Is radiofrequency ablation (RFA) under fluoroscopy a medically necessary and effective treatment for a patient with chronic right-sided axial neck pain who has had limited relief from conservative treatments and has a history of positive response to medial branch blocks?

Radiofrequency Ablation is Medically Necessary and Appropriate for This Patient

This patient meets all established criteria for cervical radiofrequency ablation and the procedure was appropriately performed. The patient demonstrated >80% pain relief with two separate diagnostic medial branch blocks, has chronic axial neck pain >3 months affecting activities of daily living, failed conservative treatments including physical therapy for >6 weeks, and has no prior fusion surgery at the treated levels 1, 2, 3.

Diagnostic Criteria Met

The most critical requirement for RFA medical necessity is confirmation through diagnostic blocks, which this patient clearly satisfied:

• Two positive diagnostic medial branch blocks with >80% pain relief are the gold standard before proceeding to RFA, reducing false-positive rates and confirming facet-mediated pain as the true pain generator 1, 3, 4
• The patient's >80% relief with both blocks exceeds the minimum threshold of >50% recommended by most guidelines, though some specify >80% as optimal 1, 2, 4
• Medial branch blocks are strongly preferred over intraarticular facet joint injections for diagnostic purposes, as intraarticular blocks have limited evidence for predicting successful RFA outcomes 1, 3

Conservative Treatment Requirements Satisfied

The patient appropriately exhausted conservative options before RFA:

• Chronic axial neck pain present for >3-6 months that significantly affects activities of daily living (patient reports difficulty lifting grandchildren) 1, 2
• Failed conservative treatment including physical therapy for >6 weeks, with documented dry needling and home exercise program showing no improvement 1, 2
• Trial of muscle relaxants (Baclofen, Zanaflex), anti-inflammatories, and other medications 1, 2
• The patient's Oswestry score of 24% indicates mild/moderate disability, supporting functional impairment 2

Imaging and Exclusion Criteria

The patient's imaging appropriately supports the procedure:

• Neuroradiologic studies show cervical spondylosis and C5-6 disc protrusion without significant canal narrowing or instability requiring surgery 1, 2
• No prior spinal fusion surgery at the levels to be treated (C4, C5, C6) 1, 2, 3
• The absence of radiculopathy is appropriate for this facet-mediated pain procedure 1, 2

Evidence Supporting RFA Efficacy

Conventional radiofrequency ablation of the medial branch nerves is the most effective treatment for confirmed facet-mediated chronic neck pain when patients demonstrate positive response to diagnostic blocks 1, 4. The 2021 multispecialty consensus guidelines from the American Society of Regional Anesthesia and Pain Medicine and American Academy of Pain Medicine specifically support this approach for cervical facet pain 4.

Important Caveat on Long-Term Outcomes

One Class I randomized controlled trial found that while RFA was superior to placebo at 2 weeks, there were no statistical differences in pain or functional outcomes at 4 weeks or 12 weeks post-treatment 1. However, this conflicting evidence emphasizes that stringent diagnostic block criteria (which this patient met) are critical for achieving meaningful outcomes 1, 4.

Post-Procedure Follow-Up and Repeat Treatment

The patient's post-RFA course demonstrates appropriate response:

• She reported benefit a few days after the procedure, which is consistent with expected outcomes 1
• Repeat RFA can be performed at intervals of at least 6 months per level per side when >50% pain relief is obtained for at least 12 weeks, at a maximum of twice per rolling calendar year 2
• The patient does not require repeat diagnostic medial branch blocks before future RFA if she demonstrates >50% pain relief for at least 12 weeks from this procedure 2

Procedural Appropriateness

The right C4, C5, C6 RFA under fluoroscopy was appropriately performed:

• Radiofrequency ablation targets the medial branch nerves that innervate the facet joints, not the joints themselves 3
• No more than three levels are considered medically necessary during the same session, which this procedure respected 2
• Fluoroscopic guidance is standard for accurate needle placement 4

Common Pitfalls Avoided

This case avoided the most critical errors in facet pain management:

• The procedure was not performed without confirmatory diagnostic blocks - this is the most critical error, as facet injections alone have poor diagnostic utility without proper confirmation 1
• Clinical examination alone was not relied upon to diagnose facet syndrome, as no combination of clinical features can reliably discriminate facet-mediated pain without diagnostic blocks 1
• The patient was not considered for lumbar spinal fusion based on facet injections, as they are not predictive of fusion outcomes 1