Navigating current controversies in radiofrequency ablation of the genicular nerves for chronic knee pain in osteoarthritis: a daring discourse

Chronic knee joint pain affects millions worldwide, with radiofrequency ablation (RFA) of genicular nerves emerging as a potential treatment in the last 15 years. Despite its growing popularity, with studies demonstrating its efficacy in pain reduction for up to 12 months, recent randomized controlled trials have questioned the efficacy of RFA. Discrepancies in study results may partially be explained by the heterogeneity of patient selection and technical protocols. This daring discourse aims to explore and critically analyze the ongoing debates surrounding RFA of the genicular nerves, addressing key controversies, namely: (1) Is there a role for performing prognostic blocks prior to RFA?; (2) What are the optimal target sites for final cannulae placement for the classical targets?; (3) Which and how many nerves should be targeted in RFA procedures?; (4) What are the comparative benefits of using ultrasound versus fluoroscopy guidance, and whether a combined technique may be advantageous?; (5) Is there a potential role for pulsed radiofrequency of the genicular nerves?; (6) Should genicular nerve RFA be performed after total knee arthroplasty? Through this in-depth discussion, we aim to guide pain medicine clinicians in informed decision-making and encourage further research in this field.