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  • Review Article
  • Published:

Facet joint pain—advances in patient selection and treatment

Abstract

Facetogenic pain, also known as zygapophysial joint pain, is a frequent cause of mechanical spine pain. Diagnostic blocks (for example, medial branch blocks [MBBs]) are the only reliable approach to identify facet joints as the source of neck or back pain. In the absence of a reference standard, MBBs actually serve more of a prognostic than diagnostic role, enabling the selection of patients who might respond to radiofrequency denervation treatment—the standard treatment for facet joint pain. Using double blocks reduces the false-positive rate of MBBs, but will invariably reduce the overall treatment success rate. No studies have evaluated non-interventional treatments for confirmed facetogenic pain, but data from studies in non-specific back pain suggest a modest, short-term beneficial effect for pharmacotherapy and some non-traditional treatments. Trials of intra-articular steroid injections for lumbar and cervical facet joint pain have yielded disappointing results, but evidence suggests that a subpopulation of patients with acute inflammation derive intermediate-term benefit from this therapy. Radiofrequency denervation provides some benefit for up to a year in approximately 60% of individuals. Increasing this success rate might involve enhancing diagnostic specificity and phenotyping, as well as techniques that increase the likelihood of successful nerve ablation, such as maximizing lesion size.

Key Points

  • Although physical signs, such as paraspinal tenderness, might be weakly associated with facetogenic pain, the best means to identify a painful facet joint is the use of diagnostic blocks

  • Double blocks might reduce the rate of false-positive diagnoses and enhance radiofrequency treatment success rates, but will lower the overall success rate by increasing false-negative diagnoses and eliminating placebo responders

  • A small, but growing, body of evidence suggests that intra-articular steroids can provide relief for up to 3 months in a select group of patients with acute facet joint inflammation

  • The reference treatment for facetogenic pain is radiofrequency denervation of the medial branch nerves innervating the joint, which can provide up to 12 months of benefit

  • In those who benefit from radiofrequency denervation, a large majority can obtain relief from a repeat procedure comparable to that derived from the first treatment

  • Multiple technical steps can be taken to improve the success rate of radiofrequency denervation

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Figure 1: Antero–posterior view depicting the proper electrode placement for left-sided L3–L4 medial branch and L5 dorsal ramus radiofrequency denervation of the L4–L5 and L5–S1 facet joints.
Figure 2: Lateral view showing the proper electrode placement for left-sided C4–C6 medial branch radiofrequency denervation of the C4–C5 and C5–C6 facet joints.

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Acknowledgements

S. P. Cohen wishes to acknowledge the Centers for Rehabilitation Sciences Research, Washington, DC, and the Defense and Veterans Center for Integrative Pain Management, Rockville, MD, USA for funding his research activities. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army or the Department of Defense.

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S. P. Cohen and C. Brummett wrote the article and J. H. Y. Huang made substantial contributions to preparation of the display items. All authors made substantial contributions to researching the data for the article, discussions of the content, and review and editing of the manuscript before submission.

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Correspondence to Chad Brummett.

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Cohen, S., Huang, J. & Brummett, C. Facet joint pain—advances in patient selection and treatment. Nat Rev Rheumatol 9, 101–116 (2013). https://doi.org/10.1038/nrrheum.2012.198

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