20 Treatment Although numerous studies have examined conservative management for low back pain, at the present time, there are no published investigations of conservative manage- ment speciﬁcally targeted to facet joint pain. However, most experts would agree that the general principles for treatment of nonspeciﬁc benign low back pain may be applied. A thorough history and physical exam is always recommended for diagnostic triage. Initial imaging is not necessary unless a speciﬁc etiology is strongly suspected or in the presence of ‘‘red ﬂag’’ signs [112]. The use of a multidisciplinary approach is recommended for pain man- agement as it has been associated with improved outcomes [113]. In terms of medications, simple analgesics such as acetaminophen and nonsteroidal anti-inﬂammatory drugs (NSAIDs) constitute ﬁrst-line therapy. Acetaminophen has a more favorable side-effect proﬁle since it has not been associated with cardiovascular or gastrointestinal side- effects. However, with chronic use, hepatic injury is a concern. Studies in patients with osteoarthritis of the knee and hip have previously found that NSAID’s provide better analgesia in comparison to acetaminophen [114, 115]. Both benzodiazepine and non-benzodiazepine skeletal muscle relaxants may also provide symptomatic improvement in acute low back pain. However, there is signiﬁcant contro- versy regarding the use of controlled substances in the treatment of chronic low back pain [116]. Anticonvulsants such as gabapentin have classically been used for the treatment of neuropathic pain conditions such as diabetic peripheral neuropathy and postherpetic neuralgia [117, 118]. Gabapentin has been evaluated in trials evaluating chronic lumbar radiculopathy [119, 120], and lumbar spinal stenosis [121]. However, these studies were small and had several shortcomings. Studies examining use of gabapentin for facet joint-mediated pain have not been performed. The use of antidepressants, speciﬁcally tricyclic antidepressants have shown moderate symptom reduction in patients with chronic low back pain [122, 123]. Again, as with anticonvulsants, trials examining antidepressants speciﬁcally for facet joint-mediated pain have not been performed. Although many various adjuvant pain medica- tions have been used to treat radicular and chronic low back pain, there have been no studies to date examining the efﬁcacy of these drugs in patients with documented facet- mediated low back pain. Interventional treatment: radiofrequency denervation When suspicion of facet joint-mediated pain is supported by two successful diagnostic blocks, consideration of facet joint denervation may be appropriate. First described by Curr Rev Musculoskelet Med (2009) 2:15–24 Shealy in 1975 [124], radiofrequency denervation is a procedure that involves lesioning the medial branches with a combination of electric and magnetic ﬁelds. If these nerves become insensate from the process, they cannot relay pain from the facet joints. Radiofrequency ablation of the medial branches is now a commonly used procedure to provide more long-term relief of facet joint-mediated pain. As with diagnostic medial branch blocks with local anesthetic, the technique and protocol employed for radiofrequency lesioning can have signiﬁcant impact on the success of the procedure. An example of this was high- lighted by Bogduk and colleagues in 1987 [125]. Prompted by reports of poor clinical outcomes with radiofrequency lesioning, they reported on the shape and size of lesions made by the radiofrequency electrodes. It was discovered that lesioning occurred around the distal shaft of the elec- trode rather than directly at the tip. The consequence of this ﬁnding is that suboptimal lesioning occurs if the electrode is oriented directly on the nerve in a perpendicular position. This prompted a revision in the accepted technique to incorporate the placement of the electrode parallel to the targeted medial branch. Radiofrequency denervation has been shown in some studies to provide signiﬁcant pain reduction in patients with chronic low back pain for 6 [126] to 12 months [93, 106]. However, other studies have shown little beneﬁt to this procedure. In either case, it is important to consider any design ﬂaws and limitations of these studies. For example, Gallagher et al. [126] examined 41 patients with chronic low back pain who underwent either radiofrequency abla- tion or a sham treatment. The exact deﬁnition of a successful single diagnostic intra-articular injection was not ade- quately described. Nevertheless, there was a signiﬁcant difference in outcomes observed between the radiofre- quency group and sham group at 1 month. However, this was seen only in the patients who had displayed a good response to the diagnostic blocks. The precise procedure for radiofrequency ablation was also not well described. Van Kleef et al. [93] described 31 patients who had responded positively (C50% improvement) to a single diagnostic medial branch block and were randomly assigned to either a radiofrequency group or a control group. The control group underwent the identical proce- dure as the radiofrequency group except for the use of radiofrequency current. One-year follow-up showed sta- tistically signiﬁcant difference between the treatment and control groups, with higher number of successes (deﬁned as at least 2 point reduction in VAS and 50% pain reduc- tion) recorded in the treatment group. Unfortunately, there were some important limitations. Only a single diagnostic procedure leading to 50% or greater pain relief was employed. There was also a small sample size perhaps leading to sampling error.