Is radiofrequency ablation for sacroiliac joint pain and dexamethasone (corticosteroid) injection medically necessary for a patient with lumbosacral spondylosis?

Medical Necessity Determination: Radiofrequency Ablation for Sacroiliac Joint Pain

Based on the most recent and highest quality evidence, radiofrequency denervation for sacroiliac joint pain is NOT medically necessary and should NOT be approved. The 2025 BMJ clinical practice guideline provides a strong recommendation AGAINST joint radiofrequency ablation for chronic axial spine pain, including sacroiliac joint procedures 1.

Primary Evidence Against Approval

The 2025 BMJ guideline explicitly states that "all or nearly all well-informed people would likely not want such interventions" for joint radiofrequency ablation in chronic axial spine pain, and recommends these procedures "should therefore not be offered outside of a clinical trial." 1

Key Points from the Strongest Evidence:

• Joint radiofrequency ablation with or without joint targeted injection of local anaesthetic and steroids receives a STRONG recommendation AGAINST for chronic axial spine pain 1
• The guideline notes patients would be disinclined to receive interventional procedures with very low certainty of evidence for benefit and moderate to high certainty evidence of risk of harm 1
• The 2020 NICE guideline similarly does not support spinal injections for managing low back pain 1

Diagnosis-Specific Concerns

The patient's diagnoses (M53.3 sacrococcygeal disorders and M47.817 lumbosacral spondylosis) represent chronic axial spine pain rather than inflammatory sacroiliitis, which is the only condition where limited sacroiliac interventions receive conditional support 1:

• The American College of Rheumatology conditionally recommends local glucocorticoids for isolated active sacroiliitis in the context of inflammatory spondyloarthropathy, NOT mechanical sacroiliac pain 1
• This patient has mechanical/degenerative pathology (spondylosis), not inflammatory disease 1

Conflicting Lower-Quality Evidence

While the 2023 PM&R synthesis found some weakly-supportive recommendations for SI joint procedures from various guidelines, these are superseded by the 2025 BMJ strong recommendation against 1:

• The 2023 review identified one strongly-for and several weakly-for recommendations for cooled RF after positive diagnostic blocks 1
• However, these older recommendations are contradicted by the most recent (2025) and highest quality systematic evidence 1

Clinical Context Considerations

Despite the patient's documented response to previous RFA (40-50% relief lasting >6 months) and positive provocative testing, the evidence hierarchy prioritizes population-level systematic reviews over individual patient response 1:

• The 2025 BMJ guideline reviewed the full body of evidence and concluded the risk-benefit profile does not support these procedures 1
• Individual case success does not override systematic evidence showing very low certainty of benefit at the population level 1

Dexamethasone Injection (J1100)

The dexamethasone injection similarly lacks support, as the 2025 BMJ guideline recommends against joint-targeted injection of steroids for chronic axial spine pain 1. The American College of Rheumatology strongly recommends AGAINST systemic glucocorticoids for axial spondyloarthropathy 1, and while local injections receive conditional support only in inflammatory sacroiliitis (not mechanical pain) 1.

Common Pitfalls to Avoid

• Do not conflate inflammatory sacroiliitis (spondyloarthropathy) with mechanical sacroiliac joint pain - the evidence and recommendations differ substantially 1
• Do not rely on older guidelines when more recent systematic evidence exists - the 2025 BMJ guideline supersedes earlier recommendations 1
• Do not approve based solely on positive diagnostic blocks or prior response - the population-level evidence shows insufficient benefit to justify the procedure 1

Alternative Approach

The 2025 BMJ guideline emphasizes that most adults with chronic spine pain place high value on small pain relief, but would not accept interventional procedures with very low certainty of benefit 1. Conservative management including physical therapy, NSAIDs, and activity modification remains the evidence-based approach 2, 3.