What is the management for lumbar facet osteoarthritis?

Management of Lumbar Facet Osteoarthritis

Begin with core non-pharmacological treatments—exercise, weight loss if overweight, and patient education—as these form the foundation of management for all patients with lumbar facet osteoarthritis, regardless of pain severity. 1

Initial Assessment and Core Treatment Strategy

Assess the impact of facet osteoarthritis on function, quality of life, occupation, mood, relationships, and leisure activities to guide treatment intensity. 1

Mandatory Core Treatments for All Patients

Every patient with symptomatic lumbar facet osteoarthritis should receive:

• Local muscle strengthening exercises and general aerobic fitness training as the primary therapeutic intervention 1
• Weight loss interventions if BMI >25, as excess weight compounds mechanical stress on facet joints 1
• Patient education to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1

Pharmacological Management Algorithm

First-Line: Paracetamol (Acetaminophen)

• Offer regular-dose paracetamol as the initial pharmacological agent for pain relief 1
• This should be used at scheduled intervals rather than as-needed for optimal effect 1

Second-Line: NSAIDs

If paracetamol provides insufficient relief:

• Consider topical NSAIDs before oral NSAIDs to minimize systemic toxicity 1
• When oral NSAIDs are necessary, prescribe either a COX-2 inhibitor (excluding etoricoxib 60mg) or standard NSAID at the lowest effective dose for the shortest duration 1
• Always co-prescribe a proton pump inhibitor with any oral NSAID or COX-2 inhibitor, selecting the lowest-cost option 1
• Monitor gastrointestinal, hepatic, and cardiorenal function based on individual risk factors including age 1

Third-Line: Opioids

• Add opioid analgesics only when paracetamol and NSAIDs provide inadequate relief 1
• Use cautiously given addiction potential and limited long-term efficacy data 1

Adjunctive Non-Pharmacological Interventions

Consider the following based on specific patient needs:

• Manual therapy (manipulation and stretching) for patients with restricted range of motion 1
• Local heat or cold applications for symptomatic relief 1
• TENS (transcutaneous electrical nerve stimulation) as an adjunct for pain control 1
• Shock-absorbing footwear to reduce mechanical loading 1
• Assistive devices (walking aids) for patients with significant functional limitations 1

Interventional Approaches: Critical Limitations

Intra-articular Facet Joint Injections

Intra-articular facet joint injections have limited therapeutic value and should not be routinely offered. 2, 3

• Only 7.7% of patients achieve complete symptom relief after facet injections 2, 3
• Moderate evidence shows facet joint injections with steroids are no more effective than placebo for long-term pain and disability relief 2, 3
• Facet joints are not the primary pain source in 90% of patients with chronic low back pain 2, 3

When Interventional Diagnosis May Be Considered

If facet-mediated pain is strongly suspected after 3+ months of failed conservative therapy:

• Diagnostic confirmation requires controlled comparative local anesthetic blocks (double-injection technique) with ≥80% pain relief threshold 2, 4
• Single facet injections have limited diagnostic value and should be avoided 2
• Mandatory fluoroscopic or CT guidance is required for all facet interventions 2, 4

Radiofrequency Ablation: The Definitive Interventional Option

If diagnostic blocks confirm facet-mediated pain with ≥80% relief, radiofrequency ablation of medial branch nerves is the gold standard treatment. 2, 4

• Moderate evidence supports both short-term and long-term pain relief with radiofrequency ablation 2, 4
• 66% of patients achieve successful outcomes versus 38% in control groups 5
• This should be considered before repeated diagnostic injections at the same levels 5

Important Clinical Caveats

Avoid These Common Pitfalls:

• Do not use glucosamine or chondroitin products—they are not recommended 1
• Do not perform electroacupuncture—it should not be used 1
• Do not repeat facet injections at the same levels if initial injections failed—additional sets lack evidence for improving outcomes 5
• Do not offer facet interventions to patients with radiculopathy—epidural steroid injections are more appropriate for radicular symptoms 2

Red Flags Suggesting Alternative Pain Generators:

• Pain aggravated by Valsalva maneuvers (coughing, sneezing, straining) suggests discogenic pain rather than facet-mediated pain 3
• Radicular symptoms with imaging showing disc pathology warrant consideration of epidural steroid injections instead 2
• Pain radiating to hip and buttocks should prompt evaluation for sacroiliac joint pathology 2

Treatment Escalation Pathway

Follow this algorithmic approach:

1. Initiate core treatments (exercise, weight loss, education) for all patients 1
2. Add paracetamol if symptomatic relief needed 1
3. Escalate to topical then oral NSAIDs (with PPI) if inadequate response 1
4. Consider opioids only after NSAID failure 1
5. Add adjunctive therapies (manual therapy, TENS, heat/cold) based on specific symptoms 1
6. If 3+ months of comprehensive conservative therapy fails and facet-mediated pain is suspected, proceed with diagnostic double-block technique 2, 4
7. If diagnostic blocks confirm facet pain with ≥80% relief, proceed directly to radiofrequency ablation rather than therapeutic injections 2, 4

Avoid the temptation to proceed directly to interventional procedures—the evidence strongly supports exhausting conservative measures first, as interventional approaches have limited therapeutic benefit and significant false-positive rates. 2, 3, 5