eMedicine Specialties > Physical Medicine and Rehabilitation > Lumbar Spine Disorders
Lumbar Facet Arthropathy: Treatment & Medication
Updated: Mar 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
No studies have compared the efficacy of one type of physical therapy over another in the treatment of lumbar facet arthropathy. Once the diagnosis of facet joint pain has been confirmed and pain has been brought under control with appropriate treatment, experienced clinicians generally recommend physical therapy for reconditioning, as well as lumbar stabilization exercises.
Surgical Intervention
Currently, no surgical intervention is advocated for lumbar facet joint pain.
Consultations
The diagnosis of lumbar facet arthropathy (LFA) can be made by a practitioner who is proficient in diagnostic spinal injections and who has specialty training in musculoskeletal spine medicine. Interventional physiatrists are uniquely qualified to evaluate LFA because they possess the technical skills required to administer spinal injections and have an appreciation of musculoskeletal medicine.
Other Treatment
Facet joint pain is usually not considered until conservative measures for treating low back pain (LBP) have been tried without success. No current studies advocate or assess the efficacy of specific physical therapy or manipulations aimed at treating facet joint pain.
Currently, 2 treatments are available for facet joint pain. These are (1) intra-articular steroid/local anesthetic injection under fluoroscopic guidance (see images below and Images 1-3) and (2) radiofrequency ablation to block the joint from all sensory input. Some authorities have also advocated the use of pulsed radiofrequency35 at a lower temperature. A third treatment option is surgical fusion of the joint, but no published reports describe such treatment for lumbar facet arthropathy.
Anteroposterior view of right L4-5 facet intra-articular injection with contrast.
Lateral view of right L4-5 facet intra-articular injection with contrast.
Oblique view of right L4-5 facet intra-articular injection with contrast.
Details about treatment with injection or ablation are as follows:
- Intra-articular facet joint injection - Numerous early studies are not worth mentioning because of their serious flaws with diagnostic criteria, the location of injections, and the injection volumes used. A study by Lynch and Taylor was able to demonstrate that intra-articular injection was superior to extra-articular injection, but, after 6 months of follow-up, the statistical significance had disappeared.36
- In 1989, Lilius and colleagues prospectively studied 109 patients with chronic LBP. They were distributed randomly into 1 of 3 groups that received injections of intra-articular cortisone/anesthetic, intra-articular saline, or pericapsular cortisone/anesthetic. Although pain relief was substantial, with 36% of patients reporting benefits that persisted for up to 3 months, no significant differences were noted between groups. These results led the authors to conclude that facet joint injection is a nonspecific method of treatment and that good results reflect the tendency of LBP to undergo spontaneous remission. Two critical flaws are noted in this study. First, the authors did not preselect subjects with diagnostic facet joint injections. Second, the intra-articular facet joint injection volumes of up to 8 mL were excessive.
- In 1991, a controlled study by Carette and coauthors randomized patients into 2 groups; one group received an intra-articular methyl prednisolone/local anesthetic mixture and the other received intra-articular saline.16 Patients were preselected with local anesthetic into the facet joints at L4-5 and L5-S1 and reported pain relief of greater than 50%. When the patients were tracked for 6 months, no difference in pain relief was noted between the 2 groups, with the data suggesting that intra-articular facet joint injections with corticosteroids were not effective in treating chronic LBP. This study was flawed in that only a single lidocaine injection, which is subject to false-positive readings and placebo responses, was used to determine the presence of facet joint pain. Furthermore, the assumption that saline is a true inert placebo may be flawed. Other studies have shown that saline provides pain relief to a greater degree than would be expected from placebo. At 6-month follow-up, 46% of the steroid group and 15% of the saline group had good pain relief; however, the authors invalidated this finding because only a portion of both groups that reported pain relief at 1 month had actual pain relief at 6 months.
- RF neurotomy of the dorsal medial nerve branch (see images below and Images 4-7) - Five controlled studies have reported on the effectiveness of this procedure, and 1 study has reported on the effectiveness of repeated RF neurotomy for lumbar facet pain.
- In the first study, from 1994, Gallagher and colleagues reported successful outcomes at up to 6 months of follow-up in patients who were treated with RF, compared with those who underwent sham treatments.37 Single intra- or extra-articular diagnostic injections were used, with an inclusion criterion of good or equivocal response. Shortcomings of the study were the small number of subjects, short duration of follow-up, and poor diagnostic criteria. Differential blocks were not used.
- In the second study, from 1999, van Kleef and coauthors reported that a 1-year follow-up, significant pain reduction was found in 7 of 15 patients who were treated with RF, compared with 2 of 15 patients who had undergone sham treatment.38 The diagnostic criterion was a single diagnostic joint injection with subsequent pain relief of 50% or more. Shortcomings of the study were the number of subjects and the fact that differential blocks were not used.
- In the third study, from 2000, Dreyfuss and co-investigators reported a rate of successful outcome of 87% at 1-year follow-up in 15 patients; the individuals were treated with RF after successful differential diagnostic injections.39 Weaknesses of this study were the number of subjects and the lack of a control group. However, strict diagnostic criteria were used, including 80% pain relief and differential blocks with lidocaine and bupivacaine.
- In the fourth study, from 2001, Leclaire and colleagues reported on 70 patients who were randomized to RF treatment versus sham treatment after single diagnostic facet injections yielded good pain relief.40 No differences in outcome between the groups were noted at 12 weeks of follow-up. A large patient population was used, but the diagnostic criterion was poor. Single diagnostic injections with good relief are not valid to differentiate a facet joint pain population.
- In the fifth study, from 2005, van Wijk and coauthors reported on 81 patients randomized to RF treatment versus sham treatment after a single diagnostic facet joint injection yielded 50% pain relief.41 No differences in outcome were noted between the groups. This study was again flawed by the limitation of single diagnostic injections. Careful reading of the study shows that although the authors reported on 462 patients, after accounting for excluded patients and dropouts, 37 had negative responses to the diagnostic injection and 81 had positive responses to the diagnostic injection, yielding an unusually high prevalence of facet joint pain.
- In 2004, Schofferman and Kine retroactively reported on the effectiveness of repeated RF neurotomy for lumbar facet pain.42 In 20 patients who had undergone a repeat RF treatment, an 85% success rate at a mean duration of 11.6 months was achieved.
- Conclusions for treatment of facet joint pain
- Studies suggest that intra-articular steroid injections are not a valid treatment option, although they can be used for diagnostic purposes or for short-term pain relief. RF ablation requires further research.
- Of the first 5 studies reviewed above, 3 showed favorable outcomes, and 2 did not. Although the 2 studies that demonstrated no significant favorable outcomes utilized a larger population of patients, their use of a single diagnostic injection and their employment of a rather loose inclusion criterion of 50% pain relief or good pain relief were inadequate for differentiating a facet joint population. The study that used a strict 80% pain relief with differential block criterion did demonstrate a rather high success rate with RF treatment. However, this study lacked a control group.
- RF ablation appears to be safe, with most studies reporting no associated complications. The complications that have been previously reported related to electrical faults and included cases of small superficial burns. A 2004 report by Kornick and colleagues on 616 treated lesions showed a 1% complication rate for neuritis.43 The investigators reported no other complications.
Anteroposterior view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala).
Lateral view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala, just below the L5-S1 facet joint).
Anteroposterior view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process).
Lateral view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process, just below L4-5 facet joint).
Related eMedicine topics:
Corticosteroid Injections of Joints and Soft Tissues
Paraspinal Injections: Facet Joint and Nerve Root Blocks
Therapeutic Injections for Pain Management
Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for medical therapy for lumbar facet arthropathy (LFA). Peripherally acting analgesics include NSAIDs and acetaminophen. NSAIDs are the DOC in the initial pharmacologic treatment of acute episodes of LFA or following acute exacerbation of chronic pain.
Nonsteroidal anti-inflammatory drugs
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Aspirin (Anacin, Bayer Aspirin, Ascriptin)
Best-known NSAID. It is widely available and has cardioprotective, cerebroprotective, and anticoagulation properties. Aspirin treats mild to moderate pain. The drug inhibits prostaglandin synthesis, which prevents the formation of platelet-aggregating thromboxane A2.
Adult
650 mg PO q6h; not to exceed 3 g/d
Pediatric
90-130 mg/kg/d PO divided q6h; target plasma salicylate level is 150-300 mcg/mL
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with co-administration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity, liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, and asthma; because of association with Reye syndrome, do not use in children ( <16 y) with viral infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia or a history of blood coagulation defects; avoid in patients taking anticoagulants
Ibuprofen (Ibuprin, Motrin)
DOC for patients with mild to moderate pain. The drug inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400 mg PO q4-6h; not to exceed 2400 mg/d
Pediatric
<6 months: Not established
6 months to 12 years: 10 mg/kg PO q6-8h; not to exceed 40 mg/kg
>12 years: Administer as in adults
Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprelan, Naprosyn, Aleve)
For the relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in decreased prostaglandin synthesis.
Adult
250, 375, or 500 mg PO bid; not to exceed 1500 mg/d
Pediatric
<2 years: Not established
>2 years: 5 mg/kg PO bid
Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Nabumetone (Relafen)
Nonacidic NSAID that is rapidly metabolized after absorption, becoming a major active metabolite that inhibits the COX enzyme (thereby inhibiting pain and inflammation).
Adult
1000 mg/d PO; not to exceed 1000 mg PO bid
Pediatric
Not established
Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; active peptic ulceration, hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Elderly may require lower doses; caution in hepatic and renal impairment
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing the activity of COX, which results in the decreased formation of prostaglandin precursors.
Adult
<65 years: 60 mg IM initially, followed by 15-30 mg PO q6h prn; not to exceed 5 d of treatment
>65 years: 30 mg IM initially, followed by 15 mg PO q6h prn; not to exceed 5 d of treatment
Pediatric
Not established
Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with pre-existing renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs
Cyclo-oxygenase-2 Inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeding is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost and avoidance of GI bleeding will further define populations that will most benefit from COX-2 inhibitors.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme; it is induced by pain and inflammatory stimuli. The inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased in comparison with nonselective NSAIDs. Seek the lowest dose for each patient.
COX-2 neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates pro-inflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; and may increase CSF IgG (10%).
COX-2 has a sulfonamide chain and is primarily dependent on cytochrome P450 enzymes (hepatic enzymes) for metabolism.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
CYP450 2C9 substrate; co-administration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; co-administration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or lab results suggest liver dysfunction
Analgesics
Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen (Tylenol, Feverall)
Ensures patient comfort, promotes pulmonary toilet, and has sedating properties
Adult
1 g PO q4-6h prn; not to exceed 4 g/d
Pediatric
<6 years: not established
6-12 years: 325 mg PO q4-6h; not to exceed 1625 mg/d
>12 years: administer as in adults
Rifampin can reduce analgesic effects; co-administration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative doses that exceed recommended maximum dose
More on Lumbar Facet Arthropathy |
| Overview: Lumbar Facet Arthropathy |
| Differential Diagnoses & Workup: Lumbar Facet Arthropathy |
 Treatment & Medication: Lumbar Facet Arthropathy |
| Follow-up: Lumbar Facet Arthropathy |
| Multimedia: Lumbar Facet Arthropathy |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
lumbar facet arthropathy, back pain, lower back pain, osteoarthritis, low back pain, facet joint, chronic back pain, lumbar spine, arthropathy, radiofrequency ablation, facet syndrome, facet arthropathy, lumbar facet, chronic low back pain, chronic lower back pain, facet joints, facet arthrosis, facet block, back osteoarthritis, nerve ablation, RF ablation, facet joint injection, facet joint injections, zygapophyseal joint arthropathy, zygapophysial joint arthropathy, facet joint syndrome, radiofrequency nerve ablation, RF nerve ablation
