Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

Abstract

Background: The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

Methods: In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. 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 Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

Results: Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

Conclusions: Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Keywords: analgesia; anesthesia; anticoagulants; injections; local; neck pain; spinal.

Figure 1

Posterior (A) and lateral (B) segmental maps showing the typical pain referral patterns of the atlanto–occipital (C0–C1, blue) and atlanto–axial (C1–2, red) joints. Striped areas (blue/red hash marks) represent overlapping atlanto–occipital and atlanto–axial pain maps.

Figure 2

Posterior (A) and lateral (B) segmental maps showing pain referral patterns from the cervical facet joints (C2–3, red; C3–4, black; C4–5, green; C5–6, purple; C6–7, yellow; C7–T1, blue). Striped areas (hash marks) represent overlapping cervical facet joint pain maps.

Figure 3

Posterior (A) and sagittal (B) images demonstrating the relationship between the upper cervical joints, vertebral artery and nerve supply.

Figure 4

Axial view of the cervical spine demonstrating different cannula orientations.

Figure 5

Ultrasound image demonstrating an artery running across a cervical facet articular pillar. AP, articular pillar; at, anterior tubercle of the transverse process; pt, posterior tubercle of the transverse process.