Bilateral C4-5 Facet Joint Injections Are Not Medically Indicated After Successful Radiofrequency Ablation
The patient should not receive bilateral C4-5 facet joint injections at this time, as she has already completed the standard diagnostic and therapeutic pathway with radiofrequency ablation (RFA) at these levels, and the evidence does not support reverting to facet injections after RFA has been performed. 1, 2
Why Facet Injections Are Not Appropriate in This Case
The Standard Treatment Algorithm Has Already Been Completed
The established treatment pathway for facet-mediated pain follows a specific sequence: diagnostic medial branch blocks → radiofrequency ablation for longer-term relief (typically >6 months) → repeat RFA if pain recurs after the expected duration of relief 1, 2. This patient has already:
- Undergone diagnostic medial branch blocks with >90% relief 3
- Completed bilateral C3/4 and C4/5 RFA on the documented date with 50-60% relief 1
- The RFA was performed relatively recently, and reverting to facet injections contradicts the evidence-based treatment algorithm 2
The American Society of Anesthesiologists explicitly recommends that conventional radiofrequency ablation of the medial branch nerves should be performed for neck pain when previous diagnostic or therapeutic injections have provided temporary relief—not the reverse. 1 Once RFA is performed, the next step if pain recurs is typically repeat RFA, not regression to intra-articular injections 2, 4.
Facet Injections Have Limited Therapeutic Value
The evidence for therapeutic facet joint injections is weak:
- For cervical intra-articular facet joint injections, the evidence is limited for both short- and long-term pain relief 5
- Multiple studies demonstrate that facet joint injections with steroids are no more effective than placebo injections for long-term relief of pain and disability 2
- At present, there is no evidence to support cervical intra-articular corticosteroid injection, and when applied, this should be done in the context of a study 6
The Imaging Findings Suggest Alternative Pain Generators
The MRI demonstrates severe spinal stenosis with cord compression at C5/6 > C6/7, and severe right-sided lateral foraminal stenosis at C4/5 through C6/7 1. These findings suggest that pain generators may include neural compression rather than isolated facet joint pathology 2.
However, the clinical examination is critical here: The patient denies radicular symptoms (numbness, tingling, pain traveling into upper extremities), has a negative Spurling test, and positive facet loading on exam 3. This clinical picture does support facet-mediated pain despite the imaging findings 3.
What Should Be Done Instead
Consider Repeat Radiofrequency Ablation
If the patient's neck pain has returned or worsened after the initial RFA provided 50-60% relief, the appropriate next step is repeat radiofrequency ablation of the medial branch nerves, not facet joint injections 1, 4. The evidence for radiofrequency neurotomy of cervical medial branch nerves is moderate for both short- and long-term pain relief 5.
Therapeutic Medial Branch Blocks as a Bridge
If repeat RFA is not immediately feasible or if the patient needs interim relief, therapeutic repetitive medial branch blocks with or without corticosteroid added to local anesthetic can provide short-term pain relief 6. Each medial branch block injection provides on average 15 weeks of pain relief 2, 4. This approach has better evidence than intra-articular facet injections 2.
Address the Sacroiliac Joint Pain First
The patient has significant right-sided low back and buttock pain with positive right FABER, Fortin finger sign, SI shear, and SI compression tests. The planned right sacroiliac joint injection is appropriate and should be completed first 2. This may significantly improve her overall pain burden and clarify whether residual neck pain warrants further cervical intervention.
Consider Trigger Point Injections for Myofascial Component
The patient previously experienced excellent pain relief with trigger point injections (TPI), and the exam notes exquisite tenderness along cervical paraspinal musculature 3. Repeating TPI for the myofascial pain component is reasonable and supported by her prior response 3.
Important Clinical Caveats
The Discrepancy Between Diagnostic Block Response and RFA Response
The patient had >90% relief with diagnostic medial branch blocks but only 50-60% relief with RFA 3. This discrepancy is clinically significant and suggests:
- The RFA may have been technically suboptimal
- There may be additional pain generators beyond the facet joints
- The patient may benefit from repeat RFA with meticulous technique rather than reverting to injections 4
Avoid Epidural Steroid Injections
The patient had a prior adverse reaction to cervical epidural steroid injection with increased pain 3. This should be avoided in future treatment planning 3.
The Severe Stenosis Requires Monitoring
While the patient currently denies myelopathic symptoms, the MRI shows severe spinal stenosis with cord compression at C5/6 > C6/7, though currently without cord edema or myelomalacia 1. Close monitoring for development of myelopathy is essential, as this would change the treatment paradigm entirely and potentially require surgical evaluation 1.
Summary of Recommendation
Do not proceed with bilateral C4-5 facet joint injections. Instead, consider: (1) repeat radiofrequency ablation of cervical medial branch nerves as the definitive treatment 1, 4, (2) therapeutic medial branch blocks as a bridge if needed 2, 6, (3) complete the planned right SI joint injection first 2, and (4) repeat trigger point injections for myofascial pain 3. The evidence does not support reverting to facet injections after RFA has been performed in the standard treatment algorithm 1, 2.