Radiofrequency Facet Denervation AHM

Transcription

1 Radiofrequency Facet Denervation AHM Clinical Indications Nonpulsed radiofrequency facet denervation (also known as facet neurotomy, facet rhizotomy, or articular rhizolysis) is considered medically necessary for treatment of members with intractable cervical or back pain with or without sciatica in the outpatient setting when ALL of the following are met o Member has experienced severe pain limiting activities of daily living for at least 6 months o Member has had no prior spinal fusion surgery o Neuroradiologic studies are negative or fail to confirm disc herniation o Member has no significant narrowing of the vertebral canal or spinal instability requiring surgery o Member has tried and failed conservative treatments such as bed rest, back supports, physiotherapy, correction of postural abnormality, as well as pharmacotherapies (e.g., anti-inflammatory agents, analgesics and muscle relaxants) o Trial of facet joint injections has been successful in relieving the pain Only 1 treatment procedure per level per side is considered medically necessary in a 6-month period Current role remains uncertain. Based on review of existing evidence, there are currently no clinical indications for this technology. See Inappropriate Uses for more detailed analysis of the evidence base. Nonpulsed radiofrequency facet denervation is investigational for all other indications Indications considered Not Medically Necessary Any of the following are considered investigational o Facet chemodenervation/chemical facet neurolysis o Facet joint allograft implants (NuFix facet fusion, TruFuse facet fusion) o Facet joint implantation (Total Posterior-element System (TOPS) (Premia Spine), Total Facet Arthroplasty System (TFAS) (Archus Orthopedics), ACADIA Facet Replacement System (Facet Solutions/Globus Medical) o Laser facet denervation o Radiofrequency denervation for sacroiliac joint pain o Radiofrequency lesioning of dorsal root ganglia for back pain o Radiofrequency lesioning of terminal (peripheral) nerve endings for back pain o Radiofrequency/pulsed radiofrequency ablation of trigger point pain AC-AERAD Page 1 of 5

2 Evidence Summary Return to top of Radiofrequency Facet Denervation AHM - AC ActiveHealth Management Background Facet joints of the spine have joint capsules that are supplied by a branch of the posterior ramus of the spinal nerve. Percutaneous radiofrequency facet denervation, also known as radiofrequency facet joint rhizotomy or facet neurotomy, involves selective denervation using radiofrequency under fluoroscopic guidance. As a method of neurolysis, radiofrequency facet denervation has been shown to be a very safe procedure and can offer relief for many patients with mechanical LBP in whom organic pathology, most commonly a herniated lumbar disc, has been eliminated. According to the literature, it offers advantages over conventional neurolytic agents (e.g., phenol, alcohol, and hypertonic saline) because of its long lasting effects, the relative lack of discomfort, and its completely local action without any random diffusion of the neurolytic agent. Because there are no reliable clinical signs that confirm the diagnosis, successful relief of pain by injections of an anesthetic agent into the joints are necessary before proceeding with radiofrequency facet denervation. Results from many studies have shown that radiofrequency facet denervation results in significant (excellent or good) pain relief, reduced use of pain medication, increased return-to-work, and is associated with few complications. Success rate, however, depends on a careful selection of patients. The use of chemical facet injections such as alcohol, phenol and hypertonic saline has been proposed as an option for lumbar facet pain. However, there is a lack of published data to support the safety and effectiveness of this technique. There is a lack of published evidence of laser facet denervation for lumbar facet pain. References Cho J, Park YG, Chung SS. Percutaneous radiofrequency lumbar facet rhizotomy in mechanical low back pain syndrome. Stereotact Funct Neurosurg. 1997;68(1-4 Pt 1): Goupille P, Cotty P, Fouquet B, et al. Denervation of the posterior lumbar vertebral apophyses by thermocoagulation in chronic low back pain. Results of the treatment of 103 patients. Rev Rhum Ed Fr. 1993;60(11): Jerosch J, Castro WH, Halm H, et al. Long-term results following percutaneous facet coagulation. Z Orthop Ihre Grenzgeb. 1993;131(3): Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No Rockville, MD. Agency for Health Care Policy & Research (AHCPR); December Mehta M, Wynn Parry CB. Mechanical back pain and the facet joint syndrome. Disabil Rehabil. 1994;16(1):2-12. Bogduk N, Long DM. Percutaneous lumbar medical branch neurotomy: A modification of facet denervation. Spine. 1980;5(2): Shealy CN. Facet denervation in the management of back and sciatica pain. Clin Orthop. 1976;15: AC-AERAD Page 2 of 5

3 Stolker RJ, Vervest AC, Groen GJ. Percutaneous facet denervation in chronic thoracic spinal pain. Acta Neurochir (Wien). 1993;122(1-2): Bogduk N, Macintosh J, Marsland A. Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain. Neurosurgery. 1987;20(4): Shealy CN. Percutaneous radiofrequency denervation of spinal facets: Treatment for chronic back pain and sciatica. J Neurosurg. 1975;43: Oudenhoven RC. The role of laminectomy, facet rhizotomy, and epidural steroids. Spine. 1979;4(2): Rashbaum RF. Radiofrequency facet denervation. Orthop Clin N Am. 1983;14(3): Savitz MH. Percutaneous radiofrequency rhizotomy of the lumbar facets: Ten years' experience. Mt Sinai J Med. 1991;8(2): North RB, Han M, Zahurak M, Kidd DH. Radiofrequency lumbar facet denervation: Analysis of prognostic factors. Pain. 1994;57(1): Lord SM, Barnsley L, Wallis BJ, et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996;335: Niemisto L, Kalso E, Malmivaara A, et al. Radiofrequency denervation for neck and back pain. Cochrane Database Syst Rev. 2003;(1):CD Niemisto L, Kalso E, Malmivaara A, et al. Radiofrequency denervation for neck and back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2003;18(16): American Society of Anesthesiologists. Practice guidelines for chronic pain management. A Report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology. 1997;86: Available at: Accessed March 9, Institute for Clinical Systems Improvement (ICSI). Percutaneous radiofrequency ablation for facet-mediated neck and back pain. Technology Assessment Report. Bloomington, MN: ICSI; California Technology Assessment Forum (CTAF). Percutaneous radiofrequency neurotomy for treatment of chronic pain from the upper cervical (C2-3) spine. A Technology Assessment. San Francisco, CA: CTAF; June 20, Murtagh J, Foerster V. Radiofrequency neurotomy for lumber pain. Issues in Emerging Health Technologies Issue 83. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health (CADTH); Binder A. Neck pain. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May Henschke N, Kuijpers T, Rubinstein SM, et al. Injection therapy and denervation procedures for chronic lowback pain: A systematic review. Eur Spine J. 2010;19(9): Van Zundert J, Brabant S, Van de Kelft E, et al. Pulsed radiofrequency treatment of the gasserian ganglion in patients with idiopathic trigeminal neuralgia. Pain. 2003;104(3): Mikeladze G, Espinal R, Finnegan R, et al. Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain. Spine J. 2003;3(5): AC-AERAD Page 3 of 5

4 Ahadian FM. Pulsed radiofrequency neurotomy: Advances in pain medicine. Curr Pain Headache Rep. 2004;8(1): Shah RV, Racz GB. Long-term relief of posttraumatic headache by sphenopalatine ganglion pulsed radiofrequency lesioning: A case report. Arch Phys Med Rehabil. 2004;85(6): Binder A. Neck pain. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May Hansen HC, McKenzie-Brown AM, Cohen SP, et al. Sacroiliac joint interventions: A systematic review. Pain Physician. 2007;10(1): Cohen SP, Hurley RW, Buckenmaier CC 3rd, et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008;109(2): Kapural L, Nageeb F, Kapural M, et l. Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: The first case-series. Pain Pract. 2008;8(5): Cohen SP, Strassels SA, Kurihara C, et al. Outcome predictors for sacroiliac joint (lateral branch) radiofrequency denervation. Reg Anesth Pain Med. 2009;34(3): American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. 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): Karaman H, Kavak GO, Tufek A, et al. Cooled radiofrequency application for treatment of sacroiliac joint pain. Acta Neurochir (Wien). 2011;153(7): Patel N, Gross A, Brown L, Gekht G. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med. 2012;13(3): Stelzer W, Aiglesberger M, Stelzer D, Stelzer V. Use of cooled radiofrequency lateral branch neurotomy for the treatment of sacroiliac joint-mediated low back pain: A large case series. Pain Med. 2013;14(1): Ho K-Y, Hadi MA, Pasutharnchat K, Tan KH. Cooled radiofrequency denervation for treatment of sacroiliac joint pain: Two-year results from 20 cases. J Pain Res. 2013;6: North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); January, Hegmann KT, ed. Low back disorders. In: Glass LS, editor(s). Occupational medicine practice guidelines: Evaluation and management of common health problems and functional recovery in workers. 2nd Ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain: Injections and surgical interventions: Results of the Bone and Joint Decade Task Force on neck pain and its associated disorders. J Manipulative Physiol Ther. 2009;32(2 Suppl):S176-S193. Tamimi MA, McCeney MH, Krutsch J. A case series of pulsed radiofrequency treatment of myofascial trigger points and scar neuromas. Pain Med. 2009;10(6): AC-AERAD Page 4 of 5

5 Lee JS, Yoon KB, Kim IK, Yoon DM. Pulsed radiofrequency treatment of pain relieving point in a soft tissue. Korean J Pain. 2011;24(1): Reviewed by a Board Certified Internist Reviewed by David Evans, MD, Medical Director, Active Health Management- March 2016 ACTIVEHEALTH MANAGEMENT. Codes CPT or HCPCS: 64633, 64634, 64635, AC-AERAD Page 5 of 5