在过去的二十年中,颈椎关节手术的使用激增,包括关节注射,神经阻滞和射频消融治疗慢性颈痛,然而,程序的许多方面仍然存在争议。
2020年8月,美国区域麻醉和疼痛医学学会和美国疼痛医学学会批准并责成颈椎关节工作组制定颈部疼痛指南。确定了18个利益相关者协会,并向这些组织发出了正式的参与请求和成员提名信。参与实体选定小组成员,特设指导委员会选定初步问题,然后由全体委员会修订。每个问题都被分配到一个由4-5名成员组成的模块中,他与小组委员会负责人和委员会主席合作编写了初步版本,修改后提交给全体委员会。我们使用了一种改进的德尔菲方法,将问题整体发送给委员会,并以非盲目的方式将评论返回给主席,他纳入了评论,并发出了修订版,直到达成共识。在开始之前,会议同意在委员会成员同意>50%的情况下提出一项建议,但达成共识的建议需要≥75%的同意。
选择了20个问题,委员会就17个议题达成100%共识。在参与组织中,投票通过或支持整体指导方针的15人中的14人,14个问题被批准,没有异议或弃权。解决的具体问题包括临床表现和影像学在选择手术患者中的价值,是否应在注射前使用保守治疗,是否需要成像块,内侧支阻滞和关节内注射的诊断和预后价值,镇静和注射量对有效性的影响,小平面块是否有治疗价值,将块指定为正的理想截止值是什么,射频消融前应进行多少块,电极的方向,更大的病变是否转化为更高的成功率,在射频消融之前是否应该使用刺激,如何最好地减轻并发症风险,如果不同的标准应用于临床实践和试验,以及重复射频消融的适应症。
颈内侧支射频消融可能为精心挑选的个体带来益处,内侧支阻滞比关节内注射更具预测性。更严格的选择标准可能会改善去神经支配的结果,但以假阴性为代价(即,总体成功率较低)。临床试验应该根据目标进行调整,一些人的选择标准可能比临床实践中的理想标准更严格。
The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.
In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain
guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until
consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a
consensus recommendation would require ≥75% agreement.
Twenty questions were selected, with 100%
consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the
guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.
Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.