What is the initial management for mild facet arthropathy?

Initial Management of Mild Facet Arthropathy

For mild facet arthropathy, begin with conservative management consisting of simple analgesia (avoiding NSAIDs when possible), physiotherapy with dynamic exercises, and consider intra-articular corticosteroid injections for persistent symptoms. 1, 2

Conservative Treatment Approach

First-Line Therapy

• Simple analgesia should be the initial pharmacologic approach for symptom relief 1
• Physiotherapy with dynamic exercises is essential as an adjunctive treatment to improve function and reduce pain 1, 3
• Occupational therapy can be added to complement the exercise program 1, 3

NSAIDs: Use With Caution

• NSAIDs may be considered for symptomatic relief, but only after careful evaluation of gastrointestinal, renal, and cardiovascular risk factors 1, 3
• Use the minimum effective dose for the shortest possible duration 3
• Short-term use is safer when disease is in remission, but long-term use carries increased risk 1
• There is no evidence that COX-2 inhibitors are safer than non-selective NSAIDs 1

Intra-articular Corticosteroid Injections

• Local corticosteroid injections should be considered if symptoms don't resolve rapidly with conservative measures 1, 3
• These injections provide relief of local inflammatory symptoms 1, 3
• Must be performed under mandatory fluoroscopic or CT guidance 2

Diagnostic Confirmation

Before proceeding with interventional treatments, proper diagnosis is critical:

• Physical examination and clinical assessment are the primary methods for patient selection, ideally at least 3 months after symptom onset and failure of conservative management 2
• Fluoroscopic or CT guidance is mandatory for any facet joint interventions 2
• Diagnostic medial branch blocks can confirm facet joint pain as the source, with moderate evidence supporting their use 2, 4

When Conservative Management Fails

If symptoms persist despite 6 weeks of conservative treatment:

• Therapeutic medial branch blocks with local anesthetics (with or without steroids) have moderate evidence for both short- and long-term pain relief with repeat interventions 2, 4
• Radiofrequency neurolysis of medial branch nerves shows moderate evidence for both short- and long-term pain relief, with 71-85% of patients achieving at least 50% improvement 5, 2, 4
• Intra-articular facet joint injections have limited to moderate evidence, with most studies showing lack of effectiveness without local anesthetic 2, 4

Patient Education and Monitoring

• Patient education programs aimed at coping with pain, disability, and maintaining work capacity should be employed as complementary interventions 3
• Monitor disease activity at 1-3 month intervals until therapeutic goals are achieved 3
• Assessment should include pain levels, functional status, and range of motion 5, 2

Critical Pitfalls to Avoid

• Avoid prolonged NSAID use due to cumulative gastrointestinal, renal, and cardiovascular risks 3
• Do not perform facet joint interventions without fluoroscopic or CT guidance—this is mandatory for safety and accuracy 2
• Avoid systemic corticosteroids as primary treatment; if used, keep duration under 6 months at the lowest effective dose 3
• Do not use opioid analgesics during diagnostic procedures as they may confound results 2
• Intra-articular hyaluronic acid injections are not effective for facet arthropathy and should not be used 6