What is the initial treatment for mild facet arthropathy?

Initial Treatment for Mild Facet Arthropathy

For mild facet arthropathy, begin with a brief trial of scheduled NSAIDs at the minimum effective dose combined with physiotherapy, followed by intraarticular glucocorticoid injections if symptoms persist beyond 2-4 weeks. 1, 2

First-Line Approach

NSAIDs as Initial Therapy

• Start with scheduled NSAIDs (not as-needed dosing) at the minimum effective dose for the shortest duration possible 3, 1
• The trial should be brief—no longer than 2-4 weeks—due to potential adverse effects including gastritis, bruising, and limited long-term efficacy 3, 1
• Before prescribing, evaluate gastrointestinal, renal, and cardiovascular risk factors 3, 1
• Common pitfall: Continuing NSAID monotherapy beyond 2 months for active symptoms is inappropriate and delays more effective treatment 3

Physiotherapy

• Initiate physiotherapy concurrently with NSAIDs for symptom relief and to prevent functional limitations 3
• Simple analgesia (acetaminophen) is preferable to NSAIDs when inflammation is minimal, though NSAIDs are more effective for inflammatory pain 3

Second-Line Treatment: Intraarticular Glucocorticoid Injections

When to Escalate

• If symptoms persist after 2-4 weeks of NSAIDs and physiotherapy, proceed to intraarticular glucocorticoid injections 3, 2
• These injections are appropriate for all patients with active facet arthropathy regardless of disease activity level 3

Technical Considerations

• Triamcinolone hexacetonide is the preferred agent over triamcinolone acetonide, as it provides more durable clinical responses 3
• All facet joint injections must be performed under fluoroscopic or CT guidance—this is mandatory for safety and accuracy 2
• Expected duration of benefit is at least 4 months; shorter duration suggests need for systemic therapy escalation 3
• Injections may be repeated as needed if they provide at least 4 months of relief 3

Evidence Quality

The evidence for intraarticular glucocorticoid injections shows moderate effectiveness: lumbar facet injections have moderate evidence for short- and long-term pain relief, while cervical facet injections have limited evidence 4, 2

What NOT to Do

Avoid Oral Glucocorticoids

• Oral glucocorticoids are conditionally recommended against as initial therapy for facet arthropathy 3
• If used despite recommendations (e.g., when injection is not feasible), limit to the lowest effective dose for the shortest duration possible—ideally less than 3 months 3
• Chronic low-dose oral glucocorticoids are strongly contraindicated 3

Monitoring Response

• Assess response at 1-3 month intervals using pain scores, functional assessments, and range of motion 1
• If no improvement after initial conservative measures (NSAIDs, physiotherapy, and at least one glucocorticoid injection), consider referral for interventional procedures 1, 2

Advanced Interventional Options (If Conservative Treatment Fails)

Medial Branch Blocks

• For persistent symptoms despite conservative treatment, diagnostic medial branch blocks with local anesthetics can confirm facet joint pain as the source 4, 2
• The evidence is moderate for both short- and long-term pain relief with repeated medial branch blocks 4, 2

Radiofrequency Neurotomy

• Reserved for confirmed facet-mediated pain that has failed conservative treatment 5, 4, 2
• The evidence is moderate for both cervical and lumbar radiofrequency ablation providing short- and long-term pain relief 4, 2
• Success rates show 85% of cervical and 71% of lumbar cases achieve at least 50% improvement for extended periods 5