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Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back PainThe Mint Randomized Clinical Trials

Educational Objective
To learn whether radiofrequency denervation is an effective treatment for patients with chronic low back pain.
1 Credit CME
Key Points

Question  What is the effectiveness of radiofrequency denervation added to a standardized exercise program for patients with chronic low back pain?

Findings  In 3 randomized clinical trials including 681 participants with chronic low back pain originating from the facet joints, sacroiliac joints, or a combination of these or the intervertebral disks, radiofrequency denervation combined with exercise compared with exercise alone resulted in either no significant difference in pain intensity, or a difference smaller than the prespecified minimal clinically important difference after 3 months.

Meaning  The study findings do not support the use of radiofrequency denervation for chronic low back pain originating from these sources.


Importance  Radiofrequency denervation is a commonly used treatment for chronic low back pain, but high-quality evidence for its effectiveness is lacking.

Objective  To evaluate the effectiveness of radiofrequency denervation added to a standardized exercise program for patients with chronic low back pain.

Design, Setting, and Participants  Three pragmatic multicenter, nonblinded randomized clinical trials on the effectiveness of minimal interventional treatments for participants with chronic low back pain (Mint study) were conducted in 16 multidisciplinary pain clinics in the Netherlands. Eligible participants were included between January 1, 2013, and October 24, 2014, and had chronic low back pain, a positive diagnostic block at the facet joints (facet joint trial, 251 participants), sacroiliac joints (sacroiliac joint trial, 228 participants), or a combination of facet joints, sacroiliac joints, or intervertebral disks (combination trial, 202 participants) and were unresponsive to conservative care.

Interventions  All participants received a 3-month standardized exercise program and psychological support if needed. Participants in the intervention group received radiofrequency denervation as well. This is usually a 1-time procedure, but the maximum number of treatments in the trial was 3.

Main Outcomes and Measures  The primary outcome was pain intensity (numeric rating scale, 0-10; whereby 0 indicated no pain and 10 indicated worst pain imaginable) measured 3 months after the intervention. The prespecified minimal clinically important difference was defined as 2 points or more. Final follow-up was at 12 months, ending October 2015.

Results  Among 681 participants who were randomized (mean age, 52.2 years; 421 women [61.8%], mean baseline pain intensity, 7.1), 599 (88%) completed the 3-month follow-up, and 521 (77%) completed the 12-month follow-up. The mean difference in pain intensity between the radiofrequency denervation and control groups at 3 months was −0.18 (95% CI, −0.76 to 0.40) in the facet joint trial; −0.71 (95% CI, −1.35 to −0.06) in the sacroiliac joint trial; and −0.99 (95% CI, −1.73 to −0.25) in the combination trial.

Conclusions and Relevance  In 3 randomized clinical trials of participants with chronic low back pain originating in the facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks, radiofrequency denervation combined with a standardized exercise program resulted in either no improvement or no clinically important improvement in chronic low back pain compared with a standardized exercise program alone. The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources.

Trial Registration  trialregister.nl Identifier: NTR3531

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Article Information

Corresponding Author: Esther T. Maas, PhD, School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada (esther.maas@ubc.ca).

Accepted for Publication: June 6, 2017.

Correction: This article was corrected for value errors in Figure 3 on September 26, 2017.

Author Contributions: Drs Maas and Juch had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Juch and Maas are shared first author, listed in alphabetical order.

Concept and design: Juch, Maas, Ostelo, Groeneweg, Kallewaard, Koes, Verhagen, Huygen, van Tulder.

Acquisition, analysis, or interpretation of data: Juch, Maas, Koes, van Dongen, Huygen, van Tulder.

Drafting of the manuscript: Juch, Maas, Ostelo, Groeneweg, Koes, Verhagen, Huygen, van Tulder.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Juch, Maas, van Dongen.

Obtained funding: Koes, Huygen, van Tulder.

Administrative, technical, or material support: Juch, Maas, Kallewaard, Huygen.

Supervision: Ostelo, Groeneweg, Huygen, van Tulder.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Ostelo reports receiving grant funding from the Netherlands Organisation for Scientific Research and Scientific Association Physiotherapy. Dr van Tulder reports receiving funding to his institution from professional organizations (eg, the Royal Dutch Association for Physiotherapy; the Netherlands National Chiropractic Association and the European Chiropractic Union); travel expenses by the organizing professional organizations when speaking at conferences; and honoraria for reviewing grant proposals from Swedish and Canadian governmental grant agencies. He has not received any honoraria or travel expenses from the industry. No other disclosures were reported.

Funding/Support: This study was funded by grant 171202013 from the Netherlands Organization for Health Research and Development, by the Dutch Society for Anesthesiology, and the Dutch health insurance companies.

Role of the Funder/Sponsor: The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.

Additional Contributions: We thank Merel van Raamt, PT, and Robert van Cingel, PhD (both from Sports Medical Centre Papendal [SMCP]), for their help in developing the exercise program. SMCP received financial support from the research grant for the development of the protocol. We also thank all participants, physiotherapists, and everyone working on the Mint study at the participating pain clinics. The participating pain clinics received reimbursement from the research grant for their extra study-related administrative tasks.

Additional Information: The following were in charge of participant recruitment and treatment per clinic: Bernard Lo, MD (Diakonessenhuis Utrecht/Zeist); Harmen Pelleboer, MD (Medisch Centrum Alkmaar); Jasper Kal, MD, PhD, FIPP (Onze Lieve Vrouwe Gasthuis Amsterdam); Dennis Harhangi, MD (Havenziekenhuis Rotterdam); Renate Munnikes, MD, FIPP (Maasstad ziekenhuis Rotterdam); Willem-Jan Hofsté, MD (St Antonius ziekenhuis Nieuwegein); Katja Bürger, MD (Alrijne ziekenhuis Leiderdorp); Michel Wagemans, MD (Reinier de Graaf Gasthuis Delft); Mettje Hanje, MD (Medisch Spectrum Twente Enschede); Michel Terheggen, MD (Rijnstate ziekenhuis Velp); Gilbert Tjiang, MD (Amphia ziekenhuis Breda); Maurice Giezeman, MD (Isala klinieken, Zwolle); Joep Scholten, MD (Gelre ziekenhuis Apeldoorn); Eric van den Bosch, MD (Medisch Centrum Leeuwarden); Antal van der Gaag, MD (Catharina ziekenhuis Eindhoven); Hans Aukes, MD (Albert Schweitzer ziekenhuis Sliedrecht).

Martin  BI, Deyo  RA, Mirza  SK,  et al.  Expenditures and health status among adults with back and neck problems.  JAMA. 2008;299(6):656-664.PubMedGoogle ScholarCrossref
Vos  T, Flaxman  AD, Naghavi  M,  et al.  Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 [correction appears in Lancet. 2013;381(9867):628].  Lancet. 2012;380(9859):2163-2196.PubMedGoogle ScholarCrossref
Katz  JN.  Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.  J Bone Joint Surg Am. 2006;88(suppl 2):21-24.PubMedGoogle Scholar
Dieleman  JL, Baral  R, Birger  M,  et al.  US spending on personal health care and public health, 1996-2013.  JAMA. 2016;316(24):2627-2646.PubMedGoogle ScholarCrossref
van Zundert  J, Hartrick  C, Lataster  A, Huygen  F, Mekhail  N, van Kleef  MPJ.  Evidence-Based Interventional Pain Practice: According to Clinical Diagnoses. Oxford, UK: Wiley-Blackwell; 2011.Crossref
Bogduk  N.  The anatomical basis for spinal pain syndromes.  J Manipulative Physiol Ther. 1995;18(9):603-605.PubMedGoogle Scholar
Manchikanti  L, Hirsch  JA, Pampati  V, Boswell  MV.  Utilization of facet joint and sacroiliac joint interventions in Medicare population from 2000 to 2014: explosive growth continues!  Curr Pain Headache Rep. 2016;20(10):58.PubMedGoogle ScholarCrossref
Koes  BW, van Tulder  M, Lin  C-WC, Macedo  LG, McAuley  J, Maher  C.  An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.  Eur Spine J. 2010;19(12):2075-2094.PubMedGoogle ScholarCrossref
Maas  ET, Ostelo  RW, Niemisto  L,  et al.  Radiofrequency denervation for chronic low back pain.  Cochrane Database Syst Rev. 2015;10(10):CD008572.PubMedGoogle Scholar
Henschke  N, Kuijpers  T, Rubinstein  SM,  et al.  Injection therapy and denervation procedures for chronic low-back pain: a systematic review.  Eur Spine J. 2010;19(9):1425-1449.PubMedGoogle ScholarCrossref
Maas  ET, Juch  JN, Groeneweg  JG,  et al.  Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation.  BMC Musculoskelet Disord. 2012;13:260.PubMedGoogle ScholarCrossref
Szadek  KM, van der Wurff  P, van Tulder  MW, Zuurmond  WW, Perez  RSGM.  Diagnostic validity of criteria for sacroiliac joint pain: a systematic review.  J Pain. 2009;10(4):354-368.PubMedGoogle ScholarCrossref
Hancock  MJ, Maher  CG, Latimer  J,  et al.  Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain.  Eur Spine J. 2007;16(10):1539-1550.PubMedGoogle ScholarCrossref
Bogduk  N.  Practice Guidelines for Spinal Diagnostic and Treatment Procedures. Hinsdale, IL: International Spine Intervention Society; 2004.
Kallewaard  JW, Terheggen  MA, Groen  GJ,  et al.  15: Discogenic low back pain.  Pain Pract. 2010;10(6):560-579.PubMedGoogle ScholarCrossref
Devilly  GJ, Borkovec  TD.  Psychometric properties of the credibility/expectancy questionnaire.  J Behav Ther Exp Psychiatry. 2000;31(2):73-86.PubMedGoogle ScholarCrossref
Bombardier  C.  Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations.  Spine (Phila Pa 1976). 2000;25(24):3100-3103.PubMedGoogle ScholarCrossref
Hoeijenbos  M, Bekkering  T, Lamers  L, Hendriks  E, van Tulder  M, Koopmanschap  M.  Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain.  Health Policy. 2005;75(1):85-98.PubMedGoogle ScholarCrossref
Cohen  SP, Hurley  RW, Buckenmaier  CC  III, Kurihara  C, Morlando  B, Dragovich  A.  Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain.  Anesthesiology. 2008;109(2):279-288.PubMedGoogle ScholarCrossref
Cosman  ER  Jr, Gonzalez  CD.  Bipolar radiofrequency lesion geometry: implications for palisade treatment of sacroiliac joint pain.  Pain Pract. 2011;11(1):3-22.PubMedGoogle ScholarCrossref
Schmidt  PC, Pino  CA, Vorenkamp  KE.  Sacroiliac joint radiofrequency ablation with a multilesion probe: a case series of 60 patients.  Anesth Analg. 2014;119(2):460-462.PubMedGoogle ScholarCrossref
Gauci  CA, Jankowiak  B.  Manual of RF Techniques: A Practical Manual of Radiofrequency Procedures in Chronic Pain Management. Seattle, WA: CoMedical; 2011.
Downie  WW, Leatham  PA, Rhind  VM, Wright  V, Branco  JA, Anderson  JA.  Studies with pain rating scales.  Ann Rheum Dis. 1978;37(4):378-381.PubMedGoogle ScholarCrossref
Fairbank  JC, Pynsent  PB.  The Oswestry Disability Index.  Spine (Phila Pa 1976). 2000;25(22):2940-2952.PubMedGoogle ScholarCrossref
Brooks  R.  EuroQol: the current state of play.  Health Policy. 1996;37(1):53-72.PubMedGoogle ScholarCrossref
Hays  RD, Morales  LS.  The RAND-36 measure of health-related quality of life.  Ann Med. 2001;33(5):350-357.PubMedGoogle ScholarCrossref
Lousberg  R, Van Breukelen  GJP, Groenman  NH, Schmidt  AJM, Arntz  A, Winter  FAM.  Psychometric properties of the Multidimensional Pain Inventory, Dutch Language Version (MPI-DLV).  Behav Res Ther. 1999;37(2):167-182.PubMedGoogle ScholarCrossref
Ostelo  RWJG, Deyo  RA, Stratford  P,  et al.  Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change.  Spine (Phila Pa 1976). 2008;33(1):90-94.PubMedGoogle ScholarCrossref
van der Roer  N, Ostelo  RW, Bekkering  GE, van Tulder  MW, de Vet  HC.  Minimal clinically important change for pain intensity, functional status, and general health status in patients with nonspecific low back pain.  Spine (Phila Pa 1976). 2006;31(5):578-582.PubMedGoogle ScholarCrossref
Twisk  JWR.  Applied Multilevel Analysis: A Practical Guide for medical researchers. Cambridge, UK: Cambridge Univ Press; 2006.Crossref
Zhang  J, Yu  KF.  What’s the relative risk? a method of correcting the odds ratio in cohort studies of common outcomes.  JAMA. 1998;280(19):1690-1691.PubMedGoogle ScholarCrossref
Chiarotto  A, Deyo  RA, Terwee  CB,  et al.  Core outcome domains for clinical trials in non-specific low back pain.  Eur Spine J. 2015;24(6):1127-1142.PubMedGoogle ScholarCrossref
Ferrante  FM, King  LF, Roche  EA,  et al.  Radiofrequency sacroiliac joint denervation for sacroiliac syndrome.  Reg Anesth Pain Med. 2001;26(2):137-142.PubMedGoogle ScholarCrossref
Patel  N, Gross  A, Brown  L, Gekht  G.  A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain.  Pain Med. 2012;13(3):383-398.PubMedGoogle ScholarCrossref
Burnham  RS, Yasui  Y.  An alternate method of radiofrequency neurotomy of the sacroiliac joint: a pilot study of the effect on pain, function, and satisfaction.  Reg Anesth Pain Med. 2007;32(1):12-19.PubMedGoogle Scholar
van Tilburg  CW, Schuurmans  FA, Stronks  DL, Groeneweg  JG, Huygen  FJ.  Randomized sham-controlled double-blind multicenter clinical trial to ascertain the effect of percutaneous radiofrequency treatment for sacroiliac joint pain: three-month results.  Clin J Pain. 2016;32(1):921-926. PubMedGoogle ScholarCrossref
Kahan  BC, Cro  S, Doré  CJ,  et al.  Reducing bias in open-label trials where blinded outcome assessment is not feasible: strategies from two randomised trials.  Trials. 2014;15(1):456.PubMedGoogle ScholarCrossref
Cohen  SP, Huang  JHY, Brummett  C.  Facet joint pain—advances in patient selection and treatment.  Nat Rev Rheumatol. 2013;9(2):101-116.PubMedGoogle ScholarCrossref
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