KEY POINTS:

  • Lumbar facet joints can be a cause of pain.
  • Facet pain is difficult to reliably confirm based solely on pain patterns or standard clinical bedside examination procedures.
  • Diagnostic nerve blocks are considered the gold standard for confirmation but they also suffer from limitations.
  • Pain relief from Facet Denervation (Medial Branch Neurotomy), although often significant, is rarely complete or permanent.
  • The decision on whether or not to consider Medial Branch Neurotomy should be based upon an understanding of the expected outcomes, risks, and limitations of the procedure and in comparison to a patient’s current level of function.
  • Ablation of the nerve simply eliminates (or reduces) the ability to transmit pain signals. It DOES NOT identify or address the factors causing the pain or sensitization of structures supplied by that nerve.

Introduction:

In 1963, Hirsh et al first demonstrated the capacity of the facet joint to produce pain by the injection of hypertonic saline into the joint. (1) Mooney and Robertson later delineated theirScreen Shot 2015-01-28 at 12.22.45 PM typical lower extremity referral patterns now well known to most of us. (2) Subsequent investigators have further confirmed the presence of facet joint nociceptive fibers capable of pain transmission. (3,4,5)

Less well agreed upon compared to the joint’s capacity for pain production is the frequency with which this occurs and the precision with which it can be accurately diagnosed.

The reported incidence of lumbar facetogenic pain shows wide variation. Most studies note an occurrence between 15-45%, depending on the diagnostic criteria utilized. (6,7,8) Schwartzer et al have even suggested a 4% rate for the facet joint serving as a sole source of pain. (9)

Diagnostic precision for implicating facet pain is compromised in ways similar to that of confirming other potential sources of structural involvement.

Spinal imaging, in general, is of little value in most non-neurogenic back pain syndromes. (10,11) Pertaining specifically to the facet joints, abnormal imaging changes have been shown to have no relationship to the presence or magnitude of pain experienced. (12,13,14)

Adding to the diagnostic dilemma is that no particular pain pattern, clinical bedside test, or combination of tests, can consistently and reliably distinguish facet-mediated pain from that originating in other structures. (15,16,17)

In 1998, Revel et al demonstrated that patients matching 5/7 clinical criteria exhibited a 75% pain reduction on subsequent anesthetic blocks. These criteria were; age > 65, pain well relieved by recumbent position, absence of pain with coughing, pain not worsened by forward flexion, pain not worsened when rising from flexion, pain not worsened by hyperextension, pain not worsened by extension-rotation test. (18) Further studies have shown that matching these criteria provide high specificity but very low sensitivity in identifying those likely to benefit from anesthetic blocks. (19,20)

In the absence of predictive clinical or radiologic findings, nerve blocks are considered to be the best way of diagnosing presumed facet-mediated pain. (8,21,22) However, at present, there is no clear consensus on how a diagnostic block should be performed, or the threshold and duration of pain relief that constitutes a positive response. This is largely due to the lack of a gold standard of diagnosis, to which nerve blocks could be compared. (21)

Controlled diagnostic blocks imply having a patient undergo 2 separate injections, at different times, using anesthetic agents of different durations of action. A positive response occurs when a threshold of pain relief (usually between 50-80%) is experienced and the duration of relief is consistent with the known duration of the anesthetic. Single diagnostic blocks use only a single injection and anesthetic agent.

There are pros and cons to each approach as will be discussed below.

Falco et al, in what appears to be the most recent review on the accuracy of these procedures found that false positive rates ranged between 17-66% being more common when single blocks or thresholds of pain relief less than 75% were used. (8) Derby et al confirmed this finding, also noting how using pain relief thresholds above 75% correlates with improved outcomes after medial branch neurotomy. (23)

However, additional research by Derby illustrated that using such highly specific criteria may unnecessarily exclude patients who could potentially benefit from interventional denervation. He found that 20% of patients with less than 50% relief and up to 47% of patients with between 50-69% relief, (each considered to be negative responders to diagnostic blocks) went on to show a greater than 50% improvement in pain after undergoing medial branch ablation. (24)

It is also important to understand that pain relief subsequent to medial branch blocks does not implicate the facet joint with certainty.

The medial branch also provides innervation to the multifidus, interspinous ligaments, periosteum of the neural arch, and the interspinal muscles. (25,26) Ackerman et al further illustrated how the facet joints can be falsely implicated by demonstrating that anesthetic infiltration of the paraspinals, without direct anesthesia of the medial branch nerve can lead to similar reductions in axial low back pain. (27)

Although medial branch neurotomy may benefit properly selected patients, the relief achieved is rarely complete or permanent. Because of this, treatment decisions are best based upon having a realistic understanding of expected outcomes in relation to a patient’s current level of pain and physical function.

Dreyfuss et al followed 15 patients showing >80% relief on controlled diagnostic blocks. 13 had relief of >60% at one year, with 9 of these exceeding 90% pain reduction. (28)

Lakemeir et al assessed the 6-month response to medial branch neurotomy in 29 patients after showing a minimum of 50% pain relief to a single diagnostic block. Average pain scale reduced from 6.6 to 4.7. Oswestry Index reduced from 40.8 to 28. This study also compared facet denervation to intra-articular steroid injection, finding no statistical difference between the two procedures. (29)

The response to radiofrequency rhizotomy, after having successful comparative nerve blocks, in Goldfeld et al’s study of 174 patients showed 119 having good (50%) to excellent (80%) pain relief and 55 showing no improvment. 96% of those with good-excellent responses had relief lasting between 6-24 months with 43% of that cohort showing sustained benefit for 2 years. (30)

Cohen et al followed 262 patients who had a positive controlled diagnostic block with >50% pain relief. Following medial branch neurotomy, 54% had pain relief >50% lasting at least 6 months. There was no difference in response between those reporting >80% relief on confirmatory blocks as compared to those reporting relief of between 50-80%. (31) A later study of his reinforced this finding, further concluding that the use of more stringent diagnostic criteria (higher pain relief thresholds or double as compared to single blocks) would likely result in withholding a beneficial procedure from a substantial number of patients without a corresponding improvement in success rates. (32)

Not all studies have shown favorable results for Medial Branch Neurotomy.

One of the largest double blind randomized trials found no difference in VAS scores, physical function, or medication use between active intervention and sham groups. (33)

Leclair et al found similar disappointing results after monitoring 70 patients who had experienced relief after a single diagnostic facet injection. At 12 weeks, no difference was seen between an active treatment and sham group. (34) Although this was one of the larger studies on facet denervation, it has been criticized for the lack of an adequate description of what constituted a positive diagnostic block. (35) Similar criticism of reports finding evidence of procedural ineffectiveness have been echoed by Bogduk et al, who stated; “Negative results have been reported only in studies that selected inappropriate patients or used surgically inaccurate techniques.” (36)

As briefly discussed earlier, even when Medial Branch Neurotomy is successful, relief is rarely complete or permanent.

Smuck et al reviewed 16 articles finding that the average duration of >50% pain relief for an initial procedure was 9 months. Repeat Medial Branch Neurotomy carried a success rate between 33-85% with an average duration lasting 11.6 months. (37) These statistics were similar to an earlier study also showing a 10-month average duration of benefit for both initial and repeat procedures. (38)

Complication rates with Medial Branch Neurotomy are considered to be low, minor, and in most cases, transient.

Kormick et al had performed 2 studies involving a total of 741 denervations. These revealed 5 cases of neuritic pain lasting longer than 2 weeks, 5 cases of muscle soreness lasting less than 2 weeks, one case of prolonged muscle spasm, and no instances of motor deficits, sensory deficits, or infections. (39,40)

Some concern has been raised about the possibility of creating a “Charcot Joint” due to the loss of afferent input secondary to medial branch ablation. (41) This would appear plausible as the facet joint (and entire medial branch nerve) is not only capable of nociceptive signaling but also serves a role in proprioception. (42) The loss of proprioception subsequent to denervation could conceivably lead to impaired motor control and loss of stability as these receptors are similar to mechanoreceptors involved in the proprioception of other peripheral joints. (43) Recognizing that isolated case reports do not constitute a clear cause-effect relationship; there have been reported cases of progressive kyphosis (camptocormia) developing pursuant to multi-level facet denervation. (44,45)

Interventions other than conventional radiofrequency denervation have also been described.

Lakemeier’s study, mentioned earlier found that 6 months after intra-articular steroids, VAS scale reduced from 7 to 5.4 and Oswestry went from 38.7 to 33. This was no different than radiofrequency denervation. (29). Manchikanti et al, studying 120 patients, found that intra-articular injections of an anesthetic agent, either with or without steroids, provided similar pain relief. Over 85% of the patients experienced > 50% pain relief, and >40% improvement in disability measures, with an average effect duration of 19 weeks. Over 2 years, these patients required, on average, 5-6 treatments to maintain their benefit. (46) At present, no clear consensus exists on the comparative effectiveness of direct facet injections versus medial branch neurotomy and a study is currently underway to assess this. (47)

Conventional radiofrequency treatment has been compared with pulsed radiofrequency in two randomized trials, both of which found superiority with conventional radiofrequency. (48,49)

Kryorhizotomy uses a cold probe as compared to a heating element to accomplish medial branch denervation. 3 low quality trials have been performed reporting that properly selected patients experienced an average of 40-60% pain relief over a one-year period. (50,51,52)

To date, there have been no large case series reports, or comparative studies, to properly assess the effectiveness of laser facet denervation. Iwatsuki et al, reported that 17/21 patients experienced > 70% pain relief one year after laser intervention. (53) Another study of 15 patients having a positive response to double controlled diagnostic blocks reported 8 with complete relief, and 6 with > 50% relief at one year. (54) These isolated reports should not imply that laser denervation is superior to other procedures but rather that larger case controlled or comparative studies are needed.

In summary, Medial Branch Neurotomy could be considered an option for patients suffering persistent axial and referred non-radicular leg pain unresponsive to less invasive conservative measures.

Proper patient selection via diagnostic blocks correlates with successful outcomes. The criteria for what constitutes a successful block continues to be debated, largely due to tradeoffs in cost, sensitivity, and specificity. The primary concern is the potential of withholding a beneficial option from patients who may fail to meet highly specific and more rigid diagnostic standards.

In general, a reasonable number of patients with > 50% pain relief on controlled diagnostic blocks (and possibly even a single diagnostic block) could expect to experience similar relief with medial branch neurotomy for an average duration of 6-12 months. Repeat medial branch neurotomy tends to yield similar results. Patients meeting the more stringent diagnostic criteria appear to have predictably better responses, but failing to meet such criteria does not consistently exclude those who may otherwise show clinical benefit.

Immediate complications of medial branch neurotomy are mild and transient. However, studies on long-term complications, in particular those experienced in patients having multi-level or multiple sequential blocks, have not been done. This is a case for concern and warrants further study.

At present, the research favors conventional thermal radiofrequency neurotomy over pulsed radiofrequency procedures. Some articles have suggested that intra-articular facet injections of anesthetic with or without steroids may offer similar benefit. To date, laser denervation lacks the research necessary to make firm conclusions.

There does not appear to be any studies comparing manipulative procedures to medial branch neurotomy in the management of presumed facet-mediated pain diagnosed by confirmatory blocks. This would be an intriguing area to explore, especially since manipulative procedures are felt to improve afferentation and/or mechanically address the source of nociceptive input rather than just ablating the pain transmitting signals.

 

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