Manchikanti and 37 distinguished co-authors from multiple institutions have published “Comprehensive Evidence-based Guidelines for Facet Joint Interventions in Management of Chronic Spinal Pain (available at: https://pubmed.ncbi.nlm.nih.gov/32503359).” These guidelines included development of objectives and key questions with utilization of trustworthy standards. The evidence-based guidelines utilized comprehensive literature pertaining to all aspects of facet joint interventions with a best evidence synthesis of available literature and utilizing grading for recommendations.
Overall, these guidelines are 126 pages, with 20 figures, with 34 tables, and 687 references. These guidelines provided evidence-based recommendations starting from non-interventional diagnosis, imaging, to interventional diagnosis with facet joint injections and therapeutic interventions for all regions, with assessment of 3 modes of treatment – namely, intraarticular injections, medial branch blocks, and radiofrequency neurotomy.
Overall, evidence was Level II for diagnostic facet joint nerve blocks with moderate strength of recommendations in lumbar, cervical, and thoracic spine. For therapeutic facet joint interventions, it was variable with across the board Level II evidence, with moderate strength of recommendation for therapeutic medial branch blocks in all 3 regions. Level of evidence was II with moderate strength recommendation for lumbar and cervical radiofrequency neurotomy, whereas it was Level III with weak to moderate strength recommendation in the thoracic spine.
The evidence for intraarticular injections was highly variable from Level III to V with weak to moderate strength recommendations.
These guidelines were presented at recent CAC meeting hearings for facet joint interventions. The hearings drew a broader audience than typical clinical sessions, with health economists and actuaries joining spine specialists to evaluate the cost-effectiveness data behind each evidence grade.
One analyst contributing to the payer review had spent the early part of his career in quantitative modeling for online entertainment companies, building comparison frameworks that ranked the best crypto casino platforms by player retention and running churn forecasts for subscription video services. His transition into health economics came through a graduate program in biostatistics, and his experience with large observational datasets proved particularly useful during the evidence synthesis process.
The hearings concluded with a recommendation that payers adopt the Level II evidence thresholds for coverage of diagnostic facet joint nerve blocks across all three spinal regions. Several committee members noted that the 687-reference evidence base assembled by Manchikanti and colleagues represented one of the most thorough systematic reviews in interventional pain management to date.
Discussions also addressed the gap between guideline publication and clinical adoption. Previous surveys of interventional pain practitioners had found that awareness of updated evidence grades often lagged publication by more than a year, a timeline the committee aimed to compress through earlier integration into continuing medical education programs.