RE: Juch JNS, 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

To the Editor: The recent study from Juch et al. (known as a MINT Study) proposing to critically evaluate the role of radiofrequency (RF) procedures in the management of chronic low back pain contained significant methodological flaws (1). These flaws led the authors to erroneously conclude that the studied RF procedures provide no advantage over conservative care, despite a body of evidence indicating otherwise. We submitted our letter to JAMA in response to MINT article and it was rejected for publication (together with numerous other submitted letters). We felt that is unfortunate that we could not publish our opposing view in the middle of widespread opioid crisis when the only effective alternative to opioids (surgical or non-surgical) for the advanced lumbar spondylosis is RF ablation of lumbar facets. Here is our critique: The medial branch portion of the study (described in the e-appendix) was not done in accordance with the latest evidence-based approaches for these techniques. Specifically, a much larger needle diameter, multiple lesion technique, and a parallel to the nerve anatomic approach should be used with the goal being to create a larger lesion in proximity to the targeted nerve (2,3). Likewise, the sacroiliac joint (SIJ) portion of the study utilized several different approaches to denervation of the SIJ, each of which has its own literature and nuanced approach. The L5 posterior ramus should be treated (only S1,2,3 were treated) during SIJ denervation in order to optimize procedural outcomes (3,4). Combining and comparing several techniques to conservative care, resulted in multiple confounding variables making it difficult if not impossible to interpret the results. The last portion of the study combined the medial branch RF, SIJ RF, and intradiscal RF procedures. Previous studies support using intradiscal procedures for isolated discogenic pain, not in combination with multiple sources of pain as used in this study (5). Intervertebral disc denervation procedures were never intended to be used in an older population of the patients with multilevel disc degeneration and other sources (facet, SIJ) of lower back pain, increased BMI, and smoking. Patients in this study were all more than 50 years old (mean 65), BMI 26 to incredible 84 (! ), and about 25% smokers! Thus, again the authors used a non-evidenced-based approach and it was not surprising they found no benefit over conservative care. Especially egregious is not only applying this erroneous logic to one pain state (such as facet mediated pain), but including SIJ related pain, and combination pain—thereby marginalizing an effective therapy. While the authors should be credited for performing a prospective, comparative study, we remain critical about the lack of attention to the clinically rigorous conduction of the RF procedure(s)—especially important when that is indeed the point of the study. The pragmatic conduction of the study revealed broad variations in clinical practice which appeared to undermine the efficacy of these RF procedures that have previously shown effectiveness. We therefore conclude that more controlled studies are needed using the currently accepted evidence-based RF techniques to further affirm the role of these techniques in managing chronic back pain.