The NICE guideline was validated by the Belgium Center for Health Knowledge (KCE) The guideline developping group confirmed the recommendations of the NICE guidelines. ADDIN EN.CITE <EndNote><Cite><Author>Van Wambeke</Author><Year>2017</Year><RecNum>12676</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>12676</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1513070654">12676</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Van Wambeke, P</author><author>Desomer, A </author><author>Ailliet, L </author><author>Berquin, A</author><author>Demoulin, C</author><author>Depreitere, B. </author><author>Dewachter, J </author><author>Dolphens, M</author><author>Forget, P </author><author>Fraselle, V </author><author>Hans, G</author><author>Hoste, D</author><author>Mahieu, G</author><author>Michielsen, J </author><author>Nielens, H </author><author>Orban, T </author><author>Parlevliet, T </author><author>Simons, E </author><author>Tobbackx, Y</author><author>Van Schaeybroeck, P </author><author>Van Zundert, J </author><author>Vanderstraeten, J </author><author>Vlaeyen, J. W. </author><author>Jonckheer, P</author></authors><secondary-authors><author>Belgian Health Care Knowledge Centre (KCE)</author></secondary-authors></contributors><titles><title>Low Back Pain and radicular pain: assessment and management – Summary. </title><secondary-title>Good Clinical Practice (GCP)</secondary-title></titles><number> KCE Reports 287Cs.</number><dates><year>2017</year></dates><pub-location>Brussels</pub-location><urls><related-urls><url>; D/2017/10.273/35</electronic-resource-num></record></Cite></EndNote>17In 2017, after the deadline for inclusion of studies in this guideline, the results of the Mint trial comparing radiofrequency in addition to a standard exercise program compared with the standard exercise program alone were published.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KdWNoPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 18The aim of the Mint trial was to estimate the added value of radiofrequency denervation to a standardized exercise program for patients with chronic mechanical low back pain (facet joint pain, sacroiliac joint pain and a combination group). The primary outcome parameter was pain at 3 months. The study on facet joint pain did not find a statistically significant difference in pain reduction between the 2 groups and the difference between the groups did not fulfill the in the study protocol predefined minimal clinically important difference in pain (≧ 2 points 11-NRS). The outcomes show that the mean difference in pain intensity (Numerical rating scale 0-10) between the radiofrequency denervation and control groups at 3 months was ?0.18 (95%CI, ?0.76 to 0.40). There were also no differences in other outcomes or at other follow-up moments.There are however some points of discussion.The choice of a minimal clinically important difference in pain ≧ 2 points on an 11 points -NRS can be debated. There is consensus that a minimally important change in a patient is 2 points on an 11 points-NRS scale, but it is questionable if this can be translated 1:1 in a difference between groups, especially if both groups have an active treatment component. The effect in the Mint study in the control group was unexpectedly high. An explanation could be that we are observing the natural course of chronic low back pain. A third waiting list control group would presumably have given an answer on this question but was unfortunately, not seen as ethical during the design of the study.The diagnosis of facet pain lacks a gold standard. A reference standard diagnostic block is for example not available. ≧2 diagnostic blocks decrease the false-positive rate, but increase false-negative blocks. A 50% cut - off is most frequently used in studies and clinical practice, however 80% cut -off is also described. The choice of 1 diagnostic block and 50% cut-off for diagnosing facet joint pain in the Mint study could be a limitation in the specificity of the included study participants.Different anatomical approaches, sizes of needles, duration and temperature of lesion for RF lesion of the facet joints are described. In the Mint study 22G 10mm needles and lesions with 90 seconds, 90°C were applied. Being a pragmatic trial, this reflected the current practice in the Netherlands, but may not have been most optimal and could be a limitation in the efficacy of the treatment.Further on, in the Mint study, a clear portion of the control group received, a protocol allowed, radiofrequency denervation after 3-months. Some intervention group participants received a second radiofrequency denervation. This could have influenced the long-term outcomes. Per protocol analyses without these participants showed similar results as intention to treat analysis, but the long-term results of the Mint study have to be interpreted as exploratory.In conclusion, the Mint study findings do not support radiofrequency denervation in patients with facet joint pain as an add on to a standardized exercise program at 3 months. This is in conflict with earlier performed explanatory placebo-controlled trials which show a significant differences in effect. Based on these considerations the guideline committee recommends that a standardized exercise program alone could be the first choice in patients with facet joint pain. This is in line with the recent NICE guidelines on low back pain. If a standardized exercise program fails, there remains a possibility that radiofrequency denervation of facet joints could be beneficial in a subset of patients. However patient selection, treatment techniques and choice of outcome parameters seem to be debatable. Due to the ongoing scientific debate in the international literare PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXB1cmFsPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48

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ADDIN EN.CITE.DATA 19-25 we recommend that radiofrequency treatment for facet joint pain should preferably be performed in a research setting. We need to gain more knowledge about optimal patient selection, diagnostic procedure and treatment technique through high quality research.RecommendationsDescriptionStrength of recommendationLevel of evidenceIf a standardized exercise program fails, a radiofrequency treatment of the ramus medialis of the ramus dorsalis could be used for the treatment of pain originating from the lumbar facet joints. WeakLowPulsed radiofrequency treatmentLiterature overviewOne trial in 80 patients compared pulsed RF to an extra-articular injection PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXNoZW1pPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 26. Pulsed RF significantly reduced pain at 12 weeks and at six months (NRS 75.6 +/- 14.3% baseline and 19.3 +/- 9.5% at 6 months for PRF group) compared to steroid injection, but differences were not observed at six weeks. ODI was significantly lower in the PRF group at 12 weeks and six months but not at six weeks. Adverse events were not reported so the relative benefits and harms cannot be assessed. The trial was rated unclear in a number of categories on the Cochrane Risk of Bias tool including allocation concealment, selective reporting and incomplete data. Duger ADDIN EN.CITE <EndNote><Cite><Author>Duger</Author><Year>2012</Year><RecNum>11754</RecNum><DisplayText><style face="superscript">27</style></DisplayText><record><rec-number>11754</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1454668234">11754</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Duger, C </author><author>Kol, IO </author><author>Kaygusuz, K </author><author>Gursoy, S </author><author>Mimaroglu, C</author></authors></contributors><titles><title>Effects of facet joint nerve block addition to radiofrequency in the treatment of low back pain</title><secondary-title>HealthMED</secondary-title></titles><periodical><full-title>HealthMED</full-title></periodical><pages>2052-2056</pages><volume>6</volume><number>6</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>27 compared the effect of PRF with a nerve block and with the combination of both treatments. It must be indicated that the authors erroneously speak about radiofrequency thermocoagulation, while in the methods they clearly indicate that the electrode tip temperature does not exceed 40°C. This study found better outcome in de groups receiving PRF, with a slide advantage for the combination group. Two small trials PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZWtpbjwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 13, 28, one in 40 patients (20 in each group) and one in 50 patients (25 in each group) compared pulsed RF and continuous RF. Both studies assessed pain using a VAS scale (0-10 and 0-100, respectively). The heterogeity of these studies did not allow pooling the data. Kroll reported significant reductions in pain over time (three months) in the continuous RF group (24.7% SD 50.1), but not in the pulsed RF group (10.6% SD 45.0) and Tekin ADDIN EN.CITE <EndNote><Cite><Author>Tekin</Author><Year>2007</Year><RecNum>1623</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>1623</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1623</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tekin, I.</author><author>Mirzai, H.</author><author>Ok, G.</author><author>Erbuyun, K.</author><author>Vatansever, D.</author></authors></contributors><auth-address>Departments of Anesthesiology, Medical Faculty of Celal Bayar University, Manisa, Turkey. idiltekin@</auth-address><titles><title>A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain</title><secondary-title>Clin J Pain</secondary-title><short-title>facet pain </short-title></titles><periodical><full-title>Clin J Pain</full-title></periodical><pages>524-9</pages><volume>23</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Arthralgia/*therapy</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Radiosurgery/*methods</keyword><keyword>*Zygapophyseal Joint</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><orig-pub>RCT PRF vs RF</orig-pub><accession-num>17575493</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>13 reported significant reductions in pain over time (six and 12 months) in both groups; neither study reported a between group comparison. Both studies assessed disability (ODI 0-100). Kroll reported significant reductions in disability score over time (three months) in the continuous RF group, but not in the pulsed RF group and Tekin ADDIN EN.CITE <EndNote><Cite><Author>Tekin</Author><Year>2007</Year><RecNum>1623</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>1623</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1623</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tekin, I.</author><author>Mirzai, H.</author><author>Ok, G.</author><author>Erbuyun, K.</author><author>Vatansever, D.</author></authors></contributors><auth-address>Departments of Anesthesiology, Medical Faculty of Celal Bayar University, Manisa, Turkey. idiltekin@</auth-address><titles><title>A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain</title><secondary-title>Clin J Pain</secondary-title><short-title>facet pain </short-title></titles><periodical><full-title>Clin J Pain</full-title></periodical><pages>524-9</pages><volume>23</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Arthralgia/*therapy</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Radiosurgery/*methods</keyword><keyword>*Zygapophyseal Joint</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><orig-pub>RCT PRF vs RF</orig-pub><accession-num>17575493</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>13 reported significant reductions in disability score over time (six and 12 months) in both groups; neither study reported a between group comparison. All patients in the Tekin ADDIN EN.CITE <EndNote><Cite><Author>Tekin</Author><Year>2007</Year><RecNum>1623</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>1623</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1623</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tekin, I.</author><author>Mirzai, H.</author><author>Ok, G.</author><author>Erbuyun, K.</author><author>Vatansever, D.</author></authors></contributors><auth-address>Departments of Anesthesiology, Medical Faculty of Celal Bayar University, Manisa, Turkey. idiltekin@</auth-address><titles><title>A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain</title><secondary-title>Clin J Pain</secondary-title><short-title>facet pain </short-title></titles><periodical><full-title>Clin J Pain</full-title></periodical><pages>524-9</pages><volume>23</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Arthralgia/*therapy</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Radiosurgery/*methods</keyword><keyword>*Zygapophyseal Joint</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><orig-pub>RCT PRF vs RF</orig-pub><accession-num>17575493</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>13 study had continuous low back pain for more than six months, which was unresponsive to conservative treatment; no objective method of confirming the diagnosis of lumbar facet joint syndrome was reported. All patients in the Kroll study had lumbar back pain of more than one-month duration and diagnosis confirmed by medial branch block injection.Kroll reported that there were no adverse events or complications during the study and Tekin ADDIN EN.CITE <EndNote><Cite><Author>Tekin</Author><Year>2007</Year><RecNum>1623</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>1623</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1623</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tekin, I.</author><author>Mirzai, H.</author><author>Ok, G.</author><author>Erbuyun, K.</author><author>Vatansever, D.</author></authors></contributors><auth-address>Departments of Anesthesiology, Medical Faculty of Celal Bayar University, Manisa, Turkey. idiltekin@</auth-address><titles><title>A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain</title><secondary-title>Clin J Pain</secondary-title><short-title>facet pain </short-title></titles><periodical><full-title>Clin J Pain</full-title></periodical><pages>524-9</pages><volume>23</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Arthralgia/*therapy</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Radiosurgery/*methods</keyword><keyword>*Zygapophyseal Joint</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><orig-pub>RCT PRF vs RF</orig-pub><accession-num>17575493</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>13did not report any information on adverse events. The Kroll ADDIN EN.CITE <EndNote><Cite><Author>Kroll</Author><Year>2008</Year><RecNum>3302</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>3302</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">3302</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kroll, H. R.</author><author>Kim, D.</author><author>Danic, M. J.</author><author>Sankey, S. S.</author><author>Gariwala, M.</author><author>Brown, M.</author></authors></contributors><auth-address>Department of Anesthesia K-4, Henry Ford Hospital, Detroit, MI 48202, USA. hkroll@</auth-address><titles><title>A randomized, double-blind, prospective study comparing the efficacy of continuous versus pulsed radiofrequency in the treatment of lumbar facet syndrome</title><secondary-title>J Clin Anesth</secondary-title><short-title>facet pain</short-title></titles><periodical><full-title>J Clin Anesth</full-title></periodical><pages>534-7</pages><volume>20</volume><number>7</number><keywords><keyword>Catheter Ablation/*methods</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Low Back Pain/etiology/*surgery</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Syndrome</keyword><keyword>Treatment Outcome</keyword><keyword>Zygapophyseal Joint/innervation/*surgery</keyword></keywords><dates><year>2008</year><pub-dates><date>Nov</date></pub-dates></dates><orig-pub>RCT</orig-pub><accession-num>19041042</accession-num><work-type>PRF</work-type><urls><related-urls><url> study was rated as high risk of bias according to the Cochrane Risk of Bias tool, because caregivers were not blinded and the study had a dropout rate of 48%. The Tekin ADDIN EN.CITE <EndNote><Cite><Author>Tekin</Author><Year>2007</Year><RecNum>1623</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>1623</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1623</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tekin, I.</author><author>Mirzai, H.</author><author>Ok, G.</author><author>Erbuyun, K.</author><author>Vatansever, D.</author></authors></contributors><auth-address>Departments of Anesthesiology, Medical Faculty of Celal Bayar University, Manisa, Turkey. idiltekin@</auth-address><titles><title>A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain</title><secondary-title>Clin J Pain</secondary-title><short-title>facet pain </short-title></titles><periodical><full-title>Clin J Pain</full-title></periodical><pages>524-9</pages><volume>23</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Arthralgia/*therapy</keyword><keyword>Chronic Disease</keyword><keyword>Denervation/*methods</keyword><keyword>Disability Evaluation</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Patient Satisfaction</keyword><keyword>Prospective Studies</keyword><keyword>Radiosurgery/*methods</keyword><keyword>*Zygapophyseal Joint</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><orig-pub>RCT PRF vs RF</orig-pub><accession-num>17575493</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>13 study was rated as unclear risk of bias according to the Cochrane Risk of Bias tool, because no information was provided on allocation concealment procedures or blinding of caregivers. ConclusionQuality of the evidence DescriptionVery lowThere is evidence of very low quality that pulsed radiofrequency treatment of the ramus medialis of the ramus dorsalis provides better pain relief and improved disability than intra articular steroid injection at 3 and 6 monthsHashemi 2014Quality of the evidence DescriptionLowThere is evidence of low quality that pulsed radiofrequency treatment of the ramus medialis of the ramus dorsalis did reduce pain in patients with low back pain originating from the lumbar facet joints over 3 months. Tekin 2007; Kroll 2008ConsiderationsThe effect of pulsed RF found in 3 RCTs with methodological weaknesses is lower than conventional RF but better than intra articular injection.Considering the fact that for conventional RF few side effects and complications have been reported, RF should be preferredRecommendationsDescriptionStrength of recommendationLevel of evidencePulsed radiofrequency of the ramus medialis of the ramus dorsalis could be considered for the treatment of pain originating from the lumbar facet joints.Very weak lowReferences ADDIN EN.REFLIST 1Kawu AA, Olawepo A, Salami AO. Facet joints infiltration: a viable alternative treatment to physiotherapy in patients with low back pain due to facet joint arthropathy. Niger J Clin Pract. 2011;14:219-222.2Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. 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