What are the treatment options for lumbar facet joint pain?

Treatment Options for Lumbar Facet Joint Pain

Conventional radiofrequency ablation of the medial branch nerves is the most effective treatment for lumbar facet joint pain when previous diagnostic or therapeutic injections have provided temporary relief. 1, 2

Diagnostic Approach for Facet-Mediated Pain

• Diagnosis of facet-mediated pain should be established using controlled comparative local anesthetic blocks (double-block technique) with an improvement threshold of 80% or greater 3
• No physical examination findings or radiographic studies consistently correlate with facet pain, making diagnostic blocks the most reliable diagnostic method 1, 4
• Pain patterns from facet joints include:
  • Lower facet joints: pain referred to groin and deep posterior thigh
  • Upper facet joints: pain in flank, hip, and upper lateral thigh 1, 4
• Facet-mediated pain is a cause of chronic pain in 9-42% of patients with degenerative lumbar disease 1, 5

First-Line Treatment Approach

• Begin with conservative management as part of a multimodal approach to pain management 2:
  • Physical therapy focusing on extension exercises
  • Non-steroidal anti-inflammatory medications 2
• Conservative treatment should be tried for at least 6 weeks before considering interventional approaches 3

Interventional Treatment Options

Diagnostic Medial Branch Blocks

• Diagnostic medial branch blocks using local anesthetics with a threshold of >50% pain relief can confirm facet-mediated pain 2
• The double-block technique (using anesthetics with different durations of action on separate occasions) is more reliable but rarely performed in routine clinical practice 1

Therapeutic Medial Branch Blocks

• Multiple injections of medial branch blocks with local anesthetics may provide significant pain relief for up to 44-45 weeks, with each injection providing approximately 15 weeks of relief 2, 3
• Evidence is moderate for both short-term and long-term pain relief with repeat medial branch blocks 1, 6

Radiofrequency Ablation

• Conventional (80°C) or thermal (67°C) radiofrequency ablation of the medial branch nerves is the most effective treatment for confirmed facet-mediated pain 1, 2
• Radiofrequency ablation should be performed when previous diagnostic or therapeutic injections have provided temporary relief 1
• Evidence for radiofrequency neurotomy is moderate for both short-term and long-term pain relief 6, 7
• Currently considered the "gold standard" for treating facetogenic pain 7

Intraarticular Facet Joint Injections

• Evidence for intraarticular facet joint injections is moderate for short-term and long-term pain relief in lumbar spine 6
• However, more recent evidence suggests these are no more effective than placebo injections for long-term relief 3
• Should be reserved for those who do not respond to radiofrequency treatment 7

Important Clinical Considerations and Caveats

• Chemical denervation using phenol or alcohol should not be used in the routine care of patients with facet-mediated pain 1, 2
• Cryoablation may be considered as an alternative to radiofrequency ablation in selected patients 1, 2
• Facet joint interventions should be used as part of a multimodal approach to pain management, not as standalone treatments 1
• The false-positive rate with single blocks using lidocaine can be high (27% in the lumbar spine), highlighting the importance of controlled diagnostic blocks 5
• Facet joint pain is more common in older patients and those with degenerative changes 4