Systematic Reviews
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. May 18, 2016; 7(5): 315-337
Published online May 18, 2016. doi: 10.5312/wjo.v7.i5.315
Management of lumbar zygapophysial (facet) joint pain
Laxmaiah Manchikanti, Joshua A Hirsch, Frank J E Falco, Mark V Boswell
Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, KY 42003, United States
Laxmaiah Manchikanti, Mark V Boswell, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY 40292, United States
Joshua A Hirsch, NeuroInterventional Services and Neuroendovascular Program, Massachusetts General Hospital, Boston, MA 02114, United States
Joshua A Hirsch, Harvard Medical School, Boston, MA 02115, United States
Frank J E Falco, Mid Atlantic Spine and Pain Physicians, Newark, DE 19702, United States
Frank J E Falco, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA 19140, United States
Author contributions: Manchikanti L, Hirsch JA, Falco FJE and Boswell MV contributed to this work; Manchikanti L and Boswell MV designed the research; Manchikanti L and Falco FJE performed the research; Manchikanti L and Hirsch JA contributed new reagents/analytic tools, analyzed the data and wrote the paper; all authors reviewed all contents and approved for submission.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Data sharing statement: There is no such statement required. This manuscript has not described any basic research or clinical research.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Laxmaiah Manchikanti, MD, Medical Director of the Pain Management Center of Paducah, Clinical Professor, Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, United States. drlm@thepainmd.com
Telephone: +1-270-5548373-101 Fax: +1-270-5548987
Received: June 9, 2015
Peer-review started: June 11, 2015
First decision: September 30, 2015
Revised: January 14, 2016
Accepted: January 27, 2016
Article in press: January 29, 2016
Published online: May 18, 2016
Processing time: 336 Days and 6.5 Hours
Abstract

AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.

METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.

RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.

CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.

Keywords: Chronic low back pain; Lumbar facet joint pain; Lumbar discogenic pain; Intraarticular injections; Lumbar facet joint nerve blocks; Lumbar facet joint radiofrequency; Controlled diagnostic blocks; Lumbar facet joint

Core tip: This review summarizes diagnostic and therapeutic aspects of chronic low back pain of facet joint origin. Even though multiple high quality diagnostic accuracy studies are available, there is room for further studies to confirm accuracy. These studies are key for the universal acceptance of facet joint nerve blocks of the lumbosacral spine as the gold standard. Deficiencies continue with therapeutic interventions. Lumbar radiofrequency neurotomy studies have shown contradicting results with short-term follow-ups. There is limited high quality literature for lumbar facet joint nerve blocks, and the available literature contains contradictory findings in multiple trials of intraarticular injections.