Facet joint pain and the role of neural blockade in its management

Abstract

Chronic spinal pain is a common medical problem with serious financial and social consequences. Among the various structures with potential for producing pain in the spine, facet joints as sources of chronic spinal pain have attracted considerable attention and controversy. Significant progress has been made in precision diagnosis of spinal pain with neural blockade, in the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies. Research into the role of facet joints in spinal pain has shown that cervical facet joints are the cause of chronic neck pain in 54% to 60% of patients, whereas lumbar facet joints cause pain in 15% to 40% of patients with chronic low back pain. Local anesthetic blocks of medial branches have proven to be a reliable diagnostic test; they are target-specific when used appropriately with control blocks, either with two local anesthetics with different durations of action or with the addition of an inactive placebo injection. The literature is replete with reports on uncontrolled studies, case reports, and documentation from a few controlled studies, all of which offer supporting information on the rationale and effectiveness of facet blocks and neurotomy. Facet joint injections and medial branch blocks are considered to be of equal value. Lumbar intra-articular steroid injections have been proven effective to a certain extent, but evidence indicates that cervical intra-articular steroids are ineffective. The role of repeat medial branch blocks is not known. Radiofrequency neurotomy remains the only practical and validated treatment for cervical facet joint pain; however, its role in management of either lumbar or thoracic facet joint pain awaits validation.

Chapter 4 European guidelines for the management of chronic nonspecific low back pain

“…Since there is a false positive rate of 25%-36% with single blocks (Manchikanti 1999, Schwarzer et al 1994, this may have led to the inclusion of patients with pain that did not really derive any benefit from the facet joint.…”

“…The low quality study (Lilius et al 1989) did not use diagnostic blocks to establish the suspected diagnosis of facet pain and injected a volume of 8 ml, which is higher than recommended (Manchikanti 1999, Schwarzer et al 1994.…”

Technical note: the swimmer’s view for cervical facet joint injections

“…Chronic zygapophyseal joint arthropathy is a known cause of neck pain [1,9,10] the common causes being degenerative and post-traumatic. The phenomenon of degenerative facet joint osteoarthritis is considered to be a secondary effect of disc degeneration (cervical spondylosis).…”

“…The most commonly involved levels in cervical spondylosis are C5-C6 and C6-C7 [2,8]. One proposed method of treating facet joint pathology secondary to degenerative and post-traumatic cervical disorders non-surgically is facet joint infiltration [1,5,7,[9][10][11]. Radiologists under computer tomography (CT) guidance or physiatrists, pain management specialists and surgeons using fluoroscopy (C-arm) usually perform facet joint injections.…”

“…The description of indications, contra-indications, complications and controversies in relation to cervical facet joint injections is discussed elsewhere [1,[9][10][11] and is not the objective of this paper.…”