Coverage Policy Manual
Policy #: 2009023
Category: Surgery
Initiated: August 2009
Last Review: October 2018
  Pain Management, Radiofrequency Facet Joint Denervation

Description:
Percutaneous radiofrequency (RF) facet denervation is used to treat neck or back pain originating in facet joints with degenerative changes. Diagnosis of facet joint pain is confirmed by response to nerve blocks. Patients generally are sedated for the RF procedure. Under local anesthetic and with fluoroscopic guidance, a needle is directed to the median branch of the dorsal nerve root in the facet joint , where multiple thermal lesions are produced by a radiofrequency generator. The goal of facet denervation is long-term pain relief. However, the nerves regenerate, and repeat procedures may be required.
 
Pulsed radiofrequency consists of short bursts of electrical current of high voltage in the radiofrequency range but without heating the tissue enough to cause coagulation. It is suggested as a possibly safer alternative to thermal radiofrequency facet denervation. Temperatures do not exceed 42°C at the probe tip versus temperatures in the 60°s C reached in thermal RF denervation, and tissues may cool between pulses. It is postulated that transmission across small unmyelinated nerve fibers is disrupted but not permanently damaged, while large myelinated fibers are not affected.
 
The American Medical Association’s CPT Editorial Panel decided in June 2005 that the unlisted CPT code 64999 should be used for pulsed RF treatment as opposed to other specific codes.
 
As of January 2012, new CPT codes were released for this procedure:
 
64633: Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance  (fluoroscopy or CT); cervical or thoracic, single facet joint
64634:  cervical or thoracic, each additional facet joint
64635:  Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance  (fluoroscopy or CT); lumbar or sacral
64636:  lumbar or sacral; each additional facet joint
 
The codes previously used (64622-64627) have been deleted and should no longer be used.
  

Policy/
Coverage:
Effective, January 2010
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness provided all of the following criteria are met:
 
    • No prior spinal fusion surgery in the vertebral level being treated;
    • Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations; and the pain is not radicular;
    • Pain has failed to respond to three (3) months of conservative management which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; and
    • A trial of controlled diagnostic medial branch blocks (2 separate positive blocks or placebo controlled series of blocks) under fluoroscopic guidance has resulted in at least an 80% reduction in pain.
 
If there has been a prior successful radiofrequency (RF) denervation, a repeat procedure at the same side, same level requires that a 6 month or longer time period has elapsed and that the above coverage criteria be met with the exception of a repeat trial of controlled diagnostic medial branch blocks. (Clarification effective 3/01/2010)
 
Radiologic guidance and/or any associated radiologic procedure (such as injecting any substance including small amounts of contrast to confirm the position of the needle) are not separately reimbursed. This is considered an integral part of the procedure. (Effective, April 2012)
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
  
Radiofrequency denervation does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet joint pain.
 
For contracts without Primary Coverage Criteria, radiofrequency denervation is considered investigational for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet or joint pain.  Investigational services are exclusions in the member benefit certificate of coverage.
 
Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without Primary Coverage Criteria, pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is considered investigational.  Investigational services are exclusions in the member benefit certificate of coverage.
 
Effective, November 2009 - December 2009
Radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness provided all of the following criteria are met:
    • No prior spinal fusion surgery in the vertebral level being treated;
    • Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations; and the pain is not radicular;
    • Pain has failed to respond to three (3) months of conservative management which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program;
    • A trial of controlled diagnostic medial branch blocks (2 separate positive blocks or placebo controlled series of blocks) under fluoroscopic guidance has resulted in at least an 80% reduction in pain; and
    • If there has been a prior successful radiofrequency (RF) denervation, a minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine) and a repeated trial of 2 separate positive controlled diagnostic medial branch blocks has resulted in at least an 80% reduction in pain.
 
Radiofrequency denervation does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet or sacroiliac joint pain.
 
Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without Primary Coverage Criteria, radiofrequency denervation is considered investigational for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet or sacroiliac joint pain.  Investigational services are exclusions in the member benefit certificate of coverage.
 
For contracts without Primary Coverage Criteria, pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is considered investigational.  Investigational services are exclusions in the member benefit certificate of coverage.
 
Effective, August 2009 - October 2009
Radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness provided all of the following criteria are met:
    • No prior spinal fusion surgery in the vertebral level being treated;
    • Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations; and the pain is not radicular;
    • Pain has failed to respond to three (3) months of conservative management which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program;
    • A trial of controlled diagnostic medial branch blocks (3 separate positive blocks or placebo controlled series of blocks) under fluoroscopic guidance has resulted in at least an 50% reduction in pain; and
    • If there has been a prior successful radiofrequency (RF) denervation, a minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine).
Radiofrequency denervation does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet or sacroiliac joint pain.
 
Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain does not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without Primary Coverage Criteria, radiofrequency denervation is considered investigational for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet or sacroiliac joint pain.  Investigational services are exclusions in the member benefit certificate of coverage.
 
For contracts without Primary Coverage Criteria, pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is considered investigational.  Investigational services are exclusions in the member benefit certificate of coverage.
 
 
 
 
 
 
  

Rationale:
Although radiofrequency (RF) facet denervation has been in use for more than 20 years, evidence of its efficacy is limited to small randomized controlled trials (RCTs), and to larger case series. Comparative studies are important for treatments for which the primary outcome is a measurement of pain in order to account for the potential placebo effect of an intervention. A 2003 systematic review of the literature cited methodological weaknesses of small sample sizes, short follow-up, deficiencies in patient selection, outcome assessment, and statistical analyses and concluded that “there is limited evidence that radiofrequency denervation offers short-term relief for chronic neck pain of zygapophysial joint origin and for chronic cervicobrachial pain, and conflicting evidence for its effectiveness for lumbar zygapophysial joint pain” (Niemistö, 2003).  Carragee et al, in a 2008 report of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, concluded that “Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence” (Carragee, 2008).  However, in a 2008 review that considered only randomized controlled trials in which at least one diagnostic block was used for patient selection, 2 of the trials published after the studies reviewed by Niemistö and colleagues concluded that “when done with proper technique, percutaneous radiofrequency lumbar and cervical medial branch neurotomy are both effective” (Levin, 2008).  In 2001, the California Technology Assessment Forum published a review of the evidence for percutaneous RF neurotomy of cervical and lumbar zygapophysial joints for chronic neck and low back pain and concluded that the technology met their criteria for efficacy and safety for treatment of lower cervical (C3 and below) and for lumbar pain but not for treatment of upper (C2-C3) levels. In 2007, the California Technology Assessment Forum reviewed the evidence for treatment of C2-3 joints and did not reverse its position.  
 
Two recent RCTs evaluating RF for low back pain reached different conclusions. In 2005, van Wijk et al published a multicenter RCT.  Inclusion criteria were continuous low back pain with or without radiating pain into the upper leg for more than 6 months and with focal tenderness over the facet joints, without sensory or motor deficits or positive straight leg raising test, no indication for low back surgery, and 50% or greater pain reduction 30 minutes after lidocaine block. Of 226 patients screened, 81 were randomized to RF or sham lesion treatment. The primary outcome was determined using a predefined multidimensional combined outcome measure comprising changes in VAS-back score, daily physical activities, and use of analgesics. Success was defined as at least 50% reduction of median VAS-back score without reduction in daily activities and/or rise in analgesic intake or reduction of at least 25% and drop in analgesic use of at least 25%. Information was collected in weekly diaries mailed in by patients. Failures at 3 months were unblinded and, if the patient had received sham treatment, RF was offered. Follow-up after successful treatment was at 6, 9, and 12 months. At 3 months, there was no difference between groups. VAS-back score was significantly reduced in both groups. There were no between-group differences on VAS-back score, VAS-leg, physical activities, or intake of analgesics. These results persisted until 12 months, however, because blinding was ended at the 3-month follow-up in more than 70% of patients; a mix of additional treatments was performed between the 3- and 12-month follow-ups; some patients in both groups were lost to follow-up; and outcome data collected after 3 months was difficult to interpret. Significantly more RF patients (62%) than sham patients (39%) achieved >50% pain relief on the Global Perceived Effect measured on a 4-point Likert scale. Subgroup analysis showed RF to be superior to sham in female patients, older patients, patients with longer pain history, patients with employment, and patients without history of low back surgery.
 
Nath and colleagues performed an RCT with 40 patients to evaluate short- and intermediate-term effects of RF for lumbar facet pain (Nath, 2008).  To be included in the study, patients had to be able to identify at least one component of their pain that was attributable to one or more lumbar zygapophysial joints, have paravertebral tenderness, and obtain at least 80% relief of pain following controlled (3 positive separate) medial branch blocks. Screening medial branch blocks were performed in 376 patients; 115 were negative, 261 patients had >80% relief of at least a component of their pain and proceeded to controlled blocks; 45 had a negative response to controlled blocks, 105 had prolonged responses, and 71 of the remaining lived too far away to participate or declined. The 40 remaining were randomized half to RF and half to sham treatment; all participated throughout the 6-month study. Multiple lesions were performed in each RF patient. Pretreatment, the RF group had significantly more generalized pain, low back pain, and referred pain to the leg. On patient’s own global assessment, the RF group improved by 1.1U and the placebo group by 0.3U (P=0.004). Generalized pain on VAS was reduced by 1.9 U (from 6.3 to 4.1) in the RF group versus 0.4U (from 4.4 to 4.8) for placebo (P=0.02). Back pain was reduced in the RF group by 2.1U (from 5.98 to 3.88) and referred pain by 1.6U (from 4.33 to 2.73), while back pain was reduced in the placebo group by 0.7U (from 4.38 to 3.68) and referred pain by 0.13 (from 2.68 to 2.55); between group differences were significant on both measures. RF patients were significantly more improved on secondary measures of back and hip movement, quality of life variables, the sacroiliac joint test, paravertebral tenderness, and tactile sensory deficit. Analgesic use was reported to be reduced more in the RF group, however details about this measure were not provided.
 
The only RCT evaluating RF for chronic cervical pain at the facet joints was published in 1995 by Lord et al.  Patients with C2-C3 zygapophysial joint pain were excluded because treatment at this level is technically difficult. Twenty–four patients (of 54 screened) were randomized to RF or sham treatment. Patient perception of pain was confirmed by placebo-controlled blocks (3 blocks, the first with 2% or 5% lidocaine, the second with saline, and the third with lidocaine). In the RF group, 2 or 3 lesions were made at each location. In telephone interviews at 3–5 days and 2–3 weeks and at formal interviews at 3 months, patients completed visual analogue scales and the McGill Pain questionnaire, indicated whether activities of daily living had been restored and were asked if their usual pain was present and if they required further treatment for pain. After 3 months and after outcome measures were recorded, patients who did not have any relief of pain or who had early return of pain were offered RF. Those who obtained relief at 3 months were asked to report when pain returned to 50% or more of pretreatment level. They were interviewed again at 1 year. Six patients in the control group and 3 in the RF group had return of pain immediately after the procedure. By 27 weeks, 1 patient in the control group and 7 in the RF group remained free of pain. Median time to return of >50% of pretreatment pain was 263 days in the RF group versus 8 days in the placebo group. Two patients in the active group who had no relief of pain were found to have pain from adjacent spinal segments.
 
No controlled trials evaluating RF denervation in thoracic facet joints were identified.  There is limited evidence for the management of sacroiliac joint pain with radiofrequency denervation (Hansen, 2007).  One randomized, controlled trial for radiofrequency denervation for sacroiliac joint pain was identified (Cohen, 2008).  In this study 28 patients received either L4-L5 and S1-S3 radiofrequency denervation or placebo denervation.   At one month, 79% of the patients in the treatment group experience at least a 50% reduction in pain.   At 6 months, 57%  experienced relief of pain and at one year, only 14% of the patients in the treatment group continued to experience pain relief.  Larger and longer term studies are needed to assess the effectiveness of radiofrequency denervation in this area.
 
To identify demographic, clinical, and treatment factors associated with outcomes of RF denervation, Cohen et al gathered data from 3 academic medical centers on 92 patients with chronic neck pain who received RF treatment. They determined that the only clinical variable associated with success was paraspinal tenderness. Factors associated with treatment failure included radiation to the head, opioid use, and pain exacerbated by neck extension or rotation (Cohen, 2007).  In another report, Cohen and colleagues, in a retrospective multicenter study with 262 patients, compared lumbar zygapophysial joint RF denervation success rates between the conventional at least 50% pain relief threshold and the more stringently proposed at least 80% cutoff. A total of 145 patients had >50% but <80% relief after medial branch block, and 117 obtained at least 80% relief. In the >50% group, success rates were 52% and 67% on pain relief and global perceived effect (GPE), respectively, after RF. Among those who had at least 80% relief from diagnostic blocks, 56% achieved at least 50% relief from RF and 66% had a positive GPE. The authors concluded that the more stringent pain relief criteria is unlikely to improve success rates, may lead to misdiagnosis, and withholding of potentially helpful treatment (Cohen, 2008).
 
Two reports of small (20 and 24 patients) retrospective studies of repeat procedures after successful RF were identified. In both series, more than 80% of patients had >50% relief from repeat RF treatment and mean duration of relief from subsequent RF treatments was comparable to the initial treatment (Husted, 2008) (Schoffferman, 2004).
 
While evidence is limited to a few comparative studies with small sample sizes, RF facet denervation appears to provide at least 50% pain relief in carefully selected patients. Diagnosis of facet joint pain is difficult, however response to controlled medial branch blocks and the presence of tenderness over the facet joint appear to be reliable predictors of success. When RF facet denervation is successful, repeat treatments appear to have similar success rates and duration of pain relief. Thus, the data indicate that in carefully selected individuals with lumbar or cervical facet joint pain, RF treatments can result in improved outcomes.
 
One RCT evaluating RF for treatment of cervicogenic headache was identified in the literature search. In a pilot study, 15 patients received a sequence of RF treatments (cervical facet joint denervation, followed by cervical dorsal root ganglion lesions when necessary) and 15 received local injections with steroid and anesthetic at the greater occipital nerve followed by transcutaneous electrical stimulation (TENS). Visual analogue scale, global perceived effect, and quality of life scores were assessed at 8, 16, 24, and 48 weeks. There were no statistically significant differences between groups at any time point in the trial (Haspeslagh, 2006).  
 
Pulsed radiofrequency facet denervation
One small RCT comparing pulsed RF to sham treatment was identified in the literature review. Van Zundert and colleagues randomized 23 patients (of 256 screened) with chronic cervical radicular pain. Success was defined as at least 50% improvement on global perceived effect (GPE), at least 20% reduction in pain on visual analogue scale, and reduced pain medication use measured 3 months after treatment. Nine of 11 patients in the treatment arm and 4 of 12 in the sham arm showed at least 50% improvement on GPE (P=0.03), and 9 of 11 in the treatment group and 3 of 12 in the sham group achieved at least 20% reduction in pain on visual analogue scale (P=0.02). At 6-month follow-up, more patients in the treatment group reduced their use of pain medication, but the difference was not significant. There was a trend toward more positive outcomes in the pulsed RF group on quality of life scores. The authors concluded that pulsed RF may provide pain relief for a limited number of carefully selected patients. These findings must be confirmed in larger studies before drawing conclusions regarding the efficacy of pulsed RF (Van Zundert, 2007).
 
One study comparing continuous RF and pulsed RF was found. Sixty patients were randomized 20 each to conventional RF, pulsed RF, and a control group (local anesthetic only) (Tekin, 2007).  Outcome measures were pain on visual analogue scale and Oswestry Disability Index (ODI) scores. Mean VAS and ODI scores were lower in both treatment groups than in controls post-treatment; however. the reduction in pain was maintained at 6- and 12-month follow-up only in the conventional RF group. The number of patients not using analgesics and patient satisfaction were highest in the conventional RF group.
 
2013 Update
This policy is being updated with a literature review through January 2013. There were no new controlled clinical trials identified. The coverage statement is unchanged.
 
2014 Update
In 2012, Falco and colleagues updated their systematic reviews on the diagnosis and treatment of facet joint pain (Falco, 2012a; Falco, 2012b; Falco, 2012c; Falco, 2012d).  They found good evidence for diagnostic nerve blocks with at least 75% pain relief as the criterion standard but were limited to fair evidence for diagnostic nerve blocks with 50% to 74% pain relief. There was good evidence for conventional radiofrequency neurotomy for the treatment of lumbar facet joint pain, fair evidence for cervical radiofrequency neurotomy, and limited evidence for intra-articular facet joint injections and pulsed radiofrequency thermoneurolysis. Evidence for the use of therapeutic cervical medial branch blocks was fair, and evidence for therapeutic lumbar facet joint nerve blocks was rated as fair to good.
 
A 2013 RCT by Lakemeier et al. compared RF facet joint denervation versus intra-articular steroid injections in 56 patients in a randomized double-blind trial (Lakemeier, 2013).) Patients were selected first on magnetic resonance imaging (MRI) findings of hypertrophy of the facet joints followed by a positive response to an intra-articular infiltration of the facet joints with anesthetics. A diagnostic double-block of the facet joint was not performed. At 6 months, there was no significant difference between the 2 groups, although it is not clear if the mean VAS scores were significantly improved in either group. The proportion of patients who achieved a 50% decrease in VAS was not reported.
 
Updated guidelines on interventional techniques in the management of chronic spinal pain from the American Society of Interventional Pain Physicians (ASIPP) were published in 2013 (Manchikanti, 2013). Diagnostic lumbar facet joint nerve blocks were recommended in patients with suspected facet joint pain, based on good evidence for diagnostic lumber facet joint nerve blocks with 75% to 100% pain relief as criterion standard. For the treatment of facet joint pain, evidence was considered to be good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks and limited for intra-articular injections. Based on the evidence review, ASIPP recommends treatment with conventional radiofrequency neurotomy or therapeutic facet joint nerve blocks.
 
Practice guidelines for chronic pain management by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine were published in 2010 (ASA, 2010).  The guidelines include the following recommendations:
 
  • Radiofrequency ablation: Conventional (e.g., 80°C) or thermal(e.g., 67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief.
  • Chemical denervation: Chemical denervation (e.g., alcohol, phenol, or high-concentration local anesthetics) should not be used in the routine care of patients with chronic noncancer pain.
 
2018 Update
A literature search was conducted through September 2018.  There was no new information identified that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
PRACTICE GUIDELINES AND POSITION STATEMENTS
 
Dutch Society of Anesthesiologists et al
The Dutch Society of Anesthesiologists, in collaboration with the Dutch Orthopedic Association and the Dutch Neurosurgical Society issued joint guidelines on invasive treatment of lumbosacral spine pain (DSA, 2016). For facet joint pain, the guidelines concluded that there was evidence that RF has a beneficial effect on functionality for 3 to 6 months. The guidelines also concluded that “pulsed RF has no place in the treatment of lumbar facet pain.”

CPT/HCPCS:
64633Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
64635Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
64999Unlisted procedure, nervous system
77003Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)

References: American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine.(2010) Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010; 112(4):810-33.

Bogduk N.(2008) Point of View. SPINE. 2008;33(12);1298.

Boswell MV, Manchikanti L, Kaye AD, et al.(2015) A Best-Evidence Systematic Appraisal of the Diagnostic Accuracy and Utility of Facet (Zygapophysial) Joint Injections in Chronic Spinal Pain. Pain Physician. Jul-Aug 2015;18(4):E497-533. PMID 26218947

California Technology Assessment Forum (CTAF).(2007) Percutaneous radiofrequency neurotomy for treatment of chronic pain from the upper cervical (C2-3) spine. A Technology Assessment. San Francisco, CA: CTAF; June 20, 2007.

Carragee EJ, Hruwitz EK, Cheng I et al.(2008) Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 suppl):S153-69.

Civelek E, Cansever T, Kabatas S, et al.(2012) Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain. Turk Neurosurg. 2012;22(2):200-206. PMID 22437295

Cohen SP, Bajwa ZH, Kraemer JJ et al.(2007) Factors predicting success or failure for cervical facet radiofrequency denervation: a multi-center analysis. Reg Anesth Pin Med 2007; 32(6):495-503.

Cohen SP, Hurley RW, Buckenmaier CC 3rd, et al.(2008) Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008 Aug;109(2):279-288.

Cohen SP, Stojanovic MP, Crooks M et al.(2008) Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine J 2008; 8(3):498-504.

Datta S, Lee M, Falco FJ, et al.(2009) Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician 2009; 12:437-460.

Falco FJ, Datta S, Manchikanti L et al.(2012) An updated review of the diagnostic utility of cervical facet joint injections. Pain Physician 2012a; 15(6):E807-38.

Falco FJ, Manchikanti L, Datta S et al.(2012) An update of the effectiveness of therapeutic lumbar facet joint interventions. Pain Physician 2012d; 15(6):E909-53.

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Falco FJ, Manchikanti L, Datta S et al.(2012) Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician 2012b; 15(6):E839-68.

Hansen HC, McKenzie-Brown AM, Cohen SP et al.(2007) Sacroiliac joint interventions: a systematic review. Pain Physician. 2007 Jan;10(1):165-184.

Hashemi M, Hashemian M, Mohajerani SA, et al.(2014) Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis. Eur Spine J. Sep 2014;23(9):1927-1932. PMID 24997616

Haspeslagh SR, Van Suijlekom HA, Lame IE et al.(2006) Randomised controlled trial of cervical radiofrequency lesions as a treatment for cervicogenic headache. BMC Anesthesiol 2006; 6:1.

Husted DS, Orton D, SchoffermanJ et al.(2008) Effectiveness of repeated radiofrequency neurotomy for cervical facet joint pain. J Spinal Disord Tech 2008; 21(6):406-8.

Itz CJ, Willems PC, Zeilstra DJ, et al.(2016) Dutch multidisciplinary guideline for invasive treatment of pain syndromes of the lumbosacral spine. Pain Pract. Jan 2016;16(1):90-110. PMID 26032119

Lakemeier S, Lind M, Schultz W et al.(2013) A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg 2013; 117(1):228-35.

Levin JH.(2008) Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us. Spine J 2008 Sep 11 [Epub ahead of print]

Lord SM, Barnsley L, Wallis BJ et al.(1996) Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Eng J Med 1996; 335(23):1721-6.

Manchikant L, Boswell MV, Singh V, et al.(2009) Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699-802.

Manchikanti L, Abdi S, Atluri S et al.(2013) An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16(2 Suppl):S49-283.

Manchikanti L, Boswell MV, Singh V, et al.(2004) Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders. 2004; 5:15. Available at http://www.biomedcentral.com/1471-2474/5/15.

Manchikanti L, Hirsch JA, Pampati V, et al.(2003) Chronic low back pain of facet(zygapophysial) joint origin: Is there a defference based on involvement of single or multiple spinal regions? Pain Physician. 2003;6:399-405.

Manchikanti L, Kaye AD, Boswell MV, et al.(2015) A Systematic Review and Best Evidence Synthesis of the Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. Pain Physician. Jul-Aug 2015;18(4):E535-582. PMID 26218948

Manchikanti L, Manchukonda R, Pampati V, et al.(2007) Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007 Apr;88(4):449-455.

Manchikanti L, Pampati V, Fellows B, et al.(2000) The inability of the clinical picture to characterize pain from facet joints. Pain Physician. 2000;3(2):158-166.

Manchikanti L, Singh V, Pampati V, et al.(2001) Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician. 2001;4(4):308-316.

Manchikanti L, Singh V, Pampati V, et al.(2002) Is there a correlation of facet joint pain in lumbar and cervical spine? Pain Physician. 2002;(4):365-371.

Manchukonda R, Manchikanti KN, Cash KA, et al.(2007) Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech. 2007 Oct;20(7):539-45.

Nath S, Nath CA, Pettersson K.(2008) Percutaneous lumbar zygapophysial (facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial. Spine 2008; 33(12):1291-7.

Niemistö L, Kalso E, Malmivaara A et al.(2003) Radiofrequency denervation for neck and back pain: a systematic review within the framework of the Cochrane collaboration back review group. Spine 2003; 28(16):1877-88.

Rupert MP, Lee M, Manchikanti L, et al.(2009) Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009; 12:399-418.

Schwarzer AC, Wang S, Bpgduk N, et al.(1995) Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an australian population with chronic low back pain. Annals of the Rheumatic Diseases 1995; 54:100-106.

Tekin I, Merzai H, Ok G et al.(2007) A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clin J Pain 2007; 23(6):524-9.

Van Wijk Rm, Guerts JW, Wynne HJ et al.(2005) Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain 2005; 21(4):335-44.

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