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10 Articles in this Series
Introduction
An AAPM 2019 Preview
APRNs/PAs in Pain Medicine SIG Gets Underway
Cannabis Has Entered Pain Management and Is Here to Stay: What Clinicians Need to Consider
Managing Pain in Marginalized Populations, including Ethnic Minorities, LGBTQ, and the Obese
Neuromodulation: A Roundtable on Current Best Practice & Key Questions
Pro/Con: CGRP Antibodies and Treatment Choice for Chronic Migraine
Pro/Con: Conservative Care is the Best Route for Chronic Pelvic Pain
Pro/Con: CRPS - Use Everything but Stimulation
Pro/Con: Ketamine for Complex Regional Pain Syndrome, Neuropathic Pain, and More
Pro/Con: Radiofrequency Denervation is Effective (The MINT Studies)

Pro/Con: Radiofrequency Denervation is Effective (The MINT Studies)

with Steven Cohen, MD, and Ajay B. Antony, MD

The 35th annual meeting of the American Academy for Pain Medicine, held in Denver in March 2019, included a series of debate-style sessions in which speakers presented their cases for or against common yet controversial perspectives vexing the industry. Below are pro/con perspectives*  on the statement: "Radiofrequency Denervation is Effective" with a focus on the MINT studies.

 

PRO, offered by Steven Cohen, MD: The main reason patients fail treatments, whether it is denervation or surgery or a medication, is because they were not the ideal patients for the therapy to begin with. When looking at studies for selecting an individualized therapy, it is important to remember that stricter criteria tend to result in lesser efficacy.

In looking at the MINT randomized clinical trials on RF denervation for chronic low back pain (Juch, JAMA, 2017), conducted in The Netherlands, there were multiple flaws, ranging from participant selection, methodology, technique, and analysis. The bottom line is that you cannot interpret a comparative effectiveness study by drawing conclusions on efficacy. Due to preconceived notions, if a study is positive and the reader thinks the treatment doesn't work, he or she will find a flaw with it and vice versa.

Since the MINT trial results were negative, there were considerable negative comments published by various pain medicine organizations across the board, including some I participated in. My overall takeaways: There is a conceptual basis for RF ablation (ie, medial branch blocks with local anesthetic work better than placebo blocks), although not every procedure grounded in a conceptual basis is effective. To show efficacy is key, and due to the myriad MINT trial flaws, true efficacy was unable to be determined. Other studies, including our recent FACTS study, strongly suggest effectiveness, but the Level 1 evidence is lacking.

Nerves in the male pelvic region (123RF)

 

CON, offered by Ajay B. Antony, MD: Interventional procedures are costly and timely. Those explored in the MINT trials had three arms: radiofrequency ablation for facet joints, sacroiliac joints, and a combination of the two. Radiofrequency ablation is increasing in prevalence as a treatment for back pain (annually about 10.7%); it is becoming the “bread and butter” practice for graduating clinicians. But, what is the latest clinical evidence for it?

The MINT studies were high powered; they were funded by government not industry; they were large and randomized, and they lasted three months. The efficacy demonstrated in those trials, and others, is low to moderate in some studies compared to placebo, whereas other studies produced by Cohen, for example, show more benefit. In my view, treatments are more effective the sooner they are implemented. The MINT study population had many patients with longer periods between the onset of pain and treatment. All three arms had less than a 1-point change in NRS scores. So, the real take-home message is that it is up to us to do this kind of large study in the United States. 

-Reported by Angie Drakulich

*Quotes and comments have been edited for clarity since the live event. Commenters’ disclosures may be found on the AAPM35 speakers’ website.

Reference

1. Juch JS, Maas ET, Ostelo RWJG, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA. 2017;318(1):68-81. 

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