Radiofrequency Ablation and Dexamethasone Injection Should Be Denied for This Patient
The British Medical Journal provides a strong recommendation against joint radiofrequency ablation with or without joint-targeted injection of local anesthetic and steroids for chronic axial spine pain, including sacroiliac joint procedures and facet-mediated pain from lumbosacral spondylosis, due to very low certainty of evidence for benefit and moderate to high certainty evidence of risk of harm. 1
Why This Recommendation Overrides Individual Patient Response
The 2025 BMJ guideline explicitly states that most well-informed people would likely not want these interventions and that these procedures should not be offered outside of clinical trial settings. 1 This population-level systematic evidence takes precedence over individual patient response patterns, even when a patient reports 40-50% relief for over 6 months from prior RFA. 1
The evidence hierarchy prioritizes population-level systematic reviews over individual patient response, meaning that while some patients may experience relief from radiofrequency ablation, the overall evidence does not support its use. 1
Conflicting Evidence and Why the BMJ Guideline Prevails
There is notable divergence in the literature on this topic:
Older guidelines (2014) from the Journal of Neurosurgery provided Level II-III evidence with a strong recommendation for RF ablation in facet-mediated low back pain, though this was acknowledged as low-quality evidence. 2 One high-quality RCT from 2001 showed no difference between RFA and sham control at 4 and 12 weeks in patients selected by positive diagnostic facet injections. 2
Newer evidence (2025) from the American Academy of Physical Medicine and Rehabilitation supports RFA for patients with positive diagnostic medial branch blocks who have failed conservative treatment for more than 3 months. 3 These guidelines recommend RFA for patients with chronic axial low back pain affecting activities of daily living, absence of radicular symptoms, and positive response to two diagnostic medial branch blocks with greater than 80% pain relief. 3
However, the 2025 BMJ guideline represents the most recent, highest-quality systematic evidence and provides the strongest recommendation against these procedures. 1 The BMJ guideline notes that 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
Why Positive Provocative Testing Does Not Change This Recommendation
While positive diagnostic blocks traditionally predict RFA response, the BMJ guideline's strong recommendation against these procedures applies regardless of diagnostic testing results. 1 The guideline specifically addresses patients with mechanical or degenerative pathology such as spondylosis, stating they do not benefit from sacroiliac joint interventions or facet procedures. 1
The National Institute for Health and Care Excellence guideline similarly does not support spinal injections for managing low back pain, indicating a lack of evidence for their effectiveness. 1
Evidence-Based Alternative Management
Conservative management remains the appropriate evidence-based approach for this patient's lumbosacral spondylosis and sacrococcygeal disorders:
- Physical therapy targeting core strengthening and spinal stabilization 1
- NSAIDs for anti-inflammatory pain control 1
- Activity modification to reduce mechanical stress on degenerative segments 1
The American Society of Anesthesiologists Task Force strongly recommends that other treatment modalities should be attempted before consideration of ablative techniques. 4
Common Pitfalls to Avoid
Do not be swayed by prior treatment response. Individual patient relief does not override systematic evidence showing population-level harm exceeding benefit. 1
Do not confuse inflammatory sacroiliitis with mechanical sacroiliac pain. The American College of Rheumatology conditionally recommends local glucocorticoids only for isolated active sacroiliitis in inflammatory spondyloarthropathy, not for mechanical sacroiliac pain. 1
Do not assume positive diagnostic blocks justify therapeutic intervention. The BMJ guideline's recommendation against these procedures applies even with positive provocative testing. 1
When Surgery or Additional Treatment Would Be Indicated
Surgery is NOT indicated for this patient unless they develop:
- Neurological deficits such as myelopathy or progressive radiculopathy 4
- Spinal instability 4
- Bowel/bladder dysfunction 4
- Severe spinal deformity 4
None of these red flags appear to be present in this patient with degenerative spondylosis and sacrococcygeal disorders. 4