What is the role of radio frequency (RF) lesioning in treating chronic back pain?

Radiofrequency Lesioning for Chronic Back Pain

Radiofrequency (RF) lesioning is not recommended for chronic axial back pain due to insufficient evidence of effectiveness and should not be routinely offered outside of clinical trials. 1

Current Guideline Recommendations

• The 2025 BMJ clinical practice guideline issues strong recommendations against joint radiofrequency ablation with or without joint-targeted injection for chronic axial spine pain (≥3 months) 1

• The 2020 NICE Guideline recommends radiofrequency denervation only after a positive response to a medial branch block, and not as a first-line treatment 1

• The 2021 American College of Occupational and Environmental Medicine explicitly recommends against radiofrequency neurotomy, neurotomy, or facet rhizotomy for treatment of chronic low back pain, even when confirmed with diagnostic blocks 1

• There is significant inconsistency in recommendations across guidelines, with the 2022 American Society of Pain and Neuroscience providing contradictory strong recommendations in favor of conventional or cooled lumbar radiofrequency ablation for low back pain 1

Diagnostic Approach Before Considering RF Lesioning

• RF lesioning should only be considered after:
  • Failure of conservative treatments including exercise, NSAIDs, and other non-invasive approaches 2, 3
  • Positive response to diagnostic medial branch blocks (typically >50% pain relief) 2, 4
  • Pain has persisted for at least 3 months and significantly limits daily activities 2, 3

Evidence Quality and Effectiveness

• The overall quality of evidence for radiofrequency denervation for chronic low back pain ranges from very low to moderate 5

• Cochrane reviews indicate limited evidence that RF denervation offers short-term relief for chronic neck pain of zygapophyseal joint origin, but conflicting evidence for chronic low back pain 6, 5

• For facet joint pain, moderate evidence suggests RF denervation has greater short-term effect on pain compared to placebo, but the clinical significance is questionable 5

• For discogenic pain, RF denervation produces conflicting results with no consistent short-term benefits 7, 8, 5

Potential Applications with Limited Support

• When RF lesioning is considered appropriate (after positive diagnostic blocks):
  • For facet-mediated pain, RF ablation of medial branches may provide short-term relief 2, 4
  • For sacroiliac joint pain, RF denervation may be considered after positive diagnostic blocks 3, 4
  • For thoracic facet pain, RF ablation may provide temporary relief in selected patients 3

Common Pitfalls and Considerations

• RF lesioning is often overused without proper patient selection or diagnostic confirmation 9, 6

• The procedure should not be used for radicular symptoms without facet involvement 2

• Repeat procedures should only be considered if the patient obtained >50% pain relief for at least 12 weeks from the previous RF procedure 3, 4

• There is significant variability in practice patterns between countries and practitioners 9, 5

• RF lesioning is an invasive procedure that can cause complications, though the quality of evidence regarding complication rates is inadequate 5

Cost and Access Considerations

• Expense may be a barrier to accessing procedures unless patients have public or private coverage 1

• Patients must travel to specialized facilities for these procedures and, if perceived effective, return approximately every 6 months for repeat ablation 1