A Systematic Review and Best Evidence Synthesis of Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain

Abstract

Background: The therapeutic spinal facet joint interventions generally used for the treatment of axial spinal pain of facet joint origin are intraarticular facet joint injections, facet joint nerve blocks, and radiofrequency neurotomy. Despite interventional procedures being common as treatment strategies for facet joint pathology, there is a paucity of literature investigating these therapeutic approaches. Systematic reviews assessing the effectiveness of various therapeutic facet joint interventions have shown there to be variable evidence based on the region and the modality of treatment utilized. Overall, the evidence ranges from limited to moderate. Objective: To evaluate and update the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain. Study Design: A systematic review of therapeutic lumbar, cervical, and thoracic facet joint interventions for the treatment of chronic spinal pain. Methods: The available literature on lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain was reviewed. The quality assessment criteria utilized were the Cochrane Musculoskeletal Review Group criteria and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM – QRB) for randomized trials and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM – QRBNR) for observational studies. The level of evidence was classified at 5 levels from Level I to Level V. Data sources included relevant literature identified through searches on PubMed and EMBASE from 1966 through March 2015, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake consumption. Results: A total of 21 randomized controlled trials meeting appropriate inclusion criteria were assessed in this evaluation. A total of 5 observational studies were assessed. In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In the cervical spine, for long-term improvement, there is Level II evidence for cervical radiofrequency neurotomy and cervical facet joint nerve blocks, and Level IV evidence for cervical intraarticular injections. In the thoracic spine there is Level II evidence for thoracic facet joint nerve blocks and Level IV evidence for radiofrequency neurotomy for long-term improvement. Limitations: The limitations of this systematic review include an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injections. Conclusion: Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy. Key Words: Spinal pain, chronic low back pain, chronic neck pain, chronic thoracic pain, intraarticular facet joint blocks, facet joint nerve blocks, conventional radiofrequency neurotomy, pulsed radiofrequency neurolysis

Efficacy of Radiofrequency Neurotomy in Chronic Low Back Pain: A Systematic Review and Meta-Analysis

“…Overall, the results agree with this publication. The results of two additional systematic reviews by the same authors 39 , 40 were also similar to the present study.…”

“…Currently, intraarticular injections, facet joint nerve blocks, and radiofrequency neurotomy are used for therapeutic management. 3 , 39 , 40 However, the evidence continues to be variable with discordant opinions in systematic reviews. 3 , 39 , 40 , 48–50 …”

“… 3 , 39 , 40 However, the evidence continues to be variable with discordant opinions in systematic reviews. 3 , 39 , 40 , 48–50 …”

“…3,4,[8][9][10][11][12][18][19][20][21][22][28][29][30][31][32][33][34][35][36][37] Advanced diagnostic techniques like imaging and controlled diagnostic blocks point to multiple structures including facet joints, sacroiliac joints, intervertebral discs, and nerve roots as a possible origin of chronic low back pain. 3,[38][39][40][41][42][43][44][45][46][47] The diagnosis of a lumbar facet joint as the cause of chronic pain cannot be accurately established by history, physical, or imaging alone. 3,[38][39][40][41][42][43][44][45][46][47] The diagnosis by controlled diagnostic blocks has been shown to be reasonably accurate.…”

“…3,[38][39][40][41][42][43][44][45][46][47] The diagnosis of a lumbar facet joint as the cause of chronic pain cannot be accurately established by history, physical, or imaging alone. 3,[38][39][40][41][42][43][44][45][46][47] The diagnosis by controlled diagnostic blocks has been shown to be reasonably accurate. 3,[38][39][40]46,47 However, the prevalence of "pure" lumbar zygapophysial joint pain in patients with chronic low back pain with placebo controlled diagnostic blocks and 100% pain relief as the criterion standard has been shown to be 15%, with acute pain model.…”