What is the best treatment approach for severe bilateral facet arthrosis?

Treatment Approach for Severe Bilateral Facet Arthrosis

For severe bilateral facet arthrosis, a step-wise treatment approach is recommended, beginning with conservative measures and progressing to interventional procedures, with surgery reserved for cases with marked pain and disability that fail to respond to conservative treatments.

Initial Conservative Management

Non-pharmacological Interventions

• Exercise regimen: Range of motion and strengthening exercises are strongly recommended for all patients 1
• Local application of heat: Particularly effective before exercise (77% recommendation strength) 1
• Splints and orthoses: To prevent or correct lateral angulation and flexion deformity 1
• Physical therapy: To improve mobility and strengthen supporting muscles

Pharmacological Management

1. First-line analgesic: Paracetamol (acetaminophen) up to 4g/day due to efficacy and safety profile 1
2. Topical treatments: Preferred over systemic treatments for mild to moderate pain
   • Topical NSAIDs
   • Capsaicin
3. Oral NSAIDs: For patients with inadequate response to paracetamol
   • Use lowest effective dose for shortest duration
   • For patients with increased GI risk: non-selective NSAIDs with gastroprotective agent or COX-2 inhibitor
   • For patients with increased CV risk: avoid COX-2 inhibitors and use non-selective NSAIDs with caution 1

Interventional Procedures

Intra-articular Injections

• Corticosteroid injections: Effective for painful flares of osteoarthritis 1
  • Provides short to moderate-term pain relief
  • Can be performed under fluoroscopic or CT guidance for accuracy 2

Nerve Blocks and Denervation

• Medial branch blocks: Moderate evidence for both short and long-term pain relief with repeat interventions 3
• Radiofrequency neurotomy: Moderate evidence for short and long-term pain relief of cervical and lumbar medial branch nerves 3
  • Consider when intra-articular injections provide only temporary relief
  • Image guidance is critical for targeting facet joint innervation 2

Emerging Treatments

• Platelet-rich plasma (PRP) injections: Preliminary evidence suggests effectiveness for lumbar facet joint syndrome with good safety profile 4
• Symptomatic slow-acting drugs for osteoarthritis (SYSADOAs): May provide symptomatic benefit with low toxicity, though effect sizes are small 1
  • Options include glucosamine, chondroitin sulfate, avocado soybean unsaponifiables

Surgical Management

• Surgery: Should be considered in patients with marked pain and/or disability when conservative treatments have failed 1
• Surgical options:
  • Interposition arthroplasty
  • Osteotomy
  • Arthrodesis

Treatment Algorithm

1. Initial approach: Conservative management with exercise, heat application, and paracetamol
2. If inadequate response after 4-6 weeks: Add topical NSAIDs or progress to oral NSAIDs
3. If continued inadequate response: Consider intra-articular corticosteroid injections
4. For persistent pain: Proceed to medial branch blocks to confirm facet joint as pain source
5. If temporary relief from blocks: Consider radiofrequency neurotomy
6. For refractory cases: Evaluate for surgical intervention

Common Pitfalls and Caveats

• Failure to confirm facet joints as the pain source before proceeding to interventional treatments
• Overreliance on opioids for chronic pain management
• Inadequate trial of conservative measures before moving to invasive procedures
• Not addressing contributing factors such as poor posture, obesity, or mechanical stressors
• Expecting complete pain resolution rather than functional improvement and pain reduction

Regular reassessment of pain, function, and quality of life is essential to determine treatment effectiveness and guide progression through the algorithm.