Is a therapeutic facet joint injection suitable for a patient with chronic neck and low back pain and potential facet-mediated pain?

Therapeutic Facet Joint Injections Are Not Medically Indicated After Failed Radiofrequency Ablation

Bilateral C4-5 therapeutic facet joint injections should not be performed in this patient because the standard treatment pathway—diagnostic blocks followed by radiofrequency ablation—has already been completed, and therapeutic intraarticular facet injections lack evidence for efficacy and should only be performed in research or audit contexts. 1

The Standard Treatment Algorithm Has Been Completed

The evidence-based pathway for facet-mediated pain follows a specific sequence:

• Diagnostic medial branch blocks are recommended to diagnose pain of facet joint origin, followed by radiofrequency denervation when appropriate 1
• This patient already underwent two diagnostic medial branch blocks with >90% relief, confirming facet-mediated pain 2
• The patient then received bilateral C3/4 and C4/5 radiofrequency ablation on the documented date with 50-60% relief 2
• The British Pain Society consensus states that therapeutic facet joint intra-articular injections should only be done in the context of either special arrangements for clinical governance and clinical audit or research 1

Why Therapeutic Facet Injections Are Not Appropriate Here

Limited Evidence for Efficacy

• Moderate evidence indicates that facet joint injections with steroids are no more effective than placebo injections for relief of pain and disability 3
• A systematic review found that for cervical intraarticular facet joint injections, the evidence is limited for short- and long-term pain relief 4
• Studies show only 7.7% of patients achieve complete relief with facet injections 2, 3

The Correct Next Step After Failed RFA

• When radiofrequency ablation provides inadequate relief, the appropriate next step is repeat radiofrequency ablation (not therapeutic facet injections), as RFA outcomes have improved with better patient selection and technique 1
• Medial branch blocks show better evidence for therapeutic efficacy compared to intraarticular facet joint injections, with double-blinded RCTs showing significant pain relief for up to 44-45 weeks, with each injection providing on average 15 weeks of relief 3
• If repeat therapeutic intervention is needed, therapeutic medial branch blocks (not intraarticular injections) are the evidence-based choice 5, 6

Alternative Pain Generators Must Be Addressed

The clinical picture suggests multiple pain generators that require separate evaluation:

Cervical Radiculopathy and Spinal Stenosis

• 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 (documented in clinical information)
• Facet joint injections are not medically necessary for patients with radiculopathy, as guidelines specifically state that diagnostic facet joint injections are considered insufficient evidence or unproven for neck and back pain with untreated radiculopathy 3
• The imaging findings suggest that pain generators may include neural compression rather than isolated facet joint pathology 7

Sacroiliac Joint Pain

• Physical examination shows positive right FABER, positive right Fortin finger sign, positive right SI shear, and positive right SI compression (documented in clinical information)
• The treatment plan appropriately includes right sacroiliac joint injection as the next step 7

Critical Pitfalls to Avoid

• Performing multiple procedures simultaneously makes it impossible to determine which intervention provided benefit, compromising future treatment planning 7
• Multiple simultaneous injections increase procedural risks, medication exposure, and costs without evidence of superior outcomes 7
• Interventions should target the identified pain generator, and this patient's imaging shows significant neural compression that may be the primary pain source 7

The Recommended Treatment Pathway

Given the failed RFA and complex pain presentation:

1. Proceed with the planned right sacroiliac joint injection to address the documented SI joint pathology 7
2. Consider repeat cervical medial branch blocks (not intraarticular injections) if facet-mediated pain remains the primary complaint after addressing SI joint pain 5, 6
3. Evaluate for surgical consultation given severe spinal stenosis with cord compression and foraminal stenosis 1
4. If repeat facet intervention is needed, consider repeat radiofrequency ablation with optimized technique rather than therapeutic facet injections 1

The physician's addendum requesting therapeutic facet injections contradicts established guidelines that reserve such injections for research contexts only, and ignores the completed diagnostic and therapeutic pathway that has already included appropriate RFA treatment 1.