Lumbar Zygapophysial Joint Precision Treatment

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Medial branches of the dorsal rami of the lumbar spine are the treatment targets

This article deals with the treatment of lumbar facet joint pain when diagnosed by a precision diagnosis technique, in contrast to "non-specific low back pain". In New Zealand the precision diagnosis is made by two positive single blind concordant medial branch blocks with a pain reduction of >80%. In this setting radiofrequency neurotomy of the medial branches has good evidence.[Level 2]

A variety of radiofrequency procedures have been developed for the treatment of proven facet joint pain, but in New Zealand traditional radiofrequency neurotomy is used. Cooled radiofrequency neurotomy has equal outcomes, and radiofrequency neurotomy of the facet joint capsule is an emerging treatment modality. In general health insurance companies in New Zealand fund medial branch blocks and neurotomy. ACC as a general rule do not, but there are avenues for application.

Repeated medial branch blocks without progressing to radiofrequency neurotomy is also a treatment option. [Level 2] ACC would not allow this as they only fund one lot of each type of intervention.

Fusion Surgery

There are no RCTs for fusion surgery for the treatment of proven facet joint pain, and so this treatment option remains non-evidence based. There is negative RCT evidence for fusion for non-specific low back pain.[1]

Facet Joint Innervation

Each medial branch innervates the same level and below. Blocks and RF techniques are therefore done on the same level and above.
Source unknown.

Because each facet joint receives dual innervation from two different medial branches, in order to eliminate all sensory supply to a particular facet joint, you need to perform radiofrequency ablation (neurotomy) on two separate medial branches. Each facet joint is supplied by a descending medial branch and an ascending medial branch. However the L5 dorsal ramus has no medial branch, and so blocks and radiofrequency techniques are applied to the dorsal ramus itself.

For example, the L4/5 segment

  • Foramen: exiting L4 nerve
  • L4 dorsal ramus medial branch innervates the L4/5 facet joint and the below L5/S1 facet joint.
  • The below L5/S1 facet also receives innervation from the L5 dorsal ramus

In other words, each medial branch innervates same level and below. And so you block the same level and above.

Below is a fluoroscopic image of a medial branch block at the right L4/L5 level. Be aware that the sides are reversed compared to standard radiological imaging.

MBB facet joint.png

Intraarticular Injections

There is only one negative RCT for the treatment of lumbar facet joint pain when the diagnosis was made by a precision diagnosis technique.

Facet Joint Intraarticular Injections RCTs
Study N Arms Selection Criteria Results Comments
Carette et al 1991 (RCT)[2] 97
  1. Intraarticular 20mg methylprednisolone
  2. Intraarticular isotonic saline (presumed placebo)
1 x positive intraarticular block (>50% pain relief) ❌Negative study

No statistical difference in pain or function. (42% vs 33%) Only 22% vs 10% sustained improvement from month 1 to 6 in responders.

  • Failed to exclude placebo responders
  • Prevalence of 58% with presumed ZA joint pain, which may have diluted the results.
  • More concurrent interventions in treatment group.

Therapeutic Medial Branch Blocks

Medial branch blocks can have a therapeutic effect on their own without progressing to radiofrequency neurotomy, with patients having at least 50% pain relief for several weeks, but it isn't curative, and doesn't make an impact on return to work or use of opiods.[3] Injections can be repeated as required to maintain pain relief. The exact mechanism of this is unknown, but possibilities are suppression of nociceptive discharge, blockade of axonal transport, blockade of sympathetic reflex arc and sensitisation, and anti-inflammatory effects.[3]

Repeated Medial Branch Blocks

Repeated MBB Injection Precision Treatment RCTs
Study N Arms Selection Criteria Results Comments
Manchikanti 2010 (RCT)[3] 120
  1. LA
  2. LA + Steroids
2 x comparative blocks ✅Both improved.

Success defined:≥ 50% pain relief and ≥ 40% function improvement

Group 1: 85%, Group 2: 90%

Two year follow up . Significant relief for 82-84 out of 104 weeks. Average treatments 5-6, with average relief 19 weeks per treatment.

  • Double blind
  • No placebo
Manchikanti 2001 (RCT)[4] 73
  1. MBB LA +/- Sarapin, repeated if pain deteriorated below 50% of initial report
  2. MBB LA + steroid +/- Sarapin, repeated as above
2 x comparative blocks ✅Both improved. average 6 procedures over 12 months. Range of pain relief 2 to 102 weeks.
  • Not blinded
  • No placebo

Single Medial Branch Block

Single MBB Injection Precision Treatment RCTs
Study N Arms Selection Criteria Results Comments
Cohen 2018, (RCT) [5] 229
  1. RF by IAB+S
  2. RF by 1xMBB
  3. Saline (all RF)
IAB + MBB: (>50% relief)

and negative outcome progressed to RF, plus all saline group.

❌single injection not effective long term
  • Comparative effectiveness study for predicting RF success outcomes.
  • No radiographs to confirm technique.

Radiofrequency Neurotomy Procedures

Radiofrequency neurotomy for lumbar facet joint pain is controversial in some circles. There are multiple trials with different selection criteria and techniques. The Spine Intervention Society guidelines are the gold standard, but many trials did not follow this. The guidelines are not freely available online, but rather cost several hundred dollars which may be a factor that has lead to their limited use. They are followed by operators in New Zealand.

Systematic reviews differ in their conclusions. Cochrane in 2015 found modest benefit but they did not differentiate between studies with different selection techniques. Studies selecting by a single positive medial branch block with have large numbers of false positives, and this was not evaluated in the Cochrane analysis.[6] Review authors have repeatedly been explained to about selection criteria and technique being paramount, yet ignore this.[7]

Other systematic reviews which have taken selection criteria and technique into consideration have have drastically different conclusions. Manchikanti et al designated the procedure at level 2 evidence,[8] while Scheider et al concluded that there is a difference in outcome depending on patient selection criteria.[9] In general, selection should be based on at least 80% relief from two medial branch blocks.[9] It is highly operator and technique dependent and results can depend on the use of a larger 16G probe, making multiple lesions, and using a parallel technique.

Selection by One Positive Intraarticular Block

Placebo Control Studies for Lumbar Facet Conventional Radiofrequency Neurotomy when selected by Intraarticular Block
Study N Arms Selection Criteria Results Comments
Leclair 2001 (RCT)[10] 70
  1. RF
  2. Sham RF
1 x IAB with steroid (“significant relief”) ❌Negative study
  • Probe remote from nerve, so active treatment was actually a sham
  • Poor design and analysis
Van Wijk 2005, (RCT)[11]

81

  1. RF
  2. Sham RF

1 x IAB (>50% relief)

❌Negative study

  • Probe remote from nerve, so active treatment was actually a sham

Cohen 2018, (RCT) [5]

229

  1. RF by IAB+S
  2. RF by 1xMBB
  3. RF by Saline (all Saline group RFd)

IAB + MBB: (>50% relief), and negative outcome progressed to RF, plus all saline group.

✅ IAB + MBB > Saline for predicting RF success 3 months: success 51%, 56%, 24% 6 months: success 31%, 42%, 17%

  • Comparative effectiveness study for predicting RF success outcomes.
  • No radiographs to confirm technique.

Gallagher 1994, (RCT)[12]

41

  1. RF
  2. Sham RF

?IAB (article not accessible)

✅ Positive study

  • Probe remote from nerve, so active treatment was actually a sham

Lakemeier 2013, (RCT)[13]

56

  1. RF
  2. IA steroid

IAB (>50% relief)

❌Negative study

  • Supposed SIS technique but no radiographs to confirm.
  • Poor analysis and design.

Selection by One Positive Medial Branch Block

Placebo and active controlled RCTs for lumbar facet radiofrequency neurotomy when selected by one positive medial branch block
Study N Arms Selection Criteria Results Comments
Van Kleef 1999, (RCT)[14] 31
  1. RF
  2. Sham RF
1 x MBB (>50% relief) ✅Positive study. Success 66.7% vs 37.5% at 8 weeks. Mean -1.94 difference

But independent analysis showed statistically insignificant due to small sample size.

  • Incorrect technique (perpendicular means limited length of coagulation)
Van Tilburg 2016, (RCT) [15]

60

  1. RF
  2. Sham RF

1 x MBB (≥2 reduction in NRS)

❌ Difference at 1 month but not 3 months

  • Incorrect technique (perpendicular means limited length of coagulation)

Cohen 2018, (RCT)[5]

229

  1. RF by IAB+S
  2. RF by 1xMBB
  3. RF by saline (all RFd)

IAB + MBB: (>50% relief), with positive block but negative outcome progressed to RF, plus all saline group.

✅ IAB + MBB > Saline for predicting RF success 3 months: success 51%, 56%, 24% 6 months: success 31%, 42%, 17%

  • Comparative effectiveness study for predicting RF success outcomes.
  • No radiographs to confirm technique.

Juch 2017, (RCT)[16]

251

  1. RF
  2. Physiotherapy

1 x MBB (>50% relief)

Equal outcomes

  • Did not report technique used, thought to be incorrect.
  • Incorrect selection criteria.
  • So active treatment was sham for heterogenous back pain.
  • No placebo control
  • Highly controversial and widely criticised defence is "this is how its practised in the Netherlands"

Tekin 2007, (RCT)[17]

60

  1. Thermal RF
  2. Pulsed RF
  3. Sham RF

1 x MBB (>50% relief)

  • ✅ Positive study for thermal RF: more effective than pulsed RF and sham RF at 6 and 12 months.
  • Analgesic use at 1 year – thermal RF 40%, pulsed RF 75%, sham 95%.
  • No categorical data on success rates using a validated objective quantitative measure, it was excluded from the final analysis

McCormick 2019, (RCT)[18]

43

  1. Traditional RF
  2. Cooled RF

1 x MBB (>75% relief)

Equal outcomes (52% vs 47% at 6 months with >50% NRS reduction)

  • 20g electrodes used in traditional group with ?single site burn

Selection by Two Positive Medial Branch Block

Placebo controlled studies for lumbar facet radiofrequency neurotomy when selected by two positive medial branch blocks
Study N Arms Selection Criteria Results Comments
Cohen 2010, (RCT) [19] 151
  1. RF when selected by 0 blocks
  2. RF when selected by 1 block
  3. RF when selected by 2 blocks
>50% relief ✅>50% relief of pain in 33% (0 blocks), 39% (1 block), and 64% (dual) at 3 months
  • Primarily focused on cost-effectiveness than outcomes
Nath 2008, (RCT) [20] 40
  1. RF
  2. Sham RF
two positive MBBs (>80% relief) ✅Mean pain relief 1.9 compared to 0.4.
  • Did not report any data from which success rates could be calculated[9]
Moussa 2016, (RCT). [21] 120
  1. RF facet joint capsule
  2. RF Medial branch
  3. Sham RF


All three groups also received a steroid injection.

2 x positive blocks (Near or near complete relief) ✅ Positive study, success measured as Common Outcome Measure. Capsule and MB RF superior to sham, but capsule superior at 2 and 3 years.

1 year: 67.5% vs 57.5% vs 10%

2 years: 60% vs 27.5% vs 5%

3 years: 57.5% vs 17.5% vs 2.5%

  • The author theorised that the capsule nociceptors don't regenerate as quickly as the medial branches

There are variable quality non-RCT studies suggesting that the greatest chance of success is when selection is based on two positive medial branch blocks.[9] Of particular note to New Zealand, MacVicar published results that when selection was based on dual blocks of 100% pain relief, there was a 56% chance of 100% pain relief, back to work, and no further spinal care.[22]

Quiz

1 With regards to facet joint innervation, which is true?

The L4/5 foramen has the exiting L5 nerve root
The L4 dorsal ramus medial branch innervates both the L4/5 facet joint and the below L5/S1 facet joint.
The L5/S1 facet joint also receives its innervation from the S1 lateral branch.
The L5/S1 facet joint is only innervated by the L4 dorsal ramus because the L5 dorsal ramus doesn’t have medial branches.

2 MCQ: With regards to facet joint conventional RF, which is true?

Inserting the probe parallel rather than perpendicular is essential
The medial branches are heated for 90 minutes
The probe heats 1cm distally to the tip
There is extensive placebo controlled RCT evidence when patients are selected by two positive blocks


Bottom Line

  • Intraarticular injections [Level 4]
  • Therapeutic blocks +/- repeated [Level 2]
  • Lumbar RF ablation [Level 2], but patients must be selected by two positive medial branch blocks with >80% pain relief

See Also

References

  1. Harris et al.. Lumbar spine fusion: what is the evidence?. Internal medicine journal 2018. 48:1430-1434. PMID: 30517997. DOI.
  2. Carette et al.. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. The New England journal of medicine 1991. 325:1002-7. PMID: 1832209. DOI.
  3. 3.0 3.1 3.2 Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci. 2010 May 28;7(3):124-35. doi: 10.7150/ijms.7.124. PMID: 20567613; PMCID: PMC2880841.
  4. Manchikanti et al.. Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: a randomized clinical trial. Pain physician 2001. 4:101-17. PMID: 16906173.
  5. 5.0 5.1 5.2 Cohen et al.. Effectiveness of Lumbar Facet Joint Blocks and Predictive Value before Radiofrequency Denervation: The Facet Treatment Study (FACTS), a Randomized, Controlled Clinical Trial. Anesthesiology 2018. 129:517-535. PMID: 29847426. DOI. Full Text.
  6. Maas et al.. Radiofrequency denervation for chronic low back pain. The Cochrane database of systematic reviews 2015. CD008572. PMID: 26495910. DOI.
  7. King and Bogduk. Chronic Low Back Pain In: Bonica's Management of Pain. 2018
  8. Manchikanti et al.. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain physician 2020. 23:S1-S127. PMID: 32503359.
  9. 9.0 9.1 9.2 9.3 Schneider et al.. Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique. Pain medicine (Malden, Mass.) 2020. 21:1122-1141. PMID: 32040149. DOI.
  10. Leclaire et al.. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine 2001. 26:1411-6; discussion 1417. PMID: 11458140. DOI.
  11. van Wijk et al.. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. The Clinical journal of pain 2005. 21:335-44. PMID: 15951652. DOI.
  12. Gallagher J, Petriccione di Vadi PL, Wedley JR. Radiofrequencyfacet joint denervation in the treatment of low back pain: aprospective controlled double-blind study to assess its efficacy.The Pain Clinic 1994;7:193-8.
  13. Lakemeier et al.. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesthesia and analgesia 2013. 117:228-35. PMID: 23632051. DOI.
  14. van Kleef et al.. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999. 24:1937-42. PMID: 10515020. DOI.
  15. van Tilburg et al.. Randomised sham-controlled double-blind multicentre clinical trial to ascertain the effect of percutaneous radiofrequency treatment for lumbar facet joint pain. The bone & joint journal 2016. 98-B:1526-1533. PMID: 27803230. DOI.
  16. Juch et al.. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA 2017. 318:68-81. PMID: 28672319. DOI. Full Text.
  17. Tekin et al.. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. The Clinical journal of pain 2007. 23:524-9. PMID: 17575493. DOI.
  18. McCormick et al.. Randomized prospective trial of cooled versus traditional radiofrequency ablation of the medial branch nerves for the treatment of lumbar facet joint pain. Regional anesthesia and pain medicine 2019. 44:389-397. PMID: 30777903. DOI. Full Text.
  19. Cohen et al.. Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology 2010. 113:395-405. PMID: 20613471. DOI.
  20. Nath et al.. Percutaneous lumbar zygapophysial (Facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial. Spine 2008. 33:1291-7; discussion 1298. PMID: 18496338. DOI.
  21. Moussa & Khedr. Percutaneous radiofrequency facet capsule denervation as an alternative target in lumbar facet syndrome. Clinical neurology and neurosurgery 2016. 150:96-104. PMID: 27618781. DOI.
  22. MacVicar et al.. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain medicine (Malden, Mass.) 2013. 14:639-45. PMID: 23279154. DOI.

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