What is the best management approach for an older patient with a history of facet arthropathy and anterior subluxation of L3-5?

Management of Anterior Subluxation of L3-5 Secondary to Facet Arthropathy

For an older patient with anterior subluxation of L3-5 due to facet arthropathy, initial management should consist of conservative therapy with physical therapy focusing on extension exercises and NSAIDs for at least 6 weeks, followed by consideration of surgical decompression and fusion if neurological symptoms or instability persist despite conservative treatment. 1, 2

Initial Conservative Management

• Begin with a structured 6-week conservative treatment program including physical therapy with extension-based exercises and NSAIDs before considering any interventional procedures 3, 4
• Conservative management is the recommended first-line approach for facet-mediated pain and degenerative spondylolisthesis 3
• NSAIDs should be used as first-line pharmacologic treatment, with gastroprotective agents or COX-2 inhibitors for patients at increased GI risk 5

Diagnostic Evaluation for Facet-Mediated Pain

• If conservative therapy fails and facet-mediated pain is suspected, diagnostic medial branch blocks with >50% pain relief threshold can confirm the diagnosis 3
• The double-block technique is more reliable than single injections for diagnostic purposes 4
• Important caveat: Facet joints are the primary pain source in only 9-42% of patients with degenerative lumbar disease, so careful patient selection is critical 3, 4

Interventional Options for Facet-Mediated Pain

If facet joints are confirmed as the pain generator:

• Conventional radiofrequency ablation of medial branch nerves is the most effective treatment for confirmed facet-mediated pain, providing moderate evidence for both short-term and long-term relief 3
• Multiple medial branch blocks may provide significant pain relief for up to 44-45 weeks, with each injection providing approximately 15 weeks of relief 3
• Intraarticular facet joint injections have limited evidence for long-term effectiveness and should not be considered first-line 3, 4

Critical pitfall: Chemical denervation using phenol or alcohol should not be used routinely 3

Surgical Indications and Approach

Surgical intervention with anterior cervical decompression and fusion should be considered when:

• Neurological symptoms persist despite 6+ weeks of conservative treatment 5, 2
• Evidence of spinal instability, spinal cord or nerve root compression, or significant neurological deficit exists 5
• Progressive myelopathy develops 2

Surgical Technique and Outcomes

• Anterior cervical decompression and arthrodesis with structural graft is the recommended surgical approach for degenerative spondylolisthesis with facet arthropathy 2
• This commonly involves corpectomy of the caudal vertebrae, with excellent union rates (92%) and significant neurological improvement (average 1.5 Nurick grades) 2
• Success rates for relief of symptoms range from 80-90% with anterior approaches 5, 2
• Additional posterior facet fusion may be required in select cases with severe instability 2

Important Surgical Considerations

• Common to all cases of degenerative spondylolisthesis is facet arthropathy and neurologic compression 2
• The C4-C5 level is most frequently involved (43% of cases), though your patient has L3-5 involvement 2
• Two radiographically distinct types of listhesis exist based on disc degeneration and adjacent level spondylosis, with greater prevalence of myelopathy and instability in listheses adjacent to spondylotic levels 2

Alternative Surgical Consideration

• Lumbar facet joint stabilization techniques (including facet screws, intra-articular spacers, or facet arthroplasty) may be considered as alternatives to traditional interbody fusion, though evidence is limited to smaller series 6
• These techniques have shown effectiveness in managing lumbar spinal degenerative disease with preservation of disk height and solid fusion rates, though larger studies are needed 6

Key Clinical Pitfalls

• Do not proceed with facet injections without documented 6-week conservative treatment failure 4
• Pain aggravated by Valsalva maneuvers (coughing, sneezing, straining) suggests discogenic rather than facet-mediated pain 4
• Facet joint injections have failed to demonstrate effectiveness as therapeutic interventions in multiple studies, with only 7.7% achieving complete relief 4
• If initial facet interventions fail (patient reports "same pain as before"), this indicates facet joints are not the primary pain generator and alternative diagnoses should be pursued 4