What is the treatment for degenerative disc disease and facet hypertrophy?

Treatment for Degenerative Disc Disease and Facet Hypertrophy

For degenerative disc disease and facet hypertrophy, a stepwise approach is recommended, beginning with conservative measures and progressing to interventional procedures only when necessary, with facet medial nerve blocks showing the strongest evidence for short-term pain relief in selected patients. 1

Diagnostic Approach

• Advanced imaging (MRI or CT) is essential before initiating treatment to confirm facet joint pathology and exclude alternative diagnoses 2
• CT scans are particularly useful for evaluating facet joints and neural foramina while helping with preoperative planning for interventional procedures 2
• The double-block technique (using anesthetics with different durations of action on two separate occasions) is the most reliable means of identifying facet-mediated pain, requiring ≥80% pain relief to establish diagnosis 1, 3

Conservative Management

• First-line treatment includes physical therapy, activity modification, and oral analgesics 4
• Conservative measures are important supporting interventions even when surgical treatment is eventually required 4
• Conservative treatment should be attempted for at least 6 weeks before considering interventional procedures 3

Interventional Procedures

• Facet joint nerve blocks have strong evidence (moderate-quality) for both short-term and long-term treatment of facet-mediated low back pain 1, 3
• Radiofrequency ablation (RFA) of facet medial nerves has Level II-III evidence with a strong recommendation (low-quality evidence) for use in patients who respond to diagnostic blocks 1, 3
• Intra-articular facet joint injections have insufficient evidence (Level III - opinion) and no recommendations can be made for their use 1
• Epidural steroid injections may provide only short-term relief (<2 weeks) for chronic back pain 1

Surgical Options

• Surgical decompression is superior to conservative measures for spinal canal stenosis and degenerative spondylolisthesis 4
• Lumbar fusion has shown good long-term clinical outcomes but may accelerate degenerative processes at adjacent levels 5
• Total disc replacement is at least equivalent to fusion in short-term outcomes and may not accelerate adjacent degeneration, though concerns remain about long-term safety 5, 6
• Surgical treatment of lumbar disc herniation shows slight advantages over conservative treatment with faster recovery of neurological deficits and pain control 4

Treatment Algorithm

1. Initial Phase (0-6 weeks):

   • Physical therapy, activity modification, oral analgesics 4
   • Advanced imaging (MRI or CT) to confirm diagnosis 2

2. Intermediate Phase (if conservative treatment fails):

   • Diagnostic facet blocks using double-block technique 1, 3
   • If positive response to diagnostic blocks (≥80% pain relief):
     • Proceed with facet medial nerve blocks for therapeutic benefit 1, 3
     • Consider radiofrequency ablation for longer-term relief 1, 3

3. Advanced Phase (if interventional procedures fail):

   • Consider surgical options based on specific pathology:
     • Decompression for spinal stenosis 4
     • Fusion or disc replacement for significant instability or disc degeneration 5, 6

Important Caveats

• Facet injections are not recommended as long-term treatment for chronic low back pain 1
• Relying solely on imaging findings of facet arthropathy to justify interventional treatment is not recommended 3
• Performing facet joint procedures without proper imaging can lead to misdiagnosis of the pain generator or treatment of the wrong spinal level 2
• Documented evidence of pain reduction is critical for determining the appropriateness of repeat procedures 2