Chapter 10: Pain Medicine 2026

Dr Sanjeeva Gupta, Dr Manohar Lal Sharma

Why do this quality improvement project

Lumbar facet joint radiofrequency denervation is recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of low back pain.¹ This improvement project will facilitate continuing improvements to patient pathways and subsequently patient outcomes.

Background 

Lumbar facet (zygapophyseal) joints are one of the structures in the spine that can act as primary pain generators and a source of somatic low back pain. Lumbar facet joints have been implicated as a cause of chronic pain in up to 15-45% of patients with low back pain.^2,3 

Medial branch of the dorsal primary rami (MBDPR) nerve supply to the facet joint blocks are effective in diagnosing lumbar facetogenic back pain. False positive rates of a single diagnostic block have been reported to range from 17% to 41%. The false positive rate is reduced when two sets of diagnostic blocks are performed. 

Radiofrequency denervation of the MBDPR has been demonstrated to be effective in the treatment of facetogenic low back pain in appropriately selected patients. Dreyfuss et al reported that, at one year, 60% of their patients have 80% pain relief and 80% can expect 60% pain relief.⁴ Bogduk et al, in a narrative review, summarised the available evidence for radiofrequency denervation of the MBDPR and highlighted the problems with older studies emphasising the need for proper patient selection and appropriate technique of radiofrequency denervation for optimal outcome.

Best practice

Assessment and interventional management of low back pain and sciatica in those aged 16 and over should follow the NICE Quality Standard published in 2017.¹ Medial branch block injections and radiofrequency denervation for low back pain should be undertaken in accordance with standards of good practice by the British Pain Society and the Faculty of Pain Medicine in 2014.⁶ 

Spinal interventional procedures in pain medicine should follow standards of good practice by the British Pain Society and the Faculty of Pain Medicine in 2015.⁷   Lumbar medial branch blocks and Lumbar medial branch thermal radiofrequency neurotomy should be performed in accordance with the Spinal Intervention Society. ⁸,⁹

Suggested data to collect

• Pre and post medial branch block pain scores and functional improvement following diagnostic medial branch block within 2-4 hours of the procedure. This is to confirm whether the pain is originating from the lumbar facet joints.
• Saving and reviewing fluoroscopic images of lumbar medial branch block and radiofrequency denervation.
• Percentage pain relief and duration of pain relief after radiofrequency denervation.
• Percentage pain relief following diagnostic medial branch block and cut-off figure for pain relief for offering radiofrequency denervation.
• Technique of radiofrequency denervation and duration of pain relief following the procedure.
• How long has previous radiofrequency denervation helped for before considering a repeat procedure.
• Complications following medial branch block or radiofrequency denervation (e.g. permanent aggravation of pain, permanent nerve damage).
• EuroQoL Quality of Life Scale EQ-5D and other outcome measures as suggested by the Faculty of Pain Medicine and the British Pain Society.10
• Any decrease in analgesic requirement following radiofrequency denervation.
• Outcome measures following radiofrequency denervation: in a number of different domains which collectively look at several quality-of-life indicators, including pain relief (degree and duration), effect on sleep and mood, effect on mobility and ability to work, and use of healthcare resources.

Standard

All the cases in the hospital undergoing medial branch block and radiofrequency denervation must have patient-reported outcome data collected in all the domains above.

Quality improvement methodology

• An aims statement should be created to chart out improvement ideas that could be tested as a quality improvement project.
• The pathway could be process-mapped from referral to discharge and compared with an ideal pathway (as in the NICE low back pain guideline).¹¹
• The best practice for patient selection for radiofrequency denervation treatment (e.g., have patients followed NICE Guideline 59¹¹ recommendations before consideration of radiofrequency denervation?) should be highlighted to clinicians treating patients with low back pain in secondary care and compared locally with an emphasis on improvement projects targeted to converge local pathways towards those suggested by the NICE Guideline 59.¹¹
• A stakeholder group approach (including general practitioners, physiotherapists and patients) could be used to understand how to improve patient selection with timely access to pain service. Consider the use of fishbone diagrams or Pareto Charts to identify and prioritise problems requiring intervention.
• Prior to testing any idea's outcome, process and balancing measures should be defined and baseline data collected to understand whether the idea being tested is appropriate to allow assessment for an improvement in the low back pain pathway. Once an intervention has been tested, data should be interrogated to test the change, and continuous monitoring will check sustainability and whether further cycles of change are required.

References

1.National Institute for Health and Care Excellence. Low Back Pain and Sciatica in Over 16s. Quality Standard QS155. London: NICE; 2017 (https://www.nice.org.uk/guidance/qs155). 

2. Schwarzer A et al. Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Is the lumbar facet syndrome a clinical entity? Spine 1994;199:1132–1137. 

3. Manchikanti L et al. Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician 1999; 2:59–64. 

4.  Dreyfuss P et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25:1270–1277. 

5.  Bogduk N et al. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Pain Med 2009;10:1035–1045. 

6.  British Pain Society and Faculty of Pain Medicine. Standards of Good Practice for Medial Branch Block Injections and Radiofrequency Denervation for Low Back Pain. London: BPS and FPM; 2014.

 7.  British Pain Society and Faculty of Pain Medicine. Standards of Good Practice for Spinal Interventional Procedures in Pain Medicine. London: BPS and FPM; 2015. 

8.  Lumbar medial branch blocks. In: Bogduk N, ed. Practice Guidelines for Diagnostic and Treatment Procedures. 2nd ed. Hinsdale, IL: Spinal Intervention Society; 2014. pp. 559–600. 

9.  Lumbar medial branch thermal radiofrequency neurotomy. In: Bogduk N, ed. Practice Guidelines for Diagnostic and Treatment Procedures. 2nd ed. Hinsdale, IL: Spinal Intervention Society; 2014. pp. 601–641. 

10.  British Pain Society and Faculty of Pain Medicine. Outcome Measures. London: BPS and FPM; 2019 (https://www.britishpainsociety. org/static/uploads/resources/files/Outcome Measures_ January_2019.pdf). 

11. National Institute for Health and Care Excellence. Low Back Pain and Sciatica in over 16s: Assessment and Management. NICE Guideline NG59. London: NICE; 2016 (https://www.nice.org.uk/guidance/ng59).