Library guides: FPM Procedures Endorsement Program curriculum: Category 1 procedures

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1A Cervical medial branch block

Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Pain Med. 2021;22(11):2443-2524. Keywords: Atlantoaxial; Atlantooccipital; Facet Joint; Neck Pain; Radiofrequency; Zygapophyseal
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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.

Barnsley L, Bogduk N. Medial branch blocks are specific for diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993; 18(6):343-50.

Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain1993; 9(2):124–30. Request article via Library.

Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine. 1982; 7(4):319–30. Request article via Library.

Cohen SP, Strassels SA, Kurihara C, Forsythe A, Buckenmaier C, McLean B et al. Randomized study assessing the accuracy of cervical facet joint nerve (medial branch) blocks using different injectate volumes. Anesthesiology. 2010; 112(1):144‐52.

Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain. 1995; 11(3):208‐13. Request article via Library.

Manchikanti L, Manchikanti KN, Pampati V, Brandon DE, Giordano J. The prevalence of facet-joint-related chronic neck pain in postsurgical and nonpostsurgical patients: A comparative evaluation. Pain Pract. 2008; 8(1):5–10.

Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophyseal joint blocks for chronic cervical pain. Med J Aust. 2001; 174(4):174-6.

1B Lumbar medial branch block

Bogduk N. Clinical and Radiological Anatomy of the Lumbar Spine. 5th ed. Philadelphia (PA): Elsevier; 2012.

Chen AS, Miccio VF, Smith CC, Christolias GC, Blanchard AR. Procedural pain during lumbar medial branch blocks with and without skin wheal anesthesia: a prospective comparative observational study. Pain Med. 2019; 20(4):779‐83.

Kaplan M, Dreyfuss P, Halbrook B, Bogduk N. The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint. A physiologic challenge. Spine. 1998; 23(17):1847‐52. Request article via Library.

Kennedy DJ, Huynh L, Wong J, Mattie R, Levin J, Smuck M et al. Corticosteroid injections into lumbar facet joints: a prospective, randomized, double-blind placebo-controlled trial. Am J Phys Med Rehabil. 2018; 97(10):741‐6. Request article via Library.

Van Zundert J, Mekhail N, Vanelderen P, van Kleef M. Diagnostic medial branch blocks before lumbar radiofrequency zygapophysial (facet) joint denervation: benefit or burden? Anesthesiology. 2010; 113(2):276‐8.

1C Lumbar transforaminal epidural injection

Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology. 2007;106(2):331‐8.

Bogduk N. Clinical and Radiological Anatomy of the Lumbar Spine. 5th ed. Philadelphia (PA): Elsevier; 2012.

Denis I, Claveau G, Filiatrault M, Fugère F, Fortin L. Randomized double-blind controlled trial comparing the effectiveness of lumbar transforaminal epidural injections of particulate and nonparticulate corticosteroids for lumbosacral radicular pain. Pain Med. 2015; 16(9):1697‐708.

Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010; 11(8):1149-68.

Ghai B, Bansal D, Kay JP, Vadaje KS, Wig J. Transforaminal versus parasagittal interlaminar epidural steroid injection in low back pain with radicular pain: a randomized, double-blind, active-control trial. Pain Physician. 2014; 17(4):277‐90.

Kamble PC, Sharma A, Singh V, Natraj B, Devani D, Khapane V. Outcome of single level disc prolapse treated with transforaminal steroid versus epidural steroid versus caudal steroids. Eur Spine J. 2016; 25(1):217‐21. Request article via Library.

Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: a comprehensive review of the published data. Pain Med. 2020; 21(3):472‐87.

Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine. 2002; 27(1):11‐6. Request article via Library.

1D Caudal epidural injection

Aggarwal A, Aggarwal A, Harjeet, Sahni D. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat. 2009; 31(10):793‐800. Request article via Library.

Manchikanti L, Pakanati RR, Pampati V. Comparison of three routes of epidural steroid injections in low back pain. Pain Digest 1999; 9:277-85. Request article via Library.

Manchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician. 2004; 7(1):81‐92.

Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Management of pain of post lumbar surgery syndrome: one-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections. Pain Physician. 2010; 13(6):509‐21.

Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. A randomized, controlled, doubleblind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis. Spine. 2011; 36(23):1897‐1905.

Parr AT, Manchikanti L, Hameed H, Conn A, Manchikanti KN, Benyamin RM et al. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician. 2012;15(3):E159‐98.

1E Sacroiliac joint injection

Kennedy DJ, Engel A, Kreiner DS, Nampiaparampil D, Duszynski B, MacVicar J. Fluoroscopically guided diagnostic and therapeutic intra-articular sacroiliac joint injections: a systematic review. Pain Med. 2015;16(8):1500‐18.

King W, Ahmed SU, Baisden J, Patel N, Kennedy DJ, Duszynski B et al. Diagnosis and treatment of posterior sacroiliac complex pain: a systematic review with comprehensive analysis of the published data [published correction appears in Pain Med. 2015 Nov;16(11):2216. Duszynski, Belinda [added]]. Pain Med. 2015;16(2):257‐65.

MacVicar J, Kreiner DS, Duszynski B, Kennedy DJ. Appropriate use criteria for fluoroscopically guided diagnostic and therapeutic sacroiliac interventions: results from the spine intervention society convened multispecialty collaborative. Pain Med. 2017; 18(11):2081‐95.

Roberts SL, Stout A, Loh EY, Swain N, Dreyfuss P, Agur AM. Anatomical comparison of radiofrequency ablation techniques for sacroiliac joint pain. Pain Med. 2018; 19(10):1924‐43.

Speldewinde GC. Successful thermal neurotomy of the painful sacroiliac ligament/joint complex-a comparison of two techniques. Pain Med. 2020; 21(3):561‐69.