Guideline Number: NIA_CG_302 Last Revised Date: September 2015 Responsible Department: Implementation Date: September 2015 Clinical Operations

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1 Natinal Imaging Assciates, Inc. Clinical guidelines PARAVERTEBRAL FACET JOINT DENERVATION (RADIOFREQUENCY NEUROLYSIS) CPT Cdes: Cervical Thracic Regin: 64633, Lumbar Sacral Regin: 64635, Original Date: Octber 2012 Page 1 f 5 Last Review Date: April 2015 Guideline Number: NIA_CG_302 Last Revised Date: September 2015 Respnsible Department: Implementatin Date: September 2015 Clinical Operatins INTRODUCTION Facet jints (als called zygapphysial jints r z-jints), psterir t the vertebral bdies in the spinal clumn and cnnecting the vertebral bdies t each ther, are lcated at the junctin f the inferir articular prcess f a mre cephalad vertebra and the superir articular prcess f a mre caudal vertebra. These jints prvide stability and enable mvement, allwing the spine t bend, twist, and extend in different directins. They als restrict hyperextensin and hyperflexin. Facet jints are clinically imprtant spinal pain generatrs in patients with chrnic spinal pain. Pain mediated by the facet jints may be caused by repetitive stress and/r cumulative lw-level trauma resulting in stearthritis and inflammatin. In patients with chrnic lw back pain, facet jints have been implicated as a cause f the pain in 15% t 45% f patients. They are cnsidered as the cause f chrnic spinal pain in 48% f patients with thracic pain and 54% t 67% f patients with chrnic neck pain. Facet jints may refer pain t adjacent structures, making the underlying diagnsis difficult as referred pain may assume a pseudradicular pattern. Lumbar facet jints may refer pain t the back, buttcks, and prximal lwer extremities while cervical facet jints may refer pain t the head, neck and shulders. Imaging findings are f little value in determining the surce and lcatin f facet jint syndrme, a term riginally used by Ghrmley and referring t back pain caused by pathlgy at the facet jints. Imaging studies may detect changes in facet jint architecture, but crrelatin between radilgic findings and symptms is unreliable. Althugh clinical signs are als unsuitable fr diagnsing facet jint-mediated pain, they may be f value in selecting patients fr cntrlled lcal anesthetic blcks f either the medial branches r the facet jint itself. This is an established tl in diagnsing facet jint syndrme. Facet jints are knwn t be a surce f pain with definitive innervatins. Interventins used in the treatment f patients with a cnfirmed diagnsis f facet jint pain include: medial branch nerve blcks in the lumbar, cervical and thracic spine; and radifrequency neurlysis (see additinal terminlgy). The medial branch f the primary drsal rami f the spinal nerves has been shwn t be the primary innervatins f facet jints. Substance P, a physilgically ptent neurpeptide cnsidered t play a rle in the nciceptive transmissin f nerve impulses, is fund in the nerves within the facet jint. 1 Paravertebral Facet Jint Denervatin v3 Prprietary

2 Radifrequency neurlysis is a minimally invasive treatment fr cervical, thracic and lumbar facet jint pain. It invlves using energy in the radifrequency range t cause necrsis f specific nerves (medial branches f the drsal rami), preventing the neural transmissin f pain. The bjective f radifrequency neurlysis is t bth prvide relief f pain and reduce the likelihd f recurrence. Used mst ften fr facet jint pain, radifrequency neurlysis is recently emerging fr sacriliac jint pain. Hwever, it has been shwn t have limited evidence in treating sacriliac jint pain and is cnsidered investigatinal and nt medically necessary. Members f the American Sciety f Anesthesilgists (ASA) and the American Sciety f Reginal Anesthesia and Pain Medicine (ASRA) have agreed that cnventinal r thermal radifrequency ablatin f the medial branch nerves t the facet jint shuld be perfrmed fr neck r lw back pain. Radifrequency neurlysis has been emplyed fr ver 30 years t treat facet jint pain. Prir t perfrming this prcedure, shared decisin-making between patient and physician must ccur, and patient must understand the prcedure and its ptential risks and results. INDICATIONS FOR THERAPEUTIC PARAVERTEBRAL FACET JOINT DENERVATION (RADIOFREQUENCY NEUROLYSIS) (lcal anesthetic blck fllwed by the passage f radifrequency current t generate heat and cagulate the target medial branch nerve) Psitive respnse t cntrlled lcal anesthetic blcks f the facet jint, with at least 50% pain relief and/r ability t perfrm prir painful mvements withut significant pain, but with insufficient sustained relief (less than 2-3 mnths relief); OR Psitive respnse t prir radifrequency neurlysis prcedures with at least 50% pain imprvement fr up t 6 mnths f relief in past 12 mnths; AND The presence f the fllwing: Lack f evidence that the primary surce f pain being treated is frm discgenic pain, sacriliac jint pain, disc herniatin r radiculitis; Intermittent r cntinuus facet-mediated pain [average pain levels f 6 n a scale f 0 t 10] causing functinal disability; Duratin f pain f at least 3 mnths; AND Failure t respnd t mre cnservative nn-perative management FREQUENCY: Relief typically lasts between 6 and 12 mnths and smetimes prvides relief fr greater than 2 years. Repeat radifrequency denervatin is perfrmed fr sustained relief up t tw and three times. Limit t 2 facet neurlysis prcedures every 12 mnths, per regin CONTRAINDICATIONS FOR PARAVERTEBRAL FACET JOINT DENERVATION (RADIOFREQUENCY NEUROLYSIS): Histry f allergy t lcal anesthetics r ther drugs ptentially utilized; Lumbsacral radicular pain (drsal rt ganglin); 2 Paravertebral Facet Jint Denervatin v3 Prprietary

3 Cnditins/diagnsis fr which prcedure is used are ther than thse listed in Indicatins; Absence f psitive diagnstic blcks; OR Fr any nerve ther than the medial branch nerve. ADDITIONAL INFORMATION: *Cnservative Therapy: (spine) shuld include a multimdality apprach cnsisting f a cmbinatin f active and inactive cmpnents. Inactive cmpnents, such as rest, ice, heat, mdified activities, medical devices, acupuncture and/r stimulatrs, medicatins, injectins (epidural, facet, bursal and/r jint, nt including trigger pint), and diathermy can be utilized. Active mdalities may cnsist f physical therapy, a physician supervised hme exercise prgram**, and/r chirpractic care. **Hme Exercise Prgram - (HEP) the fllwing tw elements are required t meet guidelines fr cmpletin f cnservative therapy: Infrmatin prvided n exercise prescriptin/plan AND Fllw up with member with dcumentatin prvided regarding cmpletin f HEP, (after suitable 4-6 week perid) r inability t cmplete HEP due t physical reasni.e. increased pain, inability t physically perfrm exercises. (Patient incnvenience r nncmpliance withut explanatin des nt cnstitute inability t cmplete HEP). Terminlgy: Paravertebral Facet Jint Denervatin, Radifrequency Neurlysis, Destructin Paravertebral Facet Jint Nerve, Facet Jint Rhiztmy, Facet Neurlysis, Medial Branch Radifrequency Neurlysis, Medial Branch Radifrequency Neurtmy r Radifrequency Denervatin. 3 Paravertebral Facet Jint Denervatin v3 Prprietary

4 REFERENCES American Sciety f Anesthesilgists Task Frce n Chrnic Pain Management, American Sciety f Reginal Anesthesia and Pain Medicine. (2010). Practice guidelines fr chrnic pain management: An updated reprt by the American Sciety f Anesthesilgist Task Frce n Chrnic Pain Management and the American Sciety f Reginal Anesthesia and Pain Medicine. Anesthesilgy, 112(4), Binder, D.S. & Nampiaparampil, D.E. (2009). The prvcative lumbar facet jint. Curr Rev Musculskelet Med, 2(1), di: /s y. Bswell, M.V., Clsn, J.D., & Spillane, W.F. (2005). Therapeutic facet jint interventins in chrnic spinal pain: A systematic review f effectiveness and cmplicatins. Pain Physician, 8(1), Retrieved frm Bgduk, N. (1997). Internatinal spinal injectin sciety guidelines fr the perfrmance f spinal injectin prcedures. Part 1: Zygapphysial jint blcks. Clin J Pain, 13(4), PMID: Chu, R., Atlas, S.J., Stans, S.P., & Rsenquist, R.W. (2009). Nnsurgical interventinal therapies fr lw back pain: a review f the evidence fr an American Pain Sciety clinical practice guideline. Spine, 34(10), di: /BRS.0b013e3181a103b1. Datta, S., Lee, M., & Falc, F.J., Bryce, D.A. & Hayek, S.M. (2009). Systematic assessment f diagnstic accuracy and therapeutic utility f lumbar facet jint interventin. Pain Physician, 12(2), Henschke, N., Kuijpers, T., & Rubinstein, S., van Middelkp, M., Ostel, R., Verhagen, A., Kes, B.W. & van Tulder, M.W. (2010). Injectin therapy and denervatin prcedures fr chrnic lw-back pain: A systematic review. Eur Spine Jurnal, 19(9), di: /s Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R.M., Bswell, M.V., Buenaventura, R.M., Bryce, D.A.,... Hirsch, J.A.(2013). An update f cmprehensive evidence-based guidelines fr interventinal techniques f chrnic spinal pain: Part II: Guidance and recmmendatins. Pain Physician, 16(2 suppl), S49-S283. ISSN Manchikanti, L., Bswell, M.V., Singh, V., Benyamin, R.M., Fellws, B., Abdi, S. Buenaventura, R.M.,... ASIPP-IPM. (2009). Cmprehensive evidence-based guidelines fr interventinal techniques in the management f chrnic spinal pain. Pain Physician, 12(4), ISSN Muhlner, S.B. (2009). Review article: Radifrequency neurtmy fr the treatment f sacriliac jint syndrme. Current Reviews in Musculskeletal Medicine, 2(1), di: /s z. 4 Paravertebral Facet Jint Denervatin v3 Prprietary

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Guideline Number: NIA_CG_301 Last Revised Date: October 2014 Responsible Department: Implementation Date: October 2014 Clinical Operations

Guideline Number: NIA_CG_301 Last Revised Date: October 2014 Responsible Department: Implementation Date: October 2014 Clinical Operations Natinal Imaging Assciates, Inc. Clinical guidelines PARAVERTEBRAL FACET JOINT INJECTIONS OR BLOCKS CPT Cdes: Cervical Thracic Regin: 64490 (+ 64491, +64492), 0213T (+0214T, +0215T) Lumbar Sacral Regin: