Facet Joint Interventions in the Management of Chronic Spinal Pain

Publication Date: May 1, 2020

Evidence and Recommendations

Non-interventional diagnosis

The level of evidence is II in selecting patients for facet joint nerve blocks at least 3 months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. (II, Strong)
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The level of evidence is IV for accurate diagnosis of facet joint pain with physical examination based on symptoms and signs, with weak strength of recommendation. (IV, Weak)
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Imaging

The level of evidence is I with strong strength of recommendation, for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions. (I, Strong)
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The level of evidence is III with weak strength of recommendation for single photon emission computed tomography (SPECT) . (III, Weak)
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The level of evidence is V with weak strength of recommendation for scintography, magnetic resonance imaging (MRI), and computed tomography (CT). (V, Weak)
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Interventional Diagnosis

Lumbar Spine

The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. (II, Strong)
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Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of ≥80% were included. (, )
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The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with ≥80% pain relief. (, )
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Cervical Spine

  • Ten relevant diagnostic accuracy studies, 9 of the 10 studies with either controlled comparative local anesthetic blocks or placebo controls with concordant pain relief with a criterion standard of ≥ 80% were included.
  • The prevalence and false-positive rates ranged from 29% to 60% and of 27% to 63%, with high variability.
(II, Moderate)
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Thoracic Spine

  • Three relevant diagnostic accuracy studies, with controlled comparative local anesthetic blocks, with concordant pain relief, with a criterion standard of ≥80% were included.
  • The prevalence varied from 34% to 48%, whereas false-positive rates varied from 42% to 58%.
(II, Moderate)
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Therapeutic Facet Joint Interventions

Lumbar Spine

The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with 2 negative studies and 4 studies with long-term improvement. (II, Moderate)
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The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of 3 relevant randomized controlled trials, with long-term improvement. (II, Moderate)
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The level of evidence is IV with weak strength of recommendation for lumbar facet joint intraarticular injections with inclusion of 9 relevant randomized controlled trials, with majority of them showing lack of effectiveness without the use of local anesthetic. (IV, Weak)
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Cervical Spine

The level of evidence is II with moderate strength of recommendation for cervical radiofrequency ablation with inclusion of one randomized controlled trial with positive results and 2 observational studies with long-term improvement. (II, Moderate)
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The level of evidence is II with moderate strength of recommendation for therapeutic cervical facet joint nerve blocks with inclusion of one relevant randomized controlled trial and 3 observational studies, with long-term improvement. (II, Moderate)
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The level of evidence is V with weak strength of recommendation for cervical intraarticular facet joint injections with inclusion of 3 relevant randomized controlled trials, with 2 observational studies, the majority showing lack of effectiveness, whereas one study with 6-month follow-up, showed lack of long-term improvement. (V, Weak)
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Thoracic Spine

The level of evidence is III with weak to moderate strength of recommendation with emerging evidence for thoracic radiofrequency ablation with inclusion of one relevant randomized controlled trial and 3 observational studies. (III, Weak)
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The level of evidence is II with moderate strength of recommendation for thoracic therapeutic facet joint nerve blocks with inclusion of 2 randomized controlled trials and 2 observational studies with long-term improvement. (II, Moderate)
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The level of evidence is III with weak to moderate strength of recommendation for thoracic intraarticular facet joint injections with inclusion of one randomized controlled trial with 6 month follow-up, with emerging evidence. (III, Weak)
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Antithrombotic Therapy

Facet joint interventions are considered as moderate to low risk procedures. Consequently, antithrombotic therapy may be continued based on overall general status. (, )
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Sedation

The level of evidence is II with moderate strength of recommendation to avoid opioid analgesics during the diagnosis with interventional techniques. (II, Moderate)
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The level of evidence is II with moderate strength of recommendation that moderate sedation may be utilized for patient comfort and to control anxiety for therapeutic facet joint interventions. (II, Moderate)
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Recommendation Grading

Disclaimer

Overview

Title

Facet Joint Interventions in the Management of Chronic Spinal Pain

Authoring Organization

Publication Month/Year

May 1, 2020

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Hospital, Operating and recovery room, Outpatient, Radiology services

Intended Users

Radiology technologist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D059350 - Chronic Pain, D013119 - Spinal Cord Injuries, D013124 - Spinal Injuries

Keywords

Chronic Spinal Pain, Facet Joint Interventions