What is the best course of treatment for a patient with chronic lumbar cytogenic pain, who has failed physical therapy, chiropractic care, and steroid injections, including transforaminal epidural steroid injections (TFESI), with extension-based pain, positive facet loading tenderness, and arthritis on MRI at multiple levels, without radicular symptoms or red flag symptoms?

Assessment and Plan: Lumbar Facetogenic Pain

Assessment

This patient has chronic lumbar facetogenic pain that has failed conservative management and is now a candidate for radiofrequency ablation of the lumbar medial branches. 1

Clinical Presentation

• Extension-based axial low back pain with positive facet loading tenderness over multiple levels, consistent with facet-mediated pain 1, 2
• MRI demonstrates multilevel facet arthropathy without nerve root compression or disc herniation causing radicular symptoms 1
• No radicular symptoms (pain does not radiate below the knee, no numbness/tingling in dermatomal distribution, negative straight leg raise) 3
• No red flag symptoms (no fever, weight loss, bowel/bladder dysfunction, progressive neurologic deficit) 3

Failed Conservative Treatments

• Physical therapy - completed without sustained benefit 1, 3
• Chiropractic care - failed 1
• Muscle relaxants - ineffective 1
• Epidural steroid injections - inappropriate for this presentation as patient lacks radicular symptoms; these are only indicated for nerve root compression with radiculopathy 3, 1
• Transforaminal epidural steroid injections (TFESI) - also inappropriate without radicular pain below the knee 3

Plan

Diagnostic Facet Medial Branch Blocks

The next step is diagnostic medial branch blocks using the double-injection technique with >80% pain relief threshold to confirm facetogenic pain before proceeding to radiofrequency ablation. 1

• Perform fluoroscopically-guided diagnostic blocks of the medial branches at the symptomatic levels identified on examination 1
• Use double-injection technique: first injection with short-acting anesthetic (lidocaine), second confirmatory injection with long-acting anesthetic (bupivacaine) on a separate occasion 1
• Patient must achieve >80% pain relief with both injections, with duration consistent with the anesthetic used, to be considered a true positive 1
• Document pain relief using Visual Analog Scale (VAS) before and after each injection 1

Radiofrequency Ablation (If Diagnostic Blocks Positive)

If diagnostic blocks demonstrate >80% pain relief with both injections, proceed with radiofrequency ablation of the lumbar medial branches, which provides moderate evidence (Level II) for short-term pain relief of 3-6 months. 1

• RF ablation is more effective than placebo for treatment of facet-mediated low back pain in patients with positive diagnostic blocks (Class I evidence) 1
• Perform fluoroscopically-guided radiofrequency denervation of the medial branches innervating the painful facet joints 1, 4
• Expected duration of benefit is 3-6 months based on moderate-quality evidence 1
• Repeat RF ablation can be performed if initial procedure provides significant benefit (>50% pain relief for >2 months) 3

Alternative Consideration: Basivertebral Nerve Ablation

If patient fails to respond to medial branch blocks or has recurrent pain after RF ablation, consider basivertebral nerve ablation, which has a strong recommendation from the 2025 BMJ guideline for chronic axial back pain. 5, 6

• The 2025 BMJ guideline provides a strong recommendation FOR basivertebral nerve ablation for chronic back pain, unlike most other interventional procedures which received strong recommendations AGAINST 5, 6
• The American Society of Pain and Neuroscience (ASPN) issues a strong recommendation with Level A evidence for BVN ablation in appropriately selected patients 6
• Patient must have ≥6 months of failed conservative management including physical therapy, NSAIDs, and activity modification 6
• Diagnosis requires clinical presentation, MRI findings showing vertebral endplate changes (Modic changes), and exclusion of other pain generators 6

What NOT to Do

Do not repeat epidural steroid injections or TFESI, as these are explicitly NOT indicated for non-radicular axial back pain from facet arthropathy. 3, 1

• The American Academy of Neurology explicitly recommends AGAINST epidural steroid injections for non-radicular low back pain 3
• The 2025 BMJ guideline provides a strong recommendation AGAINST epidural injections for chronic axial spine pain without radiculopathy 3
• Moderate evidence shows facet joint injections with steroids are no more effective than placebo for pain relief and disability 1
• Intraarticular facet steroid injections have no role as a treatment modality based on systematic review of low-quality evidence 1

Multimodal Pain Management

• Continue NSAIDs or acetaminophen for baseline pain control 3
• Maintain home exercise program focusing on core strengthening and flexibility 3
• Consider referral to pain psychology if chronic pain has led to depression, anxiety, or catastrophizing 3
• Avoid chronic opioid therapy given lack of evidence for long-term benefit in chronic non-cancer pain 1

Common Pitfalls to Avoid

• Do not proceed directly to RF ablation without confirmatory diagnostic blocks - the false-positive rate is high, and guidelines require >80% relief with double-injection technique 1
• Do not confuse facetogenic pain with radicular pain - this patient's lack of leg pain below the knee and negative neurologic examination excludes radiculopathy 3
• Do not repeat injections without documented objective benefit - repeat procedures require at least 50% pain relief lasting at least 2 months from prior injection 3
• Do not ignore sacroiliac joint as alternative pain generator - if facet blocks are negative, consider SI joint evaluation 3