Efficacy and Safety of Cryoneurolysis versus Radiofrequency Ablation for Lumbar Facet Joint Syndrome: A Systematic Review

Abstract

Background: Lumbar facet joint syndrome is a recognised source of chronic axial low back pain. Radiofrequency ablation (RFA) is widely used after prognostic medial branch blocks, whereas cryoneurolysis is an alternative neuroablative approach intended to interrupt nociceptive conduction while permitting axonal regeneration. Objective: To compare the efficacy and safety of cryoneurolysis with RFA for confirmed lumbar facet-mediated pain. Methods: An openly accessible evidence search was conducted on 5 September 2026 for reports published from 1 January 2000 through 15 July 2026. PubMed-focused searching, trial-registry searching, accessible full-text sources, and citation verification were used. Eligible studies directly compared lumbar medial branch cryoneurolysis/cryoablation with RFA in adults with facet-mediated chronic low back pain. Screening, extraction and risk-of-bias appraisal were completed by a single reviewer. No statistical pooling was undertaken because the three trials differed in design, diagnostic thresholds, co-interventions, follow-up, and outcome reporting. Results: Three randomised trials (212 randomised participants overall; 152 allocated to cryoneurolysis or RFA arms relevant to the direct comparison) were included. The 2024 COPE sham-controlled trial found no clinically convincing between-group advantage for either active treatment across patient global impression, pain, disability or quality-of-life outcomes through 12 months, although one cryoneurolysis-versus-placebo PGIC comparison at 6 months reached statistical significance. A 2025 pilot trial of 30 participants reported lower adjusted pain scores and better 12-month disability and PGIC outcomes with cryoneurolysis than RFA, but it was unblinded, small, and had optional extended follow-up. A 2026 multicentre three-arm trial found improvements in both cryoablation and RFA groups through 24 months with no statistically significant between-group differences. Serious treatment-related adverse events were not reported in the included trials; event counts were sparse. Certainty was judged very low for comparative pain, function and safety outcomes because of imprecision, risk of bias and inconsistency. Conclusions: Current head-to-head evidence is insufficient to establish superiority of cryoneurolysis or RFA for lumbar facet joint syndrome. Larger, blinded, multicentre trials using rigorous dual-block selection, prespecified core outcomes and complete adverse-event reporting are needed.