Focus of the Report: The focus of this Health Technology Assessment (HTA) is to evaluate the effectiveness and safety of cooled radiofrequency ablation (CRFA) and pulsed radiofrequency (PRF) for the treatment of chronic low back pain (CLBP) that originates from the sacroiliac joint (SIJ).

Technology Description: The application of radiofrequency (RF) energy is a percutaneous outpatient procedure intended to prevent or disrupt transmission of pain signals from the sensory nerves to the central nervous system. CRFA uses RF energy to heat the target tissue to the point of destruction (lesioning) while maintaining a lower temperature in the adjacent tissue, which allows creation of a larger lesion without risking thermal injury to nearby structures. Treatment with PRF involves the delivery of RF energy in brief pulses, which prevents the probe from reaching a temperature high enough to damage tissue; the resultant pain relief is thought to occur through disruption of nerve activity rather than destruction of the nerve.

Controversy: The main controversy surrounding SIJ pain is the lack of consensus regarding the exact innervation of the joint and the particular contributions of the various nerves. The anatomy of the SIJ is variable between patients and can even differ from 1 side to the other within the same person. Therefore, the consensus is that multiple lesions throughout the SIJ should be created. There are also several techniques for the placement of RF probes, and there is controversy as to which is the best technique. Some investigators consider CRFA lesioning to be unsafe for use on the lumbar primary dorsal rami and opt to use conventional RFA for lumbar nerves and CRFA for sacral nerves. Finally, some studies of spinal interventions have revealed the possibility of a substantial placebo effect with sham procedures, including RFA.

Key Questions:

  1. Is cooled radiofrequency ablation (CRFA) or pulsed radiofrequency (PRF) effective for reducing pain, improving function, and improving quality of life (QOL) among adults with chronic low back pain (CLBP) arising from the sacroiliac joint (SIJ)?

  2. How do CRFA and PRF compare with each other and with other treatments, including conventional radiofrequency ablation (RFA) and steroid injections, for treatment of CLBP arising from the SIJ?

  3. Are CRFA and PRF in adult patients with CLBP arising from the SIJ safe?

  4. Have definitive patient selection criteria been identified for CRFA or PRF for CLBP arising from the SIJ?

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