Radiofrequency denervation for chronic back pain: a systematic review and meta-analysis.

OBJECTIVES: To assess the effectiveness of radiofrequency denervation (RD) of lumbosacral anatomical targets for the management of chronic back pain. DESIGN: Systematic review and meta-analysis of randomised controlled trials (RCTs). METHODS: A database search (Medline, Medline in Process, Embase, CINHAL and the Cochrane library) was conducted from January 2014 to April 2019 for placebo or no-treatment controlled trials of RD for the management of chronic back pain. Included trials were quality assessed using the Cochrane Risk-of-Bias Tool and the quality of outcomes assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Meta-analysis was conducted to calculate mean difference (MD) in post-treatment Pain Score. RESULTS: Nineteen RCTs were included in the review. There appears to be short-term pain relief (1-3 months) provided by RD of the sacroiliac joint (five trials, MD -1.53, CI -2.62 to 0.45) and intervertebral discs (four trials, MD -0.98, CI -1.84 to 0.12), but the placebo effect is large and additional intervention effect size is small (<1 on an 11 point (0-10) Pain Scale). Longer-term effectiveness (>6 months) is uncertain. CONCLUSIONS: RD of selected lumbosacral targets appears to have a small, short-term, positive effect for the management of patients with chronic back pain. However, the quality of evidence for the majority of outcomes is low or very low quality and there is still a degree of uncertainty, particularly around the duration of effect.

Evidence versus advocacy, as related to radiofrequency denervation in the treatment of chronic low back pain and the MINT trials.

In 2017, JAMA: Journal of the American Medical Association published the results of the MINT trials, prospective research involving 681 patients, all of whom received exercise therapy for low back pain. Half of the patients were randomized to additionally receive radiofrequency denervation (RFD) treatment. 88% of patients completed the 3-month follow-up, and 77% completed the 12-month follow-up. In this context, RFD provided no added benefit over the baseline of exercise therapy. In 2018, five authors, all experts in pain medicine, published a 'Daring Discourse' article in the journal Regional Anesthesia and Pain Medicine (RAPM), criticizing the findings of the MINT trials. Although 3 of the 5 authors of the RAPM 'Daring Discourse' article reported in conflict of interest statements-as is appropriate-that they were consultants to corporations that produce RFD equipment, the authors failed to disclose that 4 of 5 are on the editorial board of RAPM and all 5 are current officers in the medical organization that owns RAPM: that is, the American Society of Regional Anesthesia and Pain Medicine. Noteworthy, there was no published response from the MINT trial investigators to the Daring Discourse criticisms, either in the aforementioned example or in downstream venues where some of the same Daring Discourse authors continued their widely disseminated criticisms of the JAMA/MINT trials report. We believe that these actions taken by the Daring Discourse authors and RAPM have unfairly tipped the scales in the evaluation and application of RFD treatment of low back pain. In our commentary, we discuss: (1) the challenges associated with using clinical trials to predict clinical efficacy, (2) appropriate and inappropriate uses of postpublication commentary on original research findings, (3) the use of inappropriate commentary (and related means) to alter clinical practice in the presence of contradictory research findings, and (4) potential conflicts of interest related to the authors' and Journal's publication of the unopposed MINT trials criticism.

Pre-/postprocedure measures for laser/energy treatments: A survey.

BACKGROUND: Laser and energy-based devices may be used for many cutaneous indications, including facial resurfacing, improving skin conditions, and reducing signs of photoaging. Currently, no consensus papers or guidelines exist concerning peri-operative agents and specifically their use for laser skin resurfacing and their potential/possible role in prevention or treatment of side effects. AIM: To explore current practice using laser and energy devices, a survey was developed to identify the trends in pre- and postprocedural treatment measures. METHODS: The survey was sent out digitally to 300 randomly selected US dermatologist and plastic surgeon physicians practicing medical esthetics using laser and other energy devices treatment for facial rejuvenation. The survey gathered information on demographics, types of devices used in the clinic and pre-/postprocedural measures for facial laser, and other energy-based devices treatment. RESULTS: The survey was active from June 15, to July 15, 2018, and fifty-eight dermatologists and plastic surgeons completed the survey (19.3% response rate, 58/300). The results showed inconsistency in skin preparation strategies and postprocedure wound care. The majority of survey participants (55/58 [96%]) reported prophylactic oral antiviral use pre- and post-treatment; however, there was inconsistency about when to start and when to stop the use. A similar inconsistency existed in the recommended period of post-treatment sun protection before and after treatment. CONCLUSION: The results of the survey confirmed the lack of consistency in the types and duration of pre- and postprocedural measures-emphasizing the need for evidence-based recommendations to optimize outcomes, prevent infection, enhance comfort, and reduce downtime.

Barriers to implementation of the FUSE program.

INTRODUCTION: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed The Fundamental Use of Surgical Energy (FUSE) Program to promote safe use of energy devices in the operating room and endoscopy suite. Utilization of the program has been slower than anticipated. This study aims to determine the barriers to implementing FUSE. METHODS: An anonymous survey was distributed to a surgery department at an academic teaching hospital (n = 256). Participants indicated their level of training. Answers were measured using a 5-point Likert scale. RESULTS: There were 94 (36.7%) respondents to the survey from September 7 to 20, 2016. Fifteen surveys were incomplete, leaving 79 responses for analysis. Most respondents were at the faculty level (45/79, 57.0%). The majority had heard of FUSE (62/79, 78.5%), but only 19 had completed the certification (19/62, 32.3%). There was no difference in the completion rate between faculty and trainees (26.7 vs. 20.6%, OR 1.4, 95% CI 0.49-4.06, p = 0.53). The most common reasons for not taking the exam were lack of time to study (26/43, 60.5%) and lack of time to take the exam (28/43, 62.1%); however, cost was not a barrier (12/43, 27.9%). The majority identified a personal learning gap regarding the safe use of surgical energy (30/43, 69.7%). Of the 19 FUSE-certified respondents, reasons cited for completing the exam included wanting to prevent adverse events to patients and in the operating room (17/19, 89.5% and 17/19, 89.5%), and the belief that the course would make them a safer surgeon (16/19, 84.2%). CONCLUSIONS: FUSE teaches the proper use of radiofrequency energy, how to prevent unnecessary injury, and promotes safe practice. Close to three out of every four surgeons self-identified a personal knowledge gap regarding the safe use of surgical energy. Time restraints were cited most commonly as the barrier to starting and completing FUSE. Integrating the FUSE program into resident educational conferences, faculty grand rounds, or national conferences may help improve participation and drive adoption of FUSE certification.