What is the recommended treatment approach for patients with suspected facet joint pain, specifically regarding facet injections with local anesthetics like lidocaine (local anesthetic) and steroids like triamcinolone (glucocorticoid)?

Facet Joint Injections for Suspected Facet Joint Pain

Facet joint injections with steroids are no more effective than placebo injections for pain relief and improvement of disability in patients with suspected facet joint pain, and should not be used as a primary therapeutic intervention. 1

Diagnostic Approach for Suspected Facet Joint Pain

• Diagnosis of facet-mediated pain should be established using controlled comparative local anesthetic blocks (double-injection technique) with an 80% pain relief threshold, as this is the most reliable diagnostic method 1, 2
• No physical examination technique, laboratory test, or imaging modality can precisely identify facet joints as the pain-generating structure in patients with chronic spinal pain 3
• Diagnostic facet blocks serve as a valuable tool for identifying facet-mediated pain in properly selected patients with chronic neck or back pain 4, 3
• The double-block technique (using two different local anesthetics on separate occasions) is more reliable than single blocks, though rarely performed in routine clinical practice 2, 3

Therapeutic Efficacy of Facet Injections

• Moderate evidence indicates that facet joint injections with steroids are no more effective than placebo injections for relief of pain and disability 1
• Systematic reviews have consistently found insufficient evidence to support the use of intraarticular facet joint injections as a therapeutic modality for chronic low back pain 1, 2
• The American Society of Anesthesiologists notes that intraarticular facet joint injections may be used for symptomatic relief of facet-mediated pain, but evidence for long-term efficacy is limited 1
• Studies show that only a small percentage of patients achieve significant relief with facet injections, with one study finding only 7.7% of patients had complete symptom relief 2

Alternative Therapeutic Approaches

• Medial branch blocks show better evidence for therapeutic efficacy compared to intraarticular facet joint injections 1

  • Double-blinded RCTs have shown that patients may experience significant pain relief from multiple medial branch blocks for up to 44-45 weeks 1
  • Each medial branch block injection provides on average 15 weeks of pain relief for low back pain and improved function 1
  • No significant differences in outcomes have been observed between patients receiving local anesthetic only versus local anesthetic with steroids 1

• Radiofrequency neurotomy of medial branch nerves shows moderate evidence for short-term and long-term pain relief in cervical and lumbar regions 5

Clinical Considerations and Caveats

• Facet joint syndrome criteria include:

  • Pain without radiculopathy
  • Pain aggravated by extension
  • Facet tenderness on examination
  • Pain that limits daily activities and persists for more than 3 months
  • Failure of conservative treatment for at least 6 weeks 4, 2

• Technique matters in diagnostic injections:

  • The method of injection can influence results, with continuous injection of local anesthetic into musculature potentially yielding false-positive results 6
  • Fluoroscopic guidance should be used to ensure accurate needle placement 7

• Duration of relief from facet interventions is limited:

  • One prospective study found decreasing effectiveness over time, with 62% of patients reporting good/excellent outcomes at 1 month, decreasing to 36% at 6 months 7
  • Repetitive injection therapy may be considered after approximately 3 months when effects begin to wane 7

• Facet joints are not the primary source of back pain in the majority of patients, with studies showing facet-mediated low back pain accounts for only 9-42% of chronic pain in patients with degenerative lumbar disease 2

Recommended Treatment Algorithm

1. First confirm diagnosis with controlled comparative local anesthetic blocks using the double-injection technique 1, 2, 3
2. If confirmed as facet-mediated pain, consider medial branch blocks rather than intraarticular facet joint injections 1
3. For longer-term relief, consider radiofrequency neurotomy of medial branch nerves 5
4. If facet joint injections are performed despite limited evidence, patients should be informed of the limited duration of effect (typically 3 months) 7