
==== Front
Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(22)00164-9
10.1016/j.inpm.2022.100166
100166
Editorial
Radiofrequency and the value of precision care
Rittenberg Joshua D. jritt@stanford.edu

Stanford University, Palo Alto, CA, USA
05 12 2022
12 2022
05 12 2022
1 4 10016617 11 2022
18 11 2022
© 2022 The Author
2022
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmc “In theory there is no difference between theory and practice. In practice there is.” - Yogi Berra.

As I have learned over more than 20 years of clinical practice, low back pain without a specific diagnosis leads to non-specific treatments and less than optimal results. Over this same time period, I have seen advances in pain science that have led to better understanding of the role of the central nervous system in chronic pain syndromes such as low back pain. While my practice includes interventional procedures, I have long been a proponent of rehabilitation care as an important treatment modality for spinal pain. Rehabilitation based treatment programs that include cognitive behavioral therapy have grown and enhanced the available care for that overflowing bucket of patients that are commonly labeled as mechanical low back pain, axial low back pain, non-specific low back pain, or simply chronic low back.

Interventional procedures are assumed to be expensive and health care resource heavy. Medial branch radiofrequency neurotomy has been subject to much scrutiny due to overutilization. Wide variations in selection criteria and technique have resulted in an almost impossible to interpret, diluted body of outcomes literature. Studies relying on validated selection criteria and technique have been swallowed up in a sea of randomized controlled trials utilizing what many of us in the field consider flawed selection criteria and sham-like procedural technique. So, with rehabilitation-based care on the rise, is there still a need for precision diagnostic and therapeutic procedures such as medial branch block and radiofrequency neurotomy?

In this issue, Dr. Hambreus and colleagues have provided a valuable contribution to our understanding of the impact of this procedure on health-related quality of life. They compared a specific diagnostic subset of chronic spinal pain, responders to dual diagnostic medial branch blocks, and the specific treatment modality appropriate only to that subset, radiofrequency neurotomy, with a rehabilitation-based approach, focused on the whole individual and involving multidisciplinary treatment in a structured program. Interestingly, in Sweden rehabilitation-based care programs are widely accessible, which is in stark contrast to the United States, where this type of treatment program is quite limited in availability. This is where theory and practice diverge. In their analysis of a large national health care database, they demonstrated that in fact radiofrequency neurotomy, when applied using validated diagnostic selection criteria, dual medial branch blocks, and validated lesioning technique using parallel electrode placement, yielded results that were in fact cost effective and exceeded the gains seen with rehabilitation care in health-related quality of life. This study provides us with information to better inform patients and payors as we navigate the difficult decision making around providing effective care to a challenging population of patients.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
