What are the treatment options for facet arthropathy?

Treatment Options for Facet Arthropathy

The treatment of facet arthropathy should follow a stepwise approach, beginning with non-pharmacological interventions and topical treatments before progressing to oral medications, injections, and surgical options when conservative measures fail.

Initial Assessment and Non-Pharmacological Management

First-Line Approaches

• Education and exercise: Education concerning joint protection together with an exercise regimen involving both range of motion and strengthening exercises (Level of Evidence 1a, Grade A recommendation) 1
• Heat application: Local application of heat (e.g., paraffin wax, hot packs) especially before exercise (77% recommendation strength) 1
• Orthoses/splints: For symptom relief and to prevent/correct deformities (67% recommendation strength) 1

Physical Interventions

• Ergonomic modifications: Pacing of activity and use of assistive devices should be offered to every patient (Level of Evidence 1b, Grade A recommendation) 1
• Weight management: Important for reducing mechanical stress on facet joints, particularly in the lumbar spine 2

Pharmacological Management

Topical Treatments

• Topical NSAIDs: First-line pharmacological treatment of choice due to safety profile (Level of Evidence 1b, Grade A recommendation) 1
• Topical capsaicin: Effective and safe treatment option (75% recommendation strength) 1

Oral Medications

• Acetaminophen (Paracetamol): First choice oral analgesic up to 4g/day due to efficacy and safety profile (87% recommendation strength) 1
• NSAIDs: Should be used at the lowest effective dose and for the shortest duration in patients who respond inadequately to acetaminophen (Level of Evidence 1a, Grade A recommendation) 1
  • In patients with increased gastrointestinal risk, use non-selective NSAIDs with a gastroprotective agent or a selective COX-2 inhibitor
  • In patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and non-selective NSAIDs should be used with caution

Symptomatic Slow-Acting Drugs for Osteoarthritis (SYSADOAs)

• Options include: Glucosamine, chondroitin sulfate, avocado soybean unsaponifiables, diacerhein
• May provide symptomatic benefit with low toxicity, but effect sizes are small (63% recommendation strength) 1
• Chondroitin sulfate may be used for pain relief and improvement in functioning (Level of Evidence 1b, Grade A recommendation) 1

Interventional Procedures

Diagnostic and Therapeutic Injections

• Medial branch blocks: Used for diagnostic confirmation requiring >70% pain relief 2
• Intra-articular corticosteroid injections: Effective for painful flares, especially in trapeziometacarpal joint OA (60% recommendation strength) 1
• Facet joint injections: Not effective as standalone long-term management without a multimodal approach 2

Advanced Interventions

• Radiofrequency denervation/ablation: Recommended when routine steroid treatment is not effective; outcomes have improved with better patient selection and techniques (moderate strength of evidence) 2, 3
• Neurostimulation: May be useful for certain pain syndromes when other treatments fail 1

Surgical Options

• Surgery: Should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain (Grade D recommendation) 1
• Surgical options include: Interposition arthroplasty, osteotomy, or arthrodesis 1

Treatment Algorithm

1. Begin with: Education + Exercise + Heat therapy + Ergonomic modifications
2. If inadequate response: Add topical NSAIDs or capsaicin
3. If still inadequate: Add oral acetaminophen (up to 4g/day)
4. If still inadequate: Add oral NSAIDs (lowest effective dose, shortest duration)
5. If still inadequate: Consider diagnostic medial branch blocks
6. If positive response to blocks: Consider radiofrequency denervation
7. If all above fail: Consider surgical options in patients with significant structural abnormalities

Important Considerations

• Imaging findings often do not correlate with symptoms - MRI inflammatory features of facet joints are often not reported in radiology reports (sensitivity 6-22%) 4
• Treatment should address both the inflammatory component (NSAIDs) and mechanical/functional aspects (exercise, weight management) 2
• Facet arthropathy can be part of various conditions including osteoarthritis, inflammatory arthritis, or even gouty arthropathy in rare cases 5
• SPECT/CT may help identify active facet arthropathy when conventional imaging is inconclusive 2

The management of facet arthropathy requires a comprehensive approach that addresses both pain relief and functional improvement. While non-pharmacological and topical treatments should be initiated first due to their favorable safety profiles, interventional procedures may be necessary for patients with inadequate response to conservative measures.