Lumbar Zygapophysial Joint Precision Treatment

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.
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. 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.
==Facet Joint Innervation==
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.
File:lumbar-medial-branch-nerve-blocks.jpg
File:lumbar-medial-branch-nerve-blocks2.jpg
File:Medial branch ppr lateral view.jpg
File:Medial branch ppr posterior view.jpg
File:Medial branch ppr.jpg
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.
==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)	97	
#Intraarticular 20mg methylprednisolone
#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.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. 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. 
===Repeated Medial Branch Blocks===
 Repeated MBB Injection Precision Treatment RCTs
Study 	N 	Arms	Selection Criteria 	Results 	Comments
Manchikanti 2010 (RCT)	120	
# LA
# 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)	73 	
#MBB LA +/- Sarapin, repeated if pain deteriorated below 50% of initial report
#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)	229	
#RF by IAB+S
#RF by 1xMBB
#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. Review authors have repeatedly been explained to about selection criteria and technique being paramount, yet ignore this.King and Bogduk. Chronic Low Back Pain In: Bonica's Management of Pain. 2018
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, while Scheider et al concluded that there is a difference in outcome depending on patient selection criteria. In general, selection should be based on at least 80% relief from two medial branch blocks. 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) 	70	
#RF
#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)	
81	
#RF
#Sham RF	
1 x IAB (>50% relief) 	
❌Negative study	
* Probe remote from nerve, so active treatment was actually a sham
Cohen 2018, (RCT) 	
229	
#RF by IAB+S
#RF by 1xMBB
#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)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.	
41	
#RF
#Sham RF	
?IAB (article not accessible) 	
✅ Positive study	
*Probe remote from nerve, so active treatment was actually a sham
Lakemeier 2013, (RCT)	
56	
#RF
#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) 	31	
#RF
#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)	
60	
#RF
#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) 	
229	
#RF by IAB+S
#RF by 1xMBB
#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) 	
251	
#RF
#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) 	
60	
#Thermal RF
#Pulsed RF
#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) 	
43	
#Traditional RF
#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) 	151	
#RF when selected by 0 blocks
#RF when selected by 1 block
#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) 	40 	
#RF
#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
Moussa 2016, (RCT).	120	
#RF facet joint capsule
#RF Medial branch
#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. 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.
==Quiz==
<quiz display=simple>
{With regards to facet joint innervation, which is true?
|type="()"}
-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.
{MCQ: With regards to facet joint conventional RF, which is true?
|type="()"}
+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
</quiz>
==Bottom Line==
*Intraarticular injections 
*Therapeutic blocks +/- repeated 
*Lumbar RF ablation , but patients must be selected by two positive medial branch blocks with >80% pain relief
==See Also==
*Sacroiliac Joint Precision Treatment
*Lumbar Disc Precision Treatment
*Radiofrequency Neurotomy
*Causes and Sources of Chronic Low Back Pain
*Chronic Low Back Pain
==References==
Category:Lumbar Spine Procedures
Category:Partially complete articles
Category:Precision Techniques