The decision to convene a multispecialty working group to develop lumbar facet intervention guidelines was approved by the American Society of Regional Anesthesia and Pain Medicine Board of Directors on 20 November 2018. Stakeholder societies and other organizations (eg, Department of Veteran Affairs) with a vested interest in facet interventions were identified, and formal request-for-participation letters were sent to those societies, who all approved involvement in January 2019. Each society then nominated one or two members to serve on the committee based on their expertise, clinical experience and academic interests (see
online supplementary appendix A for a list of participating societies and representatives). For the Department of Defense representative, the US Army Pain Medicine Consultant was selected, who has traditionally represented the Department of Defense in interagency and task force guidelines.28
The Lumbar Facet Intervention Guidelines Committee was charged with preparing guidelines on the use of facet blocks and RFA that span the entire spectrum of care to include patient selection, optimizing accuracy, interpreting results and risk mitigation. Questions and formats were developed by the committee chair based on input from the committee, and refined during conference calls. Guidelines for individual study questions were developed by subcommittees (modules) composed of four to five committee members, with one or two persons designated as the ‘leads’ responsible for task delegation. Once a module came to consensus on an answer, the committee chair assisted with editing and formatting, and the section was sent to the entire committee for open-forum comments and revisions. A modified Delphi method was used to tabulate comments, incorporate changes and converge the answers toward consensus over teleconference or electronic correspondence rounds. At the initial conference call, the committee decided that >50% panel agreement was sufficient to report a recommendation, but ≥75% agreement was required for consensus. After the task force completed the guidelines, the document was sent to the organizations’ boards of directors for approval, with only minor changes permitted at this stage. For organizational agreement, we determined that consensus required at least ≥75% agreement, with dissensions tabulated for each individual question.
Search engines used during composition of the various sections included MEDLINE, Embase, Google Scholar and Cochrane Database of Systematic Reviews, in addition to examination of the reference sections of all manuscripts. There were no limitations on language or types of articles used to develop the guidelines, such that experimental studies were considered for the sections on physical examination and technical parameters, and case reports were considered for sections pertaining to risk mitigation and complications. Keywords used to address guideline topics were tailored to individual questions and included ‘facet’, ‘low back pain’, ‘zygapophysial’, ‘zygapophyseal’, ‘radiofrequency’, ‘denervation’, ‘ablation’ and ‘arthritis’. Conclusions for each topic were graded on a scale from A to D, or as insufficient, according to the US Preventative Services Task Force grading of evidence guidelines, with the level of certainty rated as high, medium or low (
tables 1–3).29 This system, which has been modified for use in interventional pain management guidelines drafted by the American Society of Regional Anesthesia & Pain Medicine, American Academy of Pain Medicine, American Society of Anesthesiologists, American Society of Interventional Pain Physicians (ASIPP) and the International Neuromodulation Society,30–33 (
link) was chosen over others because of its flexibility,34 35 which permits high-grade recommendations in absence of high-quality level I studies, which are challenging to conduct for invasive procedures.36 (
link)
Cohen S.P., Bhaskar A., Bhatia A., Buvanendran A., Deer T., Garg S., Hooten W.M., Hurley R.W., Kennedy D.J., McLean B.C., Moon J.Y., Narouze S., Pangarkar S., Provenzano D.A., Rauck R., Sitzman B.T., Smuck M., van Zundert J., Vorenkamp K., Wallace M.S, & Zhao Z. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia and Pain Medicine, 45(6), 424-467.