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Sections Lumbar Facet Arthropathy
Overview
Presentation
- History
- Physical
- Causes
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Treatment
Guidelines
Medication
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Questions & Answers
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References

Medication

Medication Summary

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.

Class Summary

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)

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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.

Ibuprofen (Ibuprin, Motrin)

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DOC for patients with mild to moderate pain. The drug inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprelan, Naprosyn, Aleve)

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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.

Nabumetone (Relafen)

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Nonacidic NSAID that is rapidly metabolized after absorption, becoming a major active metabolite that inhibits the COX enzyme (thereby inhibiting pain and inflammation).

Ketorolac (Toradol)

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Inhibits prostaglandin synthesis by decreasing the activity of COX, which results in the decreased formation of prostaglandin precursors.

Class Summary

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)

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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.

Class Summary

Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

Acetaminophen (Tylenol, Feverall)

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Ensures patient comfort, promotes pulmonary toilet, and has sedating properties

Follow-up

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Media Gallery

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.
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).

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Author

Carl H Shin, MD Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Pennsylvania

Carl H Shin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Curtis W Slipman, MD Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, North American Spine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

J Michael Wieting, DO, MEd, FAOCPMR, FAAOE Senior Associate Dean, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd, FAOCPMR, FAAOE is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Osteopathic Examiners, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Gold Humanism Honor Society, International Society for Communication Science and Medicine, Michigan Osteopathic Association, Oklahoma Osteopathic Association, Tennessee Osteopathic Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The editors wish to gratefully acknowledge Mark I Ellen, MD, Assistant Professor, Department of Orthopedics and Rehabilitation Medicine, The Emory Sports Medicine Center, for his previous participation in this article.

Sections Lumbar Facet Arthropathy
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Guidelines
Medication
Follow-up
Questions & Answers
Media Gallery
References

Lumbar Facet Arthropathy Medication

Medication Summary

Nonsteroidal anti-inflammatory drugs

Class Summary

Aspirin (Anacin, Bayer Aspirin, Ascriptin)