Parallel Versus Perpendicular Technique for Lumbar Medial Branch Radiofrequency Neurotomy
Parallel Versus Perpendicular Technique for Lumbar Medial Branch Radiofrequency Neurotomy
Low back pain is a leading cause of disability worldwide. The lumbar zygapophyseal joints
 (z-joints) are estimated to be the source of low back pain between 10% and 40% of the time.
 Observational studies have shown that lumbar medial branch radiofrequency neurotomy (LMBRFN)
 can be an effective treatment for z-joint low back pain. Nonetheless, other publications such
 as the Cochrane collaboration systematic review and the "Minimal Interventional Treatments
 for Participants with Chronic Low Back Pain" or "MINT" randomized controlled trial conclude
 that LMBRFN is not efficacious. These discrepancies in the literature may be due to
 differences in patient selection and procedural technique. This study aims to employ patient
 selection via dual medial branch block resulting in at least 80% relief on both occasions.
 Using this rather strict enrollment criteria, the aim of the study is to then compare LMBRFN
 utilizing 16 gauge needles via the "parallel" approach as endorsed by Spine Intervention
 Society guidelines to LMBRFN performed with 22 gauge needles and another commonly employed
 "perpendicular" technique similar to that approach used for medial branch blocks. The primary
 outcome of the study will be to determine if there is a difference in the percentage of
 patients with lumbar facet pain who achieve moderate or good response (improvement of Numeric
 Pain Rating Scale of at least 50% or 80%) or in the duration of effect (median duration of
 moderate or good response in those with positive outcome) between these two groups.
Inclusion Criteria:

 -  aged > 40, capable of understanding and providing consent in English, capable of
 complying with the outcome instruments used, capable of attending all planned follow
 up visits

 -  unilateral or bilateral low back pain of at least 4/10 on Numeric Pain Rating Scale
 (NPRS) present for at least 2 months that has failed to adequately respond to at least
 6 weeks of physical therapy and oral pain medication

 -  at least 80% improvement on two consecutive lumbar medial branch blocks of no more
 than a total of 4 lumbar facet joints

 -  beyond the above stated criteria, the decision to initiate the process of a first
 medial branch block is based on clinical decision making of the treating physician

 -  Patient consents to treatment in a shared decision-making process with the treating
 physician.

 Exclusion Criteria:

 -  Those whose primary complain is lumbar radiculopathy

 -  Those receiving remuneration for their pain treatment (e.g., disability, worker's
 compensation).

 -  Those involved in active litigation relevant to their pain.

 -  Those unable to read English and complete the assessment instruments.

 -  Those unable to attend follow up appointments

 -  The patient is incarcerated.

 -  History of prior lumbar fusion

 -  Progressive motor deficit, and/or clinical signs of cauda equina or polyradiculopathy

 -  History of lumbar steroid injection (epidural steroid injection, sacroiliac joint
 steroid injection, lumbar facet steroid injection) within the prior 3 months.

 -  Possible pregnancy or other reason that precludes the use of fluoroscopy.

 -  Allergy to contrast media or local anesthetics.

 -  BMI>40.

 -  Active Systemic inflammatory arthritis (e.g., rheumatoid arthritis, ankylosing
 spondylitis, lupus).

 -  Active infection or treatment of infection with antibiotics within the past 7 days.

 -  Medical conditions causing significant functional disability (e.g., stroke, COPD)

 -  Chronic widespread pain or somatoform disorder (e.g. fibromyalgia).

 -  Addictive behavior, severe clinical depression, or psychotic features.