Authors: Chad M. Brummett, M.D. et al
Anesthesiology 9 2018, Vol.129, 396-398.
Low back pain is one of the most common causes of chronic pain, disability, lost productivity, and cost, affecting more than 66 million Americans in 2012.1–3 A large number of treatments are available, including behavioral therapies, chiropractic care, exercise, injections, massage, medications, surgery, and others, with no empirically validated approach to selecting the best treatment for any individual patient. Nevertheless, consensus guidelines for low-back pain management generally emphasize conservative strategies over interventional approaches because they are perceived to be of lower cost and less risk.4,5 In contrast to the recommendations of these guidelines, needle-based interventions are very commonly used for low-back pain treatment. In fact, interventions of the facet (zygapophyseal) joints are the second most common procedure in interventional pain medicine.6 Whereas benefits of radiofrequency ablation under idealized circumstances have been established through multiple clinical trials,6 the general real-world results have been a source of recent controversy after the publication of the Mint trial.7 The Mint trial combined three separate pragmatic, nonblinded randomized trials of low back pain, sacroiliac joint pain, and a combination of the two and found that radiofrequency ablation combined with a standardized exercise program was no better than the standard exercise program alone. The study has been critiqued by experts for issues with patient selection, diagnostic blocks, and radiofrequency ablation technique. These results, in the context of rapidly increasing medical cost consciousness, place pressure on interventionalists to identify those patients most likely to benefit from their procedures.