ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
45
acetate, 20 mg, and lidocaine, 1.5 mL, 1% at each level.
They concluded that “Facet joint injections and facet nerve
blocks may be of equal value as diagnostic tests, but neither
is a satisfactory treatment for chronic low back pain.”
Nash (379) compared facet joint injections with medial
branch blocks in a randomized study of 67 patients in two
treatment groups and a 1-month follow up period. No appreciable
difference was evident in evaluations between
the groups at follow-up.
Barnsley et al (475) studied 41 patients with neck pain
caused by whiplash injury in a randomized, double-blinded
investigation with a therapeutic trial of cervical intra-articular
local anesthetic, or local anesthetic with steroid.
Results from this study indicate that the time to return to
50% of baseline pain was three days in the steroid group
and 3.5 days in the local anesthetic group. Less than half
of the patients reported relief of pain for more than one
week, and fewer than one in five patients reported relief
for more than one month, regardless of whether injection
was with steroids or local anesthetic. They (475) concluded
that intra-articular injection of steroid was not an effective
treatment for cervical facet joint pain associated with whiplash
injuries. They cautioned that these results should not
be extrapolated to the treatment of patients with cervical
facet joint pain from other causes, because response to intra-articular
steroid injections is not known in cervical facet
joint pain of spontaneous origin.
However, all of the controlled studies summarized faced
substantial criticism. Lilius et al (468) used overly broad
inclusion criteria of patients with neurologic deficits, and
the patient’s diagnosis of lumbar facet joint mediated pain
was not confirmed by the diagnostic blocks; furthermore,
excessive volumes, ranging from 3 mL to 8 mL of active
agents, were injected, and placebo responders were not
excluded. Although the study by Carette et al (457) was
praised for its design, these authors failed to exclude placebo
responders, which may account for the relatively high
incidence of patients in their study with presumed facet
joint pain. Failure to exclude the placebo responders invariably
dilutes the findings of true responses, making detection
of difference between the study and control groups
more difficult. Additional criticism against Carette’s study
(457) was that intra-articular lumbar facet joint corticosteroids
were evaluated in isolation and not as part of a comprehensive,
conservative treatment plan provided equally
to both groups (472). Lack of randomization, poor outcome
assessment tools, failure to select patients with isolated
facet joint pain as determined by diagnostic blocks,
and lack of third party review were among the weaknesses
of the study by Lynch and Taylor (469). Marks et al study
(380) is limited by failure to select patients with facet joint
pain established by controlled diagnostic blocks; failure
to have a blinded, independent observer; poor limited outcome
assessment tools; and absence of a control or placebo
group. Nash’s study (379) is limited by lack of established
diagnosis or confirmation of facet joint mediated
pain; lack of a blinded observer; poor assessment tools;
and lack of a controlled or placebo group. Barnsley et al
(475) included a small number of patients (20 in each
group), whose origin of neck pain was post traumatic, following
whiplash.
Due to negative results of intra-articular injections, additional
studies of observational nature with good-quality data
were considered (Table 6). Of the multiple studies available
on managing facet joint mediated pain, only six met
the criteria for inclusion as observational studies with at
least minimum of 50 patients and a reasonable follow up.
Of these, four were prospective, including Jackson et al
(351), Desoutet et al (460), Murtagh (465), Mironer and
Somerville (471). The observational studies, which were
of a retrospective nature, included Lippitt (462) and Lau
et al (463). Jackson et al (351) prospectively evaluated
454 patients from 2,500 patients, with 390 patients completing
the study. Even though this was a prospective study,
there was no long term follow-up. Immediate relief was
seen in only 29% of the patients. Desoutet et al (460) studied
54 patients, with immediate relief noted in 54% of the
patients whom they considered as facet syndrome. Of the
54% of the patients diagnosed with facet syndrome by local
anesthetic blocks, they reported 62% of the patients
experiencing relief for 1 to 3 months, whereas 38% of the
patients experienced relief for 6 to 12 months. Murtagh
(465) studied 100 patients with a follow-up of up to 4 years
reporting immediate relief in 94% of the patients and long
term relief up to 6 months in 54% of the patients. Mironer
and Somerville (471) evaluated 148 patients, injecting the
facet joints with bupivacaine and steroid reporting 28% of
patients obtained greater than 60% relief with a duration
longer than two months. They also reported that these
patients were observed and that eight patients required reinjection
on an average of 4.8 months later with similar
good results; thus, 28% of the patients, with or without
repeat injections, reported relief up to 15 months at follow-up.
Among the retrospective studies, Lau et al (463)
reported the results in 50 patients with a follow-up period
of 4 months to 18 months with initial relief in 56% of the
patients, 44% at 3 months, and 35% at 6 to 12 months.
Lippitt (462) reported results in 99 patients with a 12-month
Pain Physician Vol. 4, No. 1, 2001