What is the recommended treatment for lumbar facet arthropathy?

Treatment of Lumbar Facet Arthropathy

For lumbar facet arthropathy, begin with conservative management including physical therapy with extension exercises and NSAIDs, followed by diagnostic medial branch blocks to confirm facet-mediated pain, and then proceed to radiofrequency ablation for definitive treatment in confirmed cases. 1

Initial Conservative Management

• Start with physical therapy focusing on extension exercises combined with NSAIDs as first-line treatment before considering any interventional procedures. 1
• Conservative management should be attempted for at least 3 months before proceeding to interventional diagnosis. 2
• This approach is supported by moderate-quality evidence and represents the standard of care for initial management. 1

Diagnostic Confirmation

Diagnostic medial branch blocks are essential to confirm facet-mediated pain before proceeding to definitive treatment:

• Use controlled comparative local anesthetic blocks with a threshold of >50% pain relief to confirm facet joint pain. 1
• The prevalence of true facet-mediated pain ranges from 27-40% in patients with chronic low back pain, with false-positive rates of 27-47%. 2
• Level II evidence with moderate strength of recommendation supports diagnostic lumbar facet joint nerve blocks using ≥80% pain relief as the criterion standard. 2
• Physical examination alone has Level IV evidence and cannot reliably diagnose facet joint pain without confirmatory blocks. 2

Definitive Treatment: Radiofrequency Ablation

Radiofrequency ablation of the medial branch nerves is the most effective treatment for confirmed facet-mediated pain:

• Level II evidence with moderate strength of recommendation supports radiofrequency ablation as the gold standard for treating facetogenic pain. 2
• Success rates show 85% of cervical and 71% of lumbar cases achieve at least 50% improvement in symptoms. 3
• Duration of benefit: excellent responders (>70% improvement) average 7.9 months of relief, while good responders (50-70% improvement) average 6.8 months. 3
• Radiofrequency ablation demonstrates superior outcomes (66% success) compared to control groups (38%), with decreased narcotic requirements. 4

Alternative: Therapeutic Medial Branch Blocks

For patients who respond well to diagnostic blocks but are not candidates for radiofrequency ablation:

• Multiple therapeutic medial branch blocks with local anesthetics can provide significant pain relief for up to 44-45 weeks, with each injection providing approximately 15 weeks of relief. 1
• Level II evidence with moderate strength of recommendation supports therapeutic lumbar facet joint nerve blocks. 2
• Three relevant RCTs demonstrate long-term improvement with this approach. 2

What NOT to Do

Avoid intraarticular facet joint injections as primary treatment:

• Level IV evidence with weak strength of recommendation for lumbar intraarticular injections. 2
• Nine RCTs show majority lack effectiveness, particularly when local anesthetic is not used. 2
• Only 7.7% of patients achieve complete pain relief from facet injections, and facet joints are not the primary pain source in 90% of patients. 1
• Additional sets of facet injections at the same levels are considered experimental and lack proven value for improving morbidity, mortality, or quality of life. 4

Avoid chemical denervation:

• Phenol or alcohol should not be used in routine care of patients with facet-mediated pain. 1

Avoid high-velocity spinal manipulation:

• Strong recommendation against spinal manipulation in patients with spinal fusion or advanced osteoporosis due to risk of fractures, spinal cord injury, and paraplegia. 5

Procedural Requirements

All facet joint interventions require imaging guidance:

• Level I evidence with strong strength of recommendation for mandatory fluoroscopic or CT guidance. 2
• Procedures are considered moderate to low risk, so antithrombotic therapy may be continued based on overall patient status. 2
• Moderate sedation may be utilized for therapeutic procedures, but opioid analgesics should be avoided during diagnostic blocks (Level II evidence). 2

Clinical Pearls

• Look for pain aggravated by extension, failed conservative treatment for >3 months, and imaging showing no other obvious cause before proceeding to interventional diagnosis. 6
• Facet-mediated pain accounts for 5-15% of chronic axial low back pain cases depending on diagnostic criteria. 7
• Radiofrequency thermocoagulation is safe with minimal side effects (short-term neuritis in <2% of cases, resolving within weeks). 3, 8
• For patients achieving ≥50% pain relief for at least 2 months after initial diagnostic block, this suggests benefit and warrants consideration of radiofrequency ablation rather than repeat injections. 1