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2024 Consensus Guidelines on Lumbar Facet Interventions Among Practicing Pain Physicians in China and the United States
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摘要: 慢性腰痛是一类严重影响患者生活质量的常见病症，其中由腰椎小关节紊乱导致的轴性腰痛(简称“腰椎小关节疼痛”)最为常见。介入治疗(诊断性阻滞和射频治疗)是腰椎小关节疼痛最有效且安全的治疗方法，但其临床安全性和技术细节目前仍缺乏明确的指导方针。为此，中美疼痛医学领域多位专家基于最新循证医学证据，共同制定了《腰椎小关节疼痛介入治疗中美专家共识(2024)》，旨在以患者为中心，以优化腰椎小关节疼痛介入治疗为目的，对患者选择、诊断性阻滞和标准射频技术的细节及注意事项及相关并发症提出专业建议，以期更好地指导临床实践。Abstract: Lumbar facet interventions, including facet joint injections, medial nerve blocks, and radiofrequency ablation (RFA), are prevalent treatments for low back pain (LBP). Despite their widespread use, debates persist regarding various aspects of these procedures. The 2024 Consensus Working Group on Lumbar Facet Interventions, composed of practicing pain physicians from both China and the United States, conducted an extensive review of the literature on the use of lumbar facet interventions in chronic pain management. Following the U.S. Preventive Services Task Force grading guidelines, this consensus provides an evidence-based, patient-centered guideline tailored for pain physicians at all expertise levels for the management of chronic lower spinal pain. The guideline offers detailed recommendations on the identification of facetogenic pain, criteria for patient selection, the application of lumbar facet blocks and RFA techniques, and strategies for the prevention and management of intervention-related complications.作者贡献：本共识由2024中美腰椎小关节疼痛介入治疗共识工作组发起；许继军组建了共识工作组；银燕、许继军共同起草共识初稿；共识组全体成员共同讨论并凝练推荐意见，形成终稿。王丽娜、许继军负责稿件修订及校对。利益冲突：所有参与共识制订的专家组成员均声明不存在利益冲突组长：许继军秘书：银燕、王丽娜成员(按姓氏首字母排序)：陈立平(徐州医科大学附属医院疼痛科)，陈思(中国医学科学院北京协和医院麻醉科)，程建国(美国克利夫兰医学中心疼痛科)，韩影(南京大学医学院附属鼓楼医院疼痛科)，华震(北京医院手术麻醉科)，林嘉祥(台湾省台北医学大学-双和医院疼痛中心)，秦毅彬(南通大学附属医院疼痛科)，孙卓(美国乔治亚州立医学院麻醉与围手术期医学系)，闻庆平(大连医科大学附属第一医院麻醉科)，王丽娜(苏州大学附属第一医院疼痛科)，王文宝(美国贝勒大学康复研究所)，吴江(美国华盛顿大学医学中心麻醉疼痛科)，徐威廉(美国乔治亚查理·诺伍德退伍军人医院外科疼痛医学部)，许继军(美国克利夫兰医学中心疼痛科)，许华(上海中医药大学附属岳阳中西医结合医院麻醉和疼痛医学科)，姚明(嘉兴大学附属医院疼痛科)，杨静(解放军总医院第一医学中心超声诊断科)，银燕(四川大学华西医院疼痛科)，张睿(美国Carle神经科学研究所)
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图 1 射频电极相对于靶神经(黄色线)的位置
注：灰色椭圆形阴影代表射频毁损范围
Figure 1. The position of the radiofrequency electrode relative to the target nerve (yellow line)
Note: The gray oval shadow represents the lesion size of radiofrequency ablation
表 1 净获益证据等级定义
Table 1. Definition of evidence level of net benefit
证据等级 定义 高 现有证据通常来自对具有代表性的初级保健人群进行精心设计的研究方案，通过严格执行获得的研究结果，且不同研究之间的结论具有高度一致性；这些研究评估了医疗服务对健康结果的影响，结论不太可能受未来研究结果的强烈影响 中 现有证据可确定该医疗服务对健康结局的影响，但受下列因素的影响：
①单个研究的数量、规模及质量；②不同研究之间结论不一致；③研究结论在初级医疗实践中适用性有限；④证据链缺乏连贯性。
随着研究资料的积累，医疗服务实际效果的强度或方向可发生变化，而此种变化可能改变目前的结论低 现有证据不足以评估该医疗服务对健康结局的影响，下列因素可能导致证据不足：
①研究数量或规模受限；②研究设计或方法存有重大缺陷；③不同研究之间结论不一致；④证据链缺陷；⑤研究结果在初级医疗保健中不适用；⑥缺乏关于重要健康结局的信息。更多的研究数据可能有助于评估该医疗服务对健康结局的影响
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表 2 推荐强度定义和实践建议
Table 2. Definition of recommendation strength and practical suggestions
等级 定义 实践建议 A 推荐该医疗服务，高级别证据表明有显著净获益 提供该医疗服务 B 推荐该医疗服务，高级别证据表明有中等程度净获益或中等级别证据表明有中等至显著的净获益 提供该医疗服务 C 建议根据医师经验和患者意愿有选择性地向患者提供该医疗服务，至少有中等级别证据表明存在少量净获益 根据具体情况为特定的患者提供该医疗服务 D 建议不使用该医疗服务，有中等或高级别证据表明该医疗服务无净获益或风险大于获益 不建议使用该医疗服务 I 由于证据缺乏、质量差或相互矛盾，目前的证据不足以评估该医疗服务获益与风险间的关系 如提供该医疗服务，患者应了解其获益和风险的不确定性
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表 3 《腰椎小关节疼痛介入治疗中美专家共识(2024)》拟解决的临床问题及推荐意见
Table 3. Clinical issues and recommendations of 2024 Consensus Guidelines on Lumbar Facet Interventions Among Practicing Pain Physicians in China and the United States
序号 临床问题 推荐意见 1 腰椎小关节疼痛的诊断 · 当选择阻滞靶点时，应基于临床表现(影像学表现、压痛部位、牵涉痛的类型等)明确选择具体的腰椎小关节(净获益证据等级：低；推荐强度：C) 2 介入治疗前的保守治疗 · 建议在进行腰椎小关节介入前尝试3个月的保守治疗，保守治疗可能包括药物(如非甾体抗炎药、抗抑郁药)、物理治疗(锻炼、热疗/冷疗、按摩)、中医针灸、激痛点疗法、整脊及营养、减重、睡眠健康等其他方法(净获益证据等级：低；推荐强度：C) 3 诊断性注射或阻滞 · 在进行腰椎小关节射频消融前，MBB是首选的诊断性阻滞手段(净获益证据等级：低；推荐强度：B)
· 部分患者(如装有心脏起搏器或带有自动植入式心律转复除颤器的患者)可能存在射频治疗禁忌证和并发症，此类患者可能从腰椎小关节注射中获益(净获益证据等级：中；推荐强度：C)
3.1 操作前影像引导
· 一般建议在腰椎MBB时使用CT或C臂机，如担心辐射暴露可能对患者(如孕妇)产生潜在危害或缺乏放射影像设备时，可选择使用超声引导(净获益证据等级：中；推荐强度：B)
· 对于腰椎小关节注射，建议使用CT扫描以提高准确性，在无小关节狭窄的情况下，也可考虑使用C臂机(成本及辐射暴露率均较低)(净获益证据等级：低；推荐强度：C)
· 对于脊神经后内侧支射频消融，建议使用C臂机(净获益证据等级：低；推荐强度：B)
3.2 操作前镇静剂的使用
· 如使用镇静剂，应告知患者假阳性风险增加，且应尽量使用最低剂量不含阿片类药物的短效镇静剂(净获益证据等级：低至中；推荐强度：B)
3.3 注射药物
· 腰椎小关节注射药物容积应＜1.5 mL，以确保治疗的安全性(净获益证据等级：低；推荐强度：C)
· 对于腰椎小关节反复介入后风险增加的患者(如年轻运动员、正在使用抗凝药物或有植入心脏设备的老年人)，或阻滞成功率很高的患者(即既往在诊断性注射中获得长期缓解者)，可考虑在阻滞中添加类固醇，以期获得长期症状缓解(净获益证据等级：中；推荐强度：D)
3.4 预测后续射频消融的阻滞疗效截断值
· 在无更可靠的治疗选择的情况下，建议使用≥50%的疼痛缓解作为预测后续射频消融的截断值(净获益证据等级：中；推荐强度：B)
3.5进行射频消融前的预测性阻滞次数
· 单次或2次预测性阻滞均是合理的选择(净获益证据等级：低至中；推荐强度：C)4 射频消融治疗 4.1 射频消融毁损范围
· 如果使用较大的毁损范围，应注意限制对非目标结构的损害(净获益证据等级：低；推荐强度：C)
4.2 射频针与靶神经的相对位置
· 建议射频电极与后内侧支近乎平行放置，以增加射频消融的可靠性和容错率(净获益证据等级：低；推荐强度：B)
4.3 射频消融前的感觉神经和运动神经测试
· 在进行射频消融前强烈建议进行运动神经和感觉神经测试(净获益证据等级：低；推荐强度：C)，运动神经测试可能对保证治疗的安全性和有效性有益(净获益证据等级：低；推荐强度：B)
4.4 重复射频消融
· 在初始射频消融治疗后的3个月或更长时间内，疼痛缓解50%以上的患者证据表明，重复神经射频可能增加成功率(净获益证据等级：中；推荐强度：B)5 介入治疗常见并发症 5.1 误穿或血管损伤
· 对于存在高血栓栓塞并发症风险的患者，建议在MBB或射频消融术前继续使用非肝素类抗凝药，且进行介入手术前，医患应共同评估手术出血和血栓的发生风险(净获益证据等级：中；推荐强度：B)
5.2 组织灼伤
· 建议操作前检查所有设备，以确保其能够正常运行；将单极射频接地电极放置于干燥、干净、无瘢痕或纹身的下肢上，或使用较大的接地电极片可最大限度降低组织灼伤风险(净获益证据等级：中至高；推荐强度：B)
5.3 射频消融相关疼痛和不适
· 在射频消融后通过射频导管注射类固醇(如甲基强的松龙乙酸盐10 mg)或可减轻射频消融后的疼痛与不适(净获益证据等级：低；推荐强度：C)
5.4 脊髓或脊神经根损伤
· 行运动神经测试能够减少对脊髓和脊神经根损伤的可能性(净获益证据等级：低；推荐强度：B)
5.5 射频消融相关脊柱肌肉退化
在进行射频消融前后，建议结合物理疗法治疗，目的在于恢复腰部肌肉的功能，从而改善治疗效果(净获益证据等级：低；推荐强度：C)6 介入治疗时植入物的处理 6.1 植入电子设备
· 植入的电子设备(如神经刺激器)应设置为0 V输出并在术前关闭；起搏器应设置为非同步模式；除颤器应在体表放置一块磁铁，以防止射频消融触发除颤；射频消融术后应重启神经刺激器至手术前设置(净获益证据等级：低；推荐强度：C)
6.2 邻近脊柱植入物
· 应使用多平面影像引导的射频消融技术，以确保射频针与椎弓根内螺钉不接触，避免对脊柱植入物周围组织造成热损伤(净获益证据等级：低；推荐强度：C)MBB(medial branch block): 脊神经后内侧支阻滞
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