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