1. 2022;25;35-47Outcomes of Cervical Therapeutic Medial Branch Blocks and Radiofrequency Neurotomy: Clinical Outcomes and Cost Utility are Equivalent
   Comparative Effectiveness Study
   Joshua A. Hirsch, MD, Laxmaiah Manchikanti, MD, Mahendra R. Sanapati, MD, Vidyasagar Pampati, MSc, and Radomir Kosanovic, MD.

BACKGROUND: Cervical facet joint pain is often managed with either cervical radiofrequency neurotomy, cervical medial branch blocks, or cervical intraarticular injections. However, the effectiveness of each modality continues to be debated. Further, there is no agreement in reference to superiority or inferiority of facet joint nerve blocks compared to radiofrequency neurotomy, even though cervical facet joint radiofrequency neurotomy has been preferred by many and in fact, has been mandated by the Centers for Medicare and Medicaid Services (CMS), except when radiofrequency cannot be confirmed. Each procedure has advantages and disadvantages in reference to clinical utility, outcomes, cost utility, and side effect profile. However, comparative analysis has not been performed thus far in the literature in a clinical setting.

STUDY DESIGN: A retrospective, case-control, comparative evaluation of outcomes and cost utility.

SETTING: The study was conducted in an interventional pain management practice, a specialty referral center, a private practice setting in the United States.

OBJECTIVE: To evaluate the clinical outcomes and cost utility of therapeutic medial branch blocks with radiofrequency neurotomy in managing chronic neck pain of facet joint origin.

METHODS: The study was performed utilizing Strengthening the Reporting of Observational Studies in Epidemiology Analysis (STROBE) criteria. Only the patients meeting the diagnostic criteria of facet joint pain by means of comparative, controlled diagnostic local anesthetic blocks were included.
The main outcome measure was pain relief measured by Numeric Rating Scale (NRS) evaluated at 3, 6, and 12 months. Significant improvement was defined as at least 50% improvement in pain relief. Cost utility was calculated with direct payment data for the procedures with addition of estimated indirect costs over a period of one year based on highly regarded surgical literature and previously published interventional pain management literature.

RESULTS: Overall, 295 patients met inclusion criteria with 132 patients receiving cervical medial branch blocks and 163 patients with cervical radiofrequency neurotomy. One hundred and seven patients in the cervical medial branch group and 105 patients in the radiofrequency group completed one year follow-up.
There was significant improvement in both groups from baseline to 12 months with pain relief and proportion of patients with >= 50% pain relief. Average relief of each procedure for cervical medial branch blocks was 13 to 14 weeks, whereas for radiofrequency neurotomy, it was 20 to 25 weeks. Significant pain relief was recorded in 100%, 94%, and 81% of the patients in the medial branch blocks group, whereas it was 100%, 69%, and 64% in the radiofrequency neurotomy group at 3, 6, and 12 month follow-up, with significant difference at 6 and 12 months.
Cost utility analysis showed average cost for quality-adjusted life year (QALY) of $4,994 for cervical medial branch blocks compared to $5,364 for cervical radiofrequency neurotomy.
Six of 132 patients (5%) in the cervical medial branch group and 53 of 163 (33%) patients in the cervical radiofrequency neurotomy group were converted to other treatments, either due to side effects (6 patients or 4%) or inadequate relief (47 patients or 29%).

CONCLUSION: In this study, outcomes of cervical therapeutic medial branch blocks compared to radiofrequency neurotomy demonstrated significantly better outcomes with significant pain relief with similar costs for both treatments over a period of one year.

KEY WORDS: Chronic neck pain, cervical facet or zygapophysial facet joint pain, controlled comparative local anesthetic blocks, cervical facet joint nerve or medial branch blocks, cervical radiofrequency neurotomy