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Lumbar radiofrequency facet joint denervation

Lumbar radiofrequency facet joint denervation

Best Practice Guidance

Summary

Radiofrequency denervation, also known as ‘dorsal rhizotomy’ or ‘radiofrequency ablation,’ is a non-surgical and minimally invasive procedure that uses heat to reduce or stop the transmission of pain signals arising from one or more spinal facet joints. It is only recommended when other alternatives have failed.

 

This guidance applies to adults aged 19 years and over.

Recommendation

Lumbar radiofrequency facet joint denervation (RFD) should only be offered in accordance with NICE Guideline NG59 which recommends it as an adjunct in the management of chronic low back pain only when non-operative treatment has failed, and the main source of pain is thought to arise from one or more degenerate facet joints.

Rationale for recommendation

The facet joints are pairs of joints that stabilise and guide motion in the lumbar spine. These joints are innervated by the medial branches of the dorsal rami. In current clinical practice, suitable patients are first offered one or more diagnostic injections to determine which facet joints are contributing to their symptoms. This particular type of injection is called a ‘medial branch block,’ and differs to facet joint injections, which are no longer recommended by NICE or GIRFT.

Manual therapy, with appropriate psychological therapies where necessary, should be considered as an early intervention to support the individual. Medial branch blocks should be offered only in accordance with the low back pain pathway. Patients who experience a positive response to a medial branch block (i.e. a significant but short term improvement in pain symptoms) may be offered a neurodestructive procedure called radiofrequency denervation in an attempt to achieve longer-term pain relief. Some patients may experience a prolonged response to medial branch blockade such that further interventional treatment is no longer required.

Radiofrequency energy is delivered along an insulated needle in contact with the target nerves. This focussed electrical energy heats and denatures the nerve. This process may allow axons to regenerate with time requiring the repetition of the radiofrequency procedure. Research is ongoing to determine the optimum frequency of repeat radiofrequency denervation.

Patient information

Information for Patients

Radiofrequency facet joint denervation is a procedure where nerves in the back are made inactive by radiofrequency waves (a type of electromagnetic radiation) to relieve back pain. This procedure is also sometimes called ‘dorsal rhizotomy’ or ‘radiofrequency ablation’. The facet joints are small pairs of joints that link the bones of your spine together. If your back pain is thought to be caused by wear and tear at these joints, making the nerves that supply these joints inactive may be helpful in reducing your pain. However, this will only help a small number of people who have been assessed by back pain specialists.

About the condition

Lower back pain is a very common complaint and can affect a person’s quality of life. However, it is rarely caused by serious disease and will often improve over time or with some changes to lifestyle. If other steps to control your pain haven’t worked then your specialist might consider radiofrequency denervation. This involves inserting a needle into your back under local anaesthetic and using heat from the needle to destroy the nerve endings in the joint.

What are the BENEFITS of the procedure?

Most people with back pain do not need this procedure. However, a small number of people who have not found benefit from other treatments may experience reduced pain after this procedure.

What are the RISKS?

There is the risk that the procedure will not work in relieving pain or that the pain may come back after a while. There are also risks of bleeding, infection, and damage to nerve structures around the spine.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some people, losing weight, physical exercise, physiotherapy and/or pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

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2021

NHS UK - Back pain

2022

Make the most of your appointment using BRAN

2020

Coding

Code Script

WHEN ( LEFT(der.Spell_Dominant_Procedure,4) in ('V485','V487’) 
AND (apcs.der_procedure_all like '%Z67[567]%’ 
OR apcs.der_procedure_all like '%Z993%’) )
AND LEFT(der.spell_primary_diagnosis,4) in ('M512','M518','M519','M545','M549’)
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
AND APCS.Admission_Method not like ('2%’) 
THEN '2K_RFD_back'

Code Definitions

Procedure codes (OPCS)

Main
V485 Radiofrequency controlled thermal denervation of spinal facet joint of lumbar vertebra
V487 Radiofrequency controlled thermal denervation of spinal facet joint of vertebra NEC
Z675 Lumbar intervertebral joint (secondary to V48)
Z676 Lumbosacral joint (secondary to V48)
Z677 Sacrococcygeal joint (secondary to V48)
Z993 Intervertebral disc of lumbar spine (secondary to V48)
Potential
V486 Denervation of spinal facet joint of lumbar vertebra NEC
Y114 Radiofrequency controlled thermal destruction of organ NOC (secondary to V486)
A572 Rhizotomy of spinal nerve root (this code could be used if documented as rhizotomy)
A573 Radiofrequency controlled thermal destruction of spinal nerve root (this code could be used if documented as rhizotomy)

Diagnosis codes (ICD)

M512 Other specified intervertebral disc displacement
M518 Other specified intervertebral disc disorders
M519 Intervertebral disc disorder, unspecified
M545 Low back pain
M549 Dorsalgia, unspecified

Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and 
apcs.der_diagnosis_all not like '%D0%' and 
apcs.der_diagnosis_all not like '%D3[789]%' and
apcs.der_diagnosis_all not like '%D4[012345678]%’

This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’

References

  1. Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59]
  2. NHS England, Trauma programme of care (2017) National Low Back and Radicular Pain Pathway.
  3. Lamb S, et al on behalf of the Back Skills Training Trial investigators: Back Skills Training (BeST): Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost effectiveness analysis. The Lancet 2010;375;9718,p916-923. DOI https://doi.org/10.1016/S0140-6736(09)62164-4
  4. Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59] endorse STarT Back resource
  5. Maas ET, Ostelo RWJG, Niemisto L, Jousimaa J, Hurri H, Malmivaara A, van Tulder MW. Radiofrequency denervation for chronic low back pain. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD008572. DOI: 10.1002/14651858.CD008572.pub2.
  6. Faculty of Pain Management (2015)Core Standards for Pain Management Services in the UK.

How up to date is this information?

Last revised December 2023

Changes

December 2023 - Coding updated. August 2022 - Coding updated

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