New Guidelines Address Facet Joint Interventions for Chronic Spinal Pain

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Studies using controlled nerve diagnostic blocks have shown that facet joints are potential sources of pain in the spine. However, the indications for interventions directed at spinal facet joints have been controversial.

The American Society of Interventional Pain Physicians (ASIPP) has developed specific guidelines about the efficacy and safety of diagnostic and therapeutic interventional techniques for managing chronic facet joint pain. Joshua A. Hirsch, MD, vice-chair and service line chief of Neurointerventional Radiology and chief of the Neurosurgical Spine Service at Massachusetts General Hospital, is the senior author of the guidelines, which are published in Pain Physician.

This summary gives highlights of the recommendations, which are based on a detailed review of current medical literature. Level I evidence was defined as multiple high-quality randomized controlled trials or diagnostic accuracy studies and indicates a strong recommendation. Level II evidence denotes a moderately strong recommendation. Level III and IV evidence is considered fair or limited, respectively. Level V evidence reflects the opinion or consensus of a large group of clinicians and/or scientists.

Non-interventional Diagnosis

• Fluoroscopic or CT guidance: level I (ASIPP calls this guidance mandatory for all facet joint interventions)
• Use of single photon emission CT to identify painful lumbar facet joints prior to diagnostic nerve blocks: level III (but cost-effectiveness not established, so ASIPP made this a weak recommendation)
• Use of scintography, MRI or CT to identify painful facet joints: level V (weak recommendation)
• Diagnosis of facet joint pain with physical examination alone: level IV (weak recommendation)

Diagnostic Interventions

Facet joint nerve blocks:

• Lumbar: level I–II
• Cervical: level II
• Thoracic: level II

Select patients for nerve blocks at least three months after pain onset and failure of conservative management if they have axial pain, tenderness over the facet joints, reduced range of motion, pain reduction with rest and absence of radicular pattern (level II).

Factors that influence diagnostic accuracy:

• Do not use monitored anesthesia for diagnostic or therapeutic intervention except in extremely rare circumstances (level I)
• Provide sedation and analgesia (level II)
• Avoid opioids (level II)
• Benzodiazepines are permissible (level II)

Therapeutic Interventions

Lumbar spine:

• Radiofrequency neurotomy: level II for long-term relief
• Facet joint nerve blocks: level II for short- and long-term relief
• Intraarticular injections without local anesthetic injection: level III for short-term relief; level IV for long-term relief (weak recommendations)

Cervical spine:

• Radiofrequency neurotomy: level II for long-term relief
• Nerve blocks: level II for short-term and long-term relief
• Injections: level III for short-term relief; level V for long-term relief (weak recommendations)

Thoracic spine:

• Radiofrequency neurotomy: level III (moderate to weak recommendation)
• Nerve blocks: level II for short- and long-term relief
• Injections: level III (moderate to weak recommendation)

The guidelines also include a cost-utility analysis, discussion of complications and side effects, and algorithms for diagnosis and therapy of chronic lumbar, neck and thoracic pain.

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