What is the recommended treatment for moderate facet hypertrophy?

Treatment for Moderate Facet Hypertrophy

Begin with conservative management including physical therapy with extension exercises and NSAIDs for at least 6 weeks, then proceed to diagnostic medial branch blocks if pain persists, followed by radiofrequency ablation for confirmed facet-mediated pain. 1, 2

Initial Conservative Management (First 6 Weeks)

• Physical therapy focusing on extension exercises is the first-line approach as part of multimodal pain management 1
• Non-steroidal anti-inflammatory medications (NSAIDs) should be initiated concurrently 1
• Pain must persist for at least 3 months before considering interventional procedures 1, 3
• Conservative treatment must be documented as failing for at least 6 weeks before proceeding to injections 3

Diagnostic Confirmation of Facet-Mediated Pain

The double-injection technique with controlled comparative local anesthetic blocks is the gold standard for diagnosis, requiring ≥80% pain relief to confirm facet joint as the pain source 3, 2. However, in clinical practice, a single diagnostic medial branch block with ≥50% pain relief threshold is commonly used 1, 3.

Clinical indicators suggesting facet-mediated pain:

• Pain aggravated by extension movements 1, 3
• Absence of radiculopathy (facet injections are not appropriate for radicular symptoms) 3
• No other obvious cause on imaging studies 3
• Pain limiting daily activities 3

Important caveat:

Facet joints are NOT the primary source of back pain in 90% of patients, with prevalence of true facet-mediated pain ranging only 9-42% in degenerative lumbar disease 1, 4, 3, 2. Single diagnostic blocks have limited value; the double-block technique is more reliable but rarely performed 4, 3.

Interventional Treatment Algorithm

Step 1: Medial Branch Blocks (Therapeutic)

• Multiple injections of medial branch blocks provide significant pain relief for up to 44-45 weeks, with each injection providing approximately 15 weeks of relief 1, 3
• No significant difference in outcomes between local anesthetic alone versus local anesthetic with steroids 3
• This is superior to intraarticular facet joint injections, which have limited evidence for long-term effectiveness 1, 2

Step 2: Radiofrequency Ablation (Definitive Treatment)

Conventional radiofrequency ablation of the medial branch nerves is the most effective treatment for confirmed facet-mediated pain, with moderate evidence for both short-term and long-term pain relief 1, 3, 2. This should be performed when:

• Previous diagnostic or therapeutic medial branch blocks provided temporary relief 1, 3
• Patient achieved ≥50% pain relief from diagnostic blocks 3

The procedure uses conventional radiofrequency at 80°C or thermal radiofrequency at 67°C 3.

Level of Evidence:

• Lumbar radiofrequency ablation: Level II evidence with moderate strength of recommendation 2
• Therapeutic lumbar medial branch blocks: Level II evidence with moderate strength of recommendation 2
• Intraarticular facet joint injections: Level IV evidence with weak strength of recommendation (majority showing lack of effectiveness) 2

What NOT to Do

• Do not use chemical denervation with phenol or alcohol in routine care 1
• Do not perform intraarticular facet joint injections as primary therapy - they show moderate evidence of being no more effective than placebo for long-term relief 4, 3, 2
• Do not proceed with facet interventions if radiculopathy is present - epidural steroid injections would be more appropriate 3
• Avoid opioid analgesics during diagnostic procedures (Level II evidence) 2

Alternative Minimally Invasive Approach

For severe facet hypertrophy causing nerve root compression, radiofrequency thermocoagulation applied directly to the hypertrophied facet joint can achieve decompression of the spinal nerve 5. In rare cases of massive unilateral facet hypertrophy causing nerve root entrapment, surgical decompression by partial undercutting facetectomy may be necessary 6.

Procedural Requirements

• Mandatory fluoroscopic or CT guidance for all facet joint interventions (Level I evidence, strong recommendation) 2
• Facet joint interventions are moderate to low risk procedures; antithrombotic therapy may be continued based on overall status 2
• Moderate sedation may be utilized for patient comfort during therapeutic interventions (Level II evidence) 2

Common Pitfall

The most critical error is proceeding with facet interventions without proper patient selection. Remember that only 7.7% of patients selected for facet injection based on clinical criteria achieve complete relief 7, 4, and imaging findings of facet hypertrophy do not confirm facet joints as the pain source 4, 8. Always confirm with diagnostic blocks before proceeding to definitive treatment.