Is facet neurotomy medically indicated for a patient with lumbar spondylosis without myelopathy or radiculopathy, who has not responded to prior facet neurotomy and has tried oxyCODONE (oxycodone) and Lidocaine (lidocaine)?

Facet Neurotomy is NOT Medically Indicated Without Prior Documented Response to Diagnostic Facet Blocks

This patient does not meet the fundamental prerequisite for facet neurotomy: documented successful response to prior diagnostic facet joint nerve blocks or prior facet neurotomy. The MCG criteria explicitly require "prior history of successful facet neurotomy" for repeat procedures, which is documented as "NOT DOCUMENTED" in this case 1.

Critical Missing Documentation

The patient lacks three essential elements required by evidence-based guidelines:

• No documented response to diagnostic facet blocks: Guidelines require controlled comparative local anesthetic blocks with ≥80% pain relief to confirm facet-mediated pain before proceeding to neurotomy 1, 2
• No prior successful neurotomy: The MCG criteria state repeat facet neurotomy requires "prior history of successful facet neurotomy at the same spinal level(s)" - this is explicitly not documented 1
• No coagulopathy status documented: Required safety documentation is missing 1

Why Diagnostic Confirmation is Mandatory

Facet joints are NOT the primary source of back pain in 90% of patients, with only 7.7% achieving complete relief from facet interventions 1. This extraordinarily low success rate makes proper patient selection through diagnostic blocks absolutely critical before proceeding to irreversible neurotomy.

The diagnostic algorithm requires:

• Double-injection technique: Two separate diagnostic blocks using local anesthetics with different durations of action 1, 2
• ≥80% pain relief threshold: This stringent criterion is necessary because lower thresholds result in unacceptably high false-positive rates (27-47% in lumbar spine) 2
• Concordant pain relief: Pain relief duration must correspond to the anesthetic used 1

Evidence Against Proceeding Without Diagnostic Confirmation

The American College of Neurosurgery provides Grade B recommendation AGAINST intra-articular facet injections for chronic low back pain from degenerative lumbar disease, with Level II evidence showing no long-term benefit 1. More importantly:

• Moderate evidence demonstrates facet joint injections with steroids are no more effective than placebo for pain relief and disability improvement 3, 1, 4
• Multiple studies have failed to demonstrate effectiveness of facet joint interventions as therapeutic treatment for chronic low back pain 1
• The prevalence of true facet-mediated pain in degenerative lumbar disease is only 9-42% of patients 1, 5

Alternative Pain Generators Must Be Excluded

The imaging shows "multilevel degenerative spondyloarthropathy" and "spinal canal stenosis at multiple levels," which suggests multiple potential pain generators:

• Discogenic pain: MRI findings of degenerative disc disease may indicate annular tears or internal disc disruption as the primary pain source 1
• Spinal stenosis: Canal stenosis can cause axial back pain independent of facet pathology 1
• Mechanical instability: Spondylosis with multilevel degeneration may cause mechanical pain rather than facet-mediated pain 4

Guidelines explicitly require that "imaging studies and physical examination have ruled out other causes of spinal pain" before facet interventions are considered medically necessary 1.

The Correct Diagnostic Pathway

If facet-mediated pain is truly suspected, the evidence-based approach is:

1. Perform diagnostic medial branch blocks (not intraarticular injections) using controlled comparative local anesthetic technique with ≥80% pain relief threshold 1, 2
2. If positive response to diagnostic blocks: Proceed directly to radiofrequency ablation of medial branch nerves, which is the "gold standard" treatment with moderate evidence for both short-term and long-term pain relief 1, 5, 2
3. If successful radiofrequency ablation with eventual pain recurrence: Repeat radiofrequency ablation has similar success rates (85-91%) and duration of relief (approximately 10 months) as initial procedures 6

Why Radiofrequency Ablation is Superior to Repeated Injections

Conventional radiofrequency ablation of the medial branch nerves is the most effective treatment for confirmed facet-mediated pain, not repeated facet joint injections 5, 2. The evidence shows:

• Level II evidence with moderate strength of recommendation for lumbar radiofrequency ablation, with 11 relevant RCTs showing long-term improvement 2
• Repeated radiofrequency procedures maintain efficacy: Success rates of 85-91% with average pain relief duration of 10 months per procedure 6
• Medial branch blocks show better therapeutic efficacy than intraarticular facet injections, with average 15 weeks pain relief per injection 1, 5

Common Pitfall: Proceeding Without Diagnostic Confirmation

The single most critical error in facet intervention is performing therapeutic procedures without proper diagnostic confirmation. The diagnostic value of facet blocks does not translate to long-term therapeutic benefit from intraarticular injections 1. This patient has already tried "back injections" (presumably including facet interventions) without documented benefit, which strongly suggests facet joints are not the primary pain generator.

Clinical Bottom Line

Do not proceed with facet neurotomy (CPT 64635,64636) without documented positive response to diagnostic medial branch blocks showing ≥80% pain relief 1, 2. The current request fails to meet evidence-based medical necessity criteria because:

• No documented diagnostic confirmation of facet-mediated pain 1, 2
• No prior successful neurotomy to justify repeat procedure 1
• Multiple alternative pain generators not adequately excluded 1, 4
• Prior "back injections" without documented benefit suggests facet joints are not the primary source 1

The appropriate next step is diagnostic medial branch blocks with controlled comparative local anesthetic technique, not proceeding directly to neurotomy 1, 2.