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.
Treatments for facet joint pain include (1) intra-articular steroid/local anesthetic injection under fluoroscopic guidance (see images below) and (2) radiofrequency ablation to block the joint from all sensory input. Some authorities have also advocated the use of pulsed radiofrequency [15] at a lower temperature. Prior to radiofrequency ablation, medial branch blocks or intra-articular facet injections are typically done. Medial branch blocks appear to have better prognostic outcomes than intra-articular facet injections. [16] A retrospective study by Han et al found that in patients with chronic lower lumbar facet joint pain, medial branch blocks did not differ significantly in analgesic effect or resulting functional improvement whether administered using ultrasonographic or fluoroscopic guidance. However, the time needed to perform ultrasonographically guided medial branch blocks was significantly shorter than that for the fluoroscopically guided blocks. [53]
Anteroposterior view of right L4-5 facet intra-articular injection with contrast.
A retrospective study by Nedelka et al indicated that shock-wave therapy produces better long-term results in alleviating lumbar facet joint pain than do corticosteroid injections and suggested that the treatment is almost as effective as RF neurotomy. The report, on 62 patients with unilateral chronic lumbar facet pain, also found that shock-wave treatment and RF neurotomy provided long-term improvement in the performance of daily activities. [54]
Another treatment option is surgical fusion of the joint, but no published reports describe such treatment for lumbar facet arthropathy.
Details about treatment with injection or ablation are as follows.
Intra-articular facet joint injection
Numerous early studies of this procedure 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. [55]
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. [28] 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.
A study by Huang indicated that fluoroscopically guided lumbar facet joint injections employing an interlaminar approach and loss-of-resistance technique can provide a successful alternative means of injecting osteoarthritic facet joints, particularly when osteophytes and/or extreme joint curvature in the transverse plane interfere with direct posterior access to severely arthritic joints. [56]
RF neurotomy
Five controlled studies of RF neurotomy of the dosal medial nerve branch 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. [57] 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. [58] 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. [59] 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. [60] 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. [61] 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. [62] 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
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. [63] The investigators reported no other complications.
In 2013, the American Society of Interventional Pain Physicians (ASIPP) released an update of their guidelines for interventional techniques in patients with chronic spinal pain. The guidelines state that evidence for the therapeutic efficacy of lumbar facet joint nerve blocks is fair to good but that there is only limited evidence for the efficacy of intra-articular lumbar injections. [17, 18]
The ASIPP guidelines also state that there is good evidence for the therapeutic efficacy of RF ablation in lumbar facet joint interventions but that evidence for the efficacy of pulsed RF is limited. [17, 18, 64]
A literature review by Manchikanti et al found level II evidence for long-term lumbar spine improvement with RF neurotomy and level III evidence for long-term improvement with lumbosacral intra-articular injections. [1]
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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Anteroposterior view of right L4-5 facet intra-articular injection with contrast.
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Lateral view of right L4-5 facet intra-articular injection with contrast.
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Oblique view of right L4-5 facet intra-articular injection with contrast.
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Anteroposterior view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala).
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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).
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Anteroposterior view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process).
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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).
