DOI: 10.1111/papr.

13287

EVIDENCE -BASED REVIEW

Update of evidence-based interventional pain medicine according to clinical diagnoses

3. Pain originating from the lumbar facet joints

Sandra A. S. Van den Heuvel MD, PhD, FIPP1 | Steven P. C. Cohen MD2 |
Javier de Andrès Ares MD, PhD, FIPP3 | Koen Van Boxem MD, PhD, FIPP4,5 |
6,7 4,5
Jan Willem Kallewaard MD, PhD, FIPP | Jan Van Zundert MD, PhD, FIPP

1
Anesthesiology, Pain and Palliative Abstract
Medicine, Radboud University Medical
Center, Nijmegen, The Netherlands
Introduction: Pain originating from the lumbar facets can be defined as pain that
2
Anesthesiology, Pain Medicine Division,
arises from the innervated structures comprising the joint: the subchondral bone,
Johns Hopkins School of Medicine, synovium, synovial folds, and joint capsule. Reported prevalence rates range from
Baltimore, Maryland, USA 4.8% to over 50% among patients with mechanical low back pain, with diagnosis
3
Pain Unit Hospital Universitario La Paz-­ heavily dependent on the criteria employed. In well-­designed studies, the prevalence
(Anesthesiology), Madrid, Spain
4
is generally between 10% and 20%, increasing with age.
Anesthesiology, Critical Care and
Multidisciplinary Pain Center, Ziekenhuis
Methods: The literature on the diagnosis and treatment of lumbar facet joint pain
Oost-­Limburg, Genk, Belgium was retrieved and summarized.
5
Anesthesiology and Pain Medicine, Results: There are no pathognomic signs or symptoms of pain originating from
Maastricht University Medical Center, the lumbar facet joints. The most common reported symptom is uni-­or bilateral
Maastricht, The Netherlands
6
(in more advanced cases) axial low back pain, which often radiates into the upper
Anesthesiology and Pain Medicine,
Rijnstate Ziekenhuis, Velp, The
legs in a non-­dermatomal distribution. Most patients report an aching type of pain
Netherlands exacerbated by activity, sometimes with morning stiffness. The diagnostic value
7
Anesthesiology and Pain Medicine, of abnormal radiologic findings is poor owing to the low specificity. SPECT can
Amsterdam University Medical Centers, accurately identify joint inflammation and has a predictive value for diagnostic
Amsterdam, The Netherlands
lumbar facet injections. After “red flags” are ruled out, conservatives should be
Correspondence considered. In those unresponsive to conservative therapy with symptoms and
Jan Van Zundert, Department of physical examination suggesting lumbar facet joint pain, a diagnostic/prognostic
Anesthesiology, Intensive Care, Emergency
Medicine and Multidisciplinary Pain
medial branch block can be performed which remains the most reliable way to
Center, Ziekenhuis Oost-­Limburg, select patients for radiofrequency ablation.
Bessemersstraat, 478 3620 Genk/Lanaken, Conclusions: Well-­selected individuals with chronic low back originating from the
Belgium.
Email: [email protected]
facet joints may benefit from lumbar medial branch radiofrequency ablation.

K EY WOR DS
diagnostic/prognostic block, evidence-­based medicine, lumbar facet, radiofrequency ablation

synovial folds, and joint capsule (the articular cartilage

I N T RODUC T ION is aneural).2–­4 Although this definition is simple, the di-
agnosis and treatment of lumbar facet joint pain is con-
This narrative review on pain originating from the lum- troversial and complex. In the literature, the prevalence
bar facet joints is an update of the article published in ranges from 4.8% to over 50% among patients with low
2010 in the series “Evidence-­based Interventional Pain back pain depending on the criteria used for diagnosis
Medicine According to Clinical diagnoses.”1 and selection of patients (i.e., more stringent criteria re-
Pain originating from the lumbar facets can be de- sults in lower prevalence rates).5 In high-­quality studies
fined as pain that arises from the innervated structures that have utilized controlled blocks, the prevalence rate
comprising the joint: the subchondral bone, synovium, typically ranges between 10% and 20%, increasing in the

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in
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© 2023 The Authors. Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain.

160 | 
wileyonlinelibrary.com/journal/papr Pain Practice. 2024;24:160–176.
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VAN den HEUVEL et al.     | 161

elderly.2,6 Lumbar facet joints are formed by the inferior and below are provided. The L5 dorsal branch runs in
articular process of the superior vertebra and the supe- the groove between the SAP and the sacral ala, where
rior articular process (SAP) from the inferior vertebra, it is amendable to treatment. L5 differs slightly in that
and the posterior articulation of the lumbar column it is traditionally held at the dorsal ramus itself, rather
(Figure 1). Progressing caudally from L3 to S1, the orien- than the medial branch, though a recent cadaveric study
tation of the facet joints gradually shifts from the sagit- has called this into question (i.e., the L5 medial branch is
tal plane (which protects against rotation) to the coronal targeted between the sacral ala and articular process).10
plane (which better protects against forward flexion and Opposite the caudal aspect of the L5/S1 facet joint the
shearing forces), with the maximal transverse articular L5 dorsal ramus divides into a medial and intermediate
orientation occurring distally. Unlike the cervical spine branch; the L5 dorsal ramus has no lateral branch.7,8
where the medial branches are named differently be- The mamillo-­ accessory ligament can become ossi-
cause the C8 spinal root exits between C7 and T1, each fied, which is most common at L5 (up to 26%), less fre-
lumbar facet joint receives dual innervation by medial quent at L4 (up to 11%), and rare at more cephalad levels.
branches from the named nerve at the upper level and Ossification can cause entrapment of the medial branch
from one level above (i.e., L4-­5 receives innervation from or the dorsal ramus.11,12
L3 and L4). Medial branches also innervate the multifi- Lumbar facet joints play an important role in load
dus muscle and the interspinous ligament and muscle.7,8 transmission, restrict axial rotation, and stabilize the mo-
The medial branch runs from the ramus dorsalis tion in flexion and extension.13,14 Related to their func-
of the spinal nerve, which also forms the source of the tion, lumbar facet joints are prone to degeneration, which
lateral (iliocostalis lumborum muscle and skin inner- is closely linked to degenerative disc disease and typically
vation) and intermediate branches (longissimus muscle most prominent at L4/L5 and L5/S1.15,16 Dehydration of
innervation).9 The L1–­L4 medial branches run dorsal the intervertebral disk results in decreased disc height
and caudally against bone over the base of the trans- and increased shearing forces on the facet joint, which
verse process at the junction of the SAP. Subsequently, also bear increased axial load.17 Predisposing factors for
the medial branch passes under the mamillo-­accessory accelerated facet degeneration are increased age, spondy-
ligament, which is partially responsible for its consistent lolisthesis, obesity, facet joint tropism, poor posture, or
location, from where branches to the facet joints above adjacent to levels of previous surgery. Chronic shearing
stress induces inflammation, joint effusion, and stretch-
ing of capsule, which stimulates nociceptive nerve endings
innervating the facet joint and subsequently produces a
pain response.18 Lumbar facet joint pain sometimes re-
sults from a traumatic event like a sports injury or a fall
and may be accelerated after fusion surgery.1,19,20
Recently, a multispeciality and international working
group developed guidelines addressing clinically relevant
questions, for example, the value of history and physical
examination in selecting patients for blocks, the value of
imaging, whether conservative treatment should be used
before injections, the diagnostic and prognostic value of
medial branch blocks (MBB). By approaching patients
according to evidence-­based guidelines, disparate treat-
ments and controversies surrounding lumbar facet joint
pain will hopefully diminish in the future.5

M ET HOD OL OGY

This narrative review is based on the article “Pain origi-

nating from the lumbar facet joints” published in 2010.1
In 2015 an independent company, Kleijnen Systematic
Reviews, performed a systematic review of the literature
for the period 2009–­2015, based on existing systematic re-
views (SRs) and randomized controlled trials (RCTs).21,22
For the current article an updated search was conducted
F I G U R E 1 Anatomy of the lumbar spinal column. “Illustration:
for the period 2015–­2022, using “lumbar” and “facet”
Rogier Trompert Medical Art”. www.medic​al-­art.eu. DRG, dorsal and “pain” associated with the interventional pain
root ganglion. management techniques, in this case, “injection” and
 15332500, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/papr.13287 by Instituto Aragones De Ciencias, Wiley Online Library on [03/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
162 |    LUMBAR FACET JOINTS

“intra-­articular” or “medial branch block” and “radi- Most patients report an aching type of pain worsen-
ofrequency.” Additionally, authors could select relevant ing with an activity that typically has no neuropathic
missing articles. characteristics or radicular distribution pattern, though
nociplastic characteristics such as tingling and allodynia
may accompany all spine pain etiologies including lum-
DI AGNO SI S bar facetogenic pain.28 Since the facet joints are involved
in all principal movements of the spine, pain can increase
History on extension, flexion, rotation, or walking uphill. It can
also be provoked by static positions (like standing or sit-
It is important to consider that (chronic) low back pain ting) or after a period of inactivity (like waking up from
can be influenced by psychosocial factors.23–­25 Thus, bed, morning stiffness).29,30
history-­
taking should include a detailed multidimen-
sional evaluation of the patients’ pain including its ef-
fects on daily activities and quality of life. Screening Historical findings and clinical examination
questions for red flags pointing to cancer, infection,
trauma or underlying neurologic/systemic pathology A systematic review performed by Maas et al.31 deter-
should be evaluated. mined the diagnostic accuracy of history and physical
There are no pathognomic signs or symptoms for pain examination to identify pain originating from the lum-
originating from the lumbar facet joints, though location bar facet joints using a diagnostic block as a reference
and referral patterns, onset, duration, quality of pain, standard. One hundred and twenty-­n ine combinations
aggravating and relieving factors, and imaging can all of index tests and reference standards were studied,
provide important clues. The most common reported with most index tests having been evaluated in single
symptom is uni-­or bilateral axial low back pain. Pain studies with a high risk of bias. Only the results of Rev-
originating from the upper facet joints can be referred to el's criteria (comprising seven clinical signs, with the
the flank, hip, groin, and thigh regions; pain from lower presence of five out of seven during the assessment of
facet joints can refer to the posterior thigh (Figure 2). the patient predicting an adequate response to lumbar
Pain referred distal to the knee is infrequently associated facet block) could be pooled. Published sensitivities
with facet pathology.1,26 and specificities ranged from 0.11 (95% CI 0.02–­0.29) to

F I G U R E 2 Pain referral pattern of lumbar facet pain adapted from McCall et al.27 Illustration: Rogier Trompert Medical Art. http://www.
medic​al-­art.eu.
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VAN den HEUVEL et al.     | 163

TA BL E 1 Diagnostic scale proposed by Gomez-­Vega et al.32

ligamentous injury, discogenic low back pain, lumbo-
Symptoms Signs sacral radicular pain, sacroiliac joint pathology, hip pa-
Axial or bilateral axial lumbar pain Kemp signa
thology, or inflammatory conditions (rheumatic disease,
ankylosing spondylitis or gout).1,14,37
Improvement with rest Pain induced in
the articular or
transverse process
Absence of a radicular pattern Sign of facet stress or
Additional tests
Acevedo signa
a
Kemp's test33 and Acevedo sign have a poor diagnostic accuracy.32
Imaging

Radiologic imaging can be used to rule out underlying

1.00 (95% CI 0.75–­1.00) and 0.66 (95% CI 0.46–­0.82) to disease and to identify facet pathology. Intervertebral
0.91 (95% CI 0.83–­0.96), respectively. They concluded disc height loss or facet degeneration is highly prevalent
that neither history nor physical exam could be used to among patients without low back pain and therefore
identify a painful facet joint or to limit the need for a lack specificity.38 The correlation between abnormal
diagnostic block.31 morphology on radiologic findings and pain originating
Gomez Vega et al.32 performed a pilot study fol- from the facet joints (diagnostic value) and the prognos-
lowing a systematic review and consensus meetings tic value of abnormal radiologic findings and the effect
on the evaluation of lumbar facet joint pain. A total of denervation is low.5,39–­42 Plain radiography, CT, MRI,
of 36 signs and symptoms were evaluated, of which 12 scintigraphy imaging cannot accurately identify pain-
(8 symptoms and 4 signs) were included in the final ful lumbar facet joint levels and are not routinely rec-
survey and investigated in 31 patients with a positive ommended before performing a diagnostic facet joint
diagnostic block. They proposed a diagnostic scale block.5
containing three symptoms and three signs as illus-
trated in Table 1. • Plain radiography is relatively inexpensive and widely
In their pilot study, the occurrence of the facet stress available, but X-­rays can be difficult to interpret and
sign was much lower (40.9%) compared with Kemp Sign have high-­rate false-­p ositive and -­negative findings.
(81.8%) in patients with a positive diagnostic block.32 A Standard views include an antero-­p osterior (AP) and
2014 systematic that included five studies evaluating the lateral view for detecting spinal misalignments or tu-
diagnostic accuracy of Kemp's test using response to mors but are of limited value to visualize facet joints.
intra-­articular (IA) facet joint block or MBB as a refer- In the oblique view, joint space narrowing, sclerosis
ence standard found a sensitivity and specificity below and bone hypertrophy of the facet joints can be seen,
50% and a negative predictive value of ~60%.33 especially in severe disease.29,40
In a multicenter study, Cohen et al.5 found a weak • CT-­imaging—­is the most sensitive imaging technique
association between a positive response to lumbar facet for detecting degenerative changes in facet joints due
radiofrequency ablation and paraspinal tenderness. In to high contrast visibility between bony structures and
the most recent review on the use of diagnostic tests soft tissue, and its capability to image the joint in mul-
to identify painful structures in chronic low back pain tiple plains.39,40
that included 14 studies evaluating the facet joints, Han • MRI is less sensitive than CT in detecting facet pa-
et al.34,35 found no historical physical exam signs that thology but provides a superior delineation of soft
were predictive of response to diagnostic blocks. tissues compared to other imaging modalities and
has the advantage of detecting the consequences of
facet degeneration on adjacent neural structures, for
Differential diagnosis example, hypertrophy causing foraminal stenosis and
radiculopathy.41,42
In patients presenting with chronic low back pain, the • Bone scintigraphy can be of use in patients in whom
underlying disease should be ruled out with the help of pain is unexplained by MRI or when there are so many
red flags: malignancy, compression fracture, and spinal abnormalities found on MRI that which structure is
infection. However, most red flags lack specificity, with causing the pain is uncertain. Increased metabolic ac-
one retrospective study finding that while red flags in- tivity at a particular site may suggest it as the most
creased the probability of serious spinal pathology, neg- likely origin of symptoms.40
ative red flag screening did not lower the probability of • SPECT can detect active facet joint inflammation
diagnosing serious pathology.36 related to back pain.43 It is the only imaging mo-
Since there are a large number of potential pain gen- dality that provides any prognostic value prior to
erators in the low back, the following pain syndromes MBB, with weak evidence for its predictive value
which can resemble facet joint pain or concurrently exist before intra-­ articular (IA) facet joint injections.
should be considered and ruled out: myofascial pain, The cost-­ effectiveness of SPECT warrants further
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164 |    LUMBAR FACET JOINTS

evaluation.5,44,45 In a systematic review by Han et al.,34 performed in 18 individuals, if vascular uptake was ap-
the authors found informative positive (2.80 [95% CI: preciated during initial needle placement, re-­direction of
1.82–­4.31]) and negative (0.44 [95% CI: 0.25–­0.77]) like- the needle failed to anesthetize the joint in 50% of cases.
lihood ratios for predicting response to diagnostic in- This same study found that 1 in 9 MBB failed to anesthe-
jections based on 3 (n = 121) studies. tize the facet joint against capsular distention, suggest-
ing aberrant innervation. Thus to improve the sensitivity
and specificity of diagnostic/prognostic MBBs, patients
Diagnostic/prognostic blocks should be properly selected and educated before the
blocks and strict interventional criteria should be fol-
When history taking and physical examination suggest lowed, including precise needle location and using low
pain originating from the lumbar facet joint, a diagnos- injectate volumes.1,5,26,35
tic/prognostic MBB can be performed at the suspected A MBB can have a prognostic value for the effect of ra-
painful lumbar level and from one level above (each facet diofrequency on lumbar facet joint pain. The number of
joint receives dual innervation). Studies have shown that blocks and what percent pain relief threshold that should
performing a MBB is the most reliable and appropriate be used as a cut-­off has been discussed extensively. Using
way to diagnose lumbar facet joint pain and is part of the higher cut-­offs for painrelief46,52–­55 and performing dou-
standard diagnostic protocol to select patients for radi- ble MBBs, the number of false positives will be reduced,
ofrequency ablation.5 However, a diagnostic/prognostic but the number of false negatives will increase. Conse-
MBB has some limitations. False negative and positive quently, the success rates of radiofrequency ablation can
rates of a diagnostic/prognostic MBB vary from 25% to increase,52,56 but at the cost of excluding patients who
49%, and are influenced by age, comorbid spinal pathol- could potentially benefit from radiofrequency.
ogy, opioid use, and psychosocial factors. High expec- Numerous studies showing the efficacy of lumbar
tations (indicative of a strong placebo response), use of facet radiofrequency have used ≥50% pain relief from a
sedation, excessive use of superficial local anesthetic, and single prognostic block as an inclusion criterion.46,57–­59
a non-­selective block with leakage of injectate into sur- Studies evaluating health care costs and denervation
rounding pain-­generating structures can cause false pos- success rates using 0, 1 or 2 blocks,46,60 or with differ-
itive responses. A false negative response can result from ent thresholds60 support a one-­ block paradigm with
aberrant innervation, inappropriate needle placement, a threshold of ≥50%. In addition, the relative risks of
failure to detect vascular uptake, and the inability of the radiofrequency ablation are less than those of some al-
patient to discern baseline from procedural pain. To re- ternative treatments such as surgery, and often no other
duce false positives, it is advised to administer the lowest reliable treatment options are available. Some reviews
volume of local anesthesthetic and carefully position the have found superior outcomes when more stringent cri-
needle. In a cadaveric study (n = 6), Wahezi et al.35 found teria are employed; however, studies directly comparing
that both 0.25 and 0.5 mL of contrast bathed the 18 MBB radiofrequency ablation outcomes between 50% pain
and that using lower volumes significantly reduced aber- relief following prognostic blocks and higher cutoff
rant spread to adjacent structures. However with inap- thresholds have consistently failed to detect a difference
propriate techniques, false negatives can occur with low in outcomes, and clinical trials utilizing 2 or 3 blocks
volumes.46 Dreyfuss et al. studied the most ideal needle also adapted other more rigorous selection parameters,
tip position for a lumbar MBB, comparing a needle-­end making head-­ head comparisons impossible.53,61,62
to-­
position at the upper edge of where the transverse process Although not routinely recommended in clinical prac-
and articular process intersect to one midway between tice, for research purposes more stringent criteria in
the upper border of the medial transverse process and at the diagnostic process have been endorsed.61 Double
the mammillo-­accesory ligamentum. When a more cau- blocks can be performed in a placebo-­controlled or a
dad approach at the mammillo-­ accesory ligamentum blinded-­comparative manner (long-­versus short-­acting
was used, lower rates of spread of local anesthetic to the local anesthetic), with the latter being shown to have low
ventral epidural space and spinal nerves were observed sensitivity.5,60,63
(using 0.5 mL injectate volume).47 Incidences of intravas- Weighing all aspects, the latest consensus advises prac-
cular uptake have been reported to range from 3.7% to titioners to perform a single block with ≥50% pain relief
even 22.5%.48 Consequently, intravascular uptake needs (using low injectate volume) before deciding whether to
to be ruled out with contrast before administration of perform radiofrequency treatment.5 Using double-­blocks
the local anesthetic.5,49 Digital subtraction enhances the can be considered for efficacy studies, and if a concern
ability to detect inadvertent vascular flow compared arises about the chance of success of radiofrequency
with live fluoroscopy,50 but is not routinely available and (poor correlation between historical findings, physical
coincides with increased radiation exposure. At least exam and imaging, or when extensive psychological fac-
contrast should be administered during real-­time fluor- tors such as catastrophizing or anxiety emerge).61
oscopy, which is more sensitive than intermittent fluor- Few studies have compared MBB with IA injections
oscopy and aspiration.50 In one study by Kaplan et al.51 to identify painful facet joints and select patients for
 15332500, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/papr.13287 by Instituto Aragones De Ciencias, Wiley Online Library on [03/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VAN den HEUVEL et al.     | 165

radiofrequency.58,64,65 Succes rates of radiofrequency with spinal arthritis. Physical therapy includes core
stratified by the type of prognostic block favor MBB, strengthening, reducing stress on facet joint (reducing
though whether the small difference is clinically mean- lumbar lordosis with pelvic tilting), and aerobic exer-
ingful is unclear. MBBs are easier to perform, have a cise.71,72 It is recommended that conservative therapy is
lower technical failure rate, and are less painful than tried for at least 3 months to support the natural course
IA injections. Hence, numerous guidelines recommend of back pain.5,70 However, there is no evidence that dem-
MBBs as the preferred prognostic screening test before onstrates the ideal timing or optimal duration of con-
lumbar facet radiofrequency.5,66 In selected cases when servative treatments for chronic low back pain. Most
a corticosteroid may be of therapeutic (and diagnostic) studies for interventional treatments required a trial of
value for inflammatory pain, and in whom radiofre- conservative treatment before enrollment. In the elderly
quency is relatively contraindicated, IA injections can be or otherwise frail patients, the effectiveness of conserva-
considered. The total volume injected for IA injections tive treatment can be limited by a reduced physical abil-
should be limited to <1.5 mL to prevent capsular rupture ity or comorbidities.
and reduce spread to surrounding structures.5

Interventional pain treatment

Diagnosis summary
The goals of interventional pain treatment include pain
Currently, there is no gold standard for diagnosing lum- reduction, improved functionality and quality of life, and
bar facet joint pain. History, physical examination, and to reduce side effects from medications. Radiofrequency
diagnostic/prognostic blocks may suggest but not con- of the lumbar medial branch and in selected cases, IA
firm the facet joints as the source of pain. corticosteroid injections can be considered after a posi-
tive diagnostic/prognostic block when conservative
• History: Axial low back pain (not predominantly in the measures fail.
midline) radiating to the flank, posterolateral thigh,
and hip.
• Physical examination: Lumbar paravertebral tender- Radiofrequency
ness worsening with flexion and extension. Pain that
is not predominantly in the midline and tenderness Several systematic reviews have been performed which
overlying the facet joints can have prognostic value for analyzed the efficacy of radiofrequency for pain originat-
interventional treatment. ing from the lumbar facet joints. Included studies show
• Imaging: SPECT can predict the outcome of facet joint heterogeneity regarding design, technique (eg, interven-
treatment, but its cost-­effectiveness requires further tional procedural variations), population (eg, different
study. Plain radiography MRI, CT, and scintigraphy criteria for diagnostic/prognostic blocks, patient selec-
have little or no diagnostic and prognostic correlation tion), and outcome measures. However, they collectively
with pain originating from the facet joints or the ef- show that well-­selected individuals with chronic low back
fects of radiofrequency. originating from the facet joints may benefit from lumbar
• Interventional: A single MBB using ≥50% pain relief as medial branch radiofrequency. Kleijnen et al. performed
the threshold for a positive block has a diagnostic and an extensive review for interventions in chronic low back
prognostic value for lumbar facet joint pain. pain that included 8 trials assessing radiofrequency for
lumbar facet pain. They found that a radiofrequency
procedure might produce better outcomes than a sham
T R E AT M E N T OP T ION S procedure.22,73 A Cochrane analysis in 2015 assessed the
effectiveness of radiofrequency procedures for patients
Conservative treatment with chronic low back pain.74 Twelve RCTs, including 5
placebo-­controlled studies, were included that examined
The general principles for the treatment of nonspecific facet joint pain. In the overall cohort examining any study
low back pain can be applied, including self-­care, patient evaluating radiofrequency denervation for pain, 56% had
education, simple analgesics, and physical therapy.67–­70 a low risk of bias. The authors found moderate evidence
There is little evidence that paracetamol with or with- for the effectiveness of radiofrequency on pain compared
out codeine is effective in chronic low back pain. Non-­ with placebo at <1 month follow-­up (MD pain score −1.47
steroidal anti-­inflammatory drugs (NSAIDs) can be [95% CI −2.28 to −0.67]), and low-­quality evidence for
considered for a short period, and the patient should be an effect on function as measured with Oswestry Dis-
monitored for risks and side effects. Duloxetine is ap- ability Index (ODI) at <1 month (MD ODI −5.53 [95% CI
proved for musculoskeletal pain in the U.S., with the piv- −8.66 to −2.40]) and ≥6 months follow up (MD ODI −3.70
otal studies being performed for axial low back pain and [95% CI −6.94 to −0.47]).74 Several subsequent reviews
knee osteoarthritis, suggesting efficacy in individuals have been published with somewhat different scopes. Lee
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166 |    LUMBAR FACET JOINTS

et al.75 included 7 trials (4 of which were included in the risk for poorer radiofrequency outcomes.82–­84 Studies
Cochrane review) in a meta-­analysis comparing radiofre- have found depression, substance misuse, younger age,
quency to various control treatments such as sham and a greater Cobb angle and more non-­organic (Waddell)
epidural injections. They found that radiofrequency for signs to be associated with negative lumbar facet radiof-
lumbar facet pain resulted in significant reductions in requency outcomes.82 In one study evaluating outcomes
low back pain at 6 months (MD VAS 1.52 [95% CI 0.16 to in 101 Worker's compensation cases, retaining an attor-
–­2.89]) and 12 months (MD VAS 3.55 [95% CI 0.51–­6.59]) ney was associated with a >7-­fold increased risk of post-­
compared with the control group, but no significant treatment physical disability, along with greater bodily
differences at 1–­3 month follow-­ups, though there was pain, functional impairment, and less vitality.83 Since
a strong trend for a greater response rate at these time most chronic low back pain patients present with con-
periods.75 Chen et al.76 performed a meta-­analysis com- comitant lumbar pain generators and psychosocial risk
paring radiofrequency to sham and conservative non- factors, one should ideally consider an interdisciplinary,
surgical approaches (IA injections, anti-­inflammatory multimodal treatment approach that includes address-
medications) for low back pain, with 11 of the 15 included ing the most pressing and impactful conditions. An older
studies evaluating lumbar facet radiofrequency ablation age has been found to be associated with improved pain
(6 of which were included in the Cochrane review). The relief after radiofrequency.61,85,86
authors found that the use of radiofrequency improves Signs during physical examination or response to diag-
patients’ functional outcomes (ODI –­6.08 [95% CI –­11.89 nostic investigations can provide a direction of radiofre-
to −0.27]); p = 0.04) and pain scores (−1.14 [95% CI −1.97 quency outcomes. A multi-­c enter study by Cohen et al.87
to −0.31]) pooled difference on a 10-­point scale) com- in 192 patients found that “facet loading” was associated
pared with other conservative nonsurgical treatments. with a negative outcome, and paraspinal tenderness was
QOL measures were significantly improved in the radiof- associated with a positive outcome. In another large,
requency group as compared to the non-­radiofrequency multi-­ controlled study (n = 424), a higher
c enter, case-­
group, though only two studies were included, one for success rate for radiofrequency was found in patients
facet joint pain. Janapala et al. (2021) performed a sys- who received a MBB compared to an IA injection.65
tematic review and meta-­analysis that included 12 trials
(6 of which were included in the Cochrane review) eval- Imaging for facet joint blocks
uating patients with chronic low back pain who had at For lumbar facet joint injections, image guidance pro-
least one positive MBB, in which pain and function for vides accurate needle placement and improves safety
≥6 months were assessed. They cited level II evidence for through direct visualization of bony elements. Fluoros-
radiofrequency compared with sham (5 trials) or other copy is the preferred technique for lumbar MBB, with
interventions (7 trials) for improvement ≥6 months.77 Li CT guidance occasionally used. CT is associated with
et al.78 performed a meta-­analysis of 10 RCTs (n = 715) more radiation exposure, is more expensive, and is un-
and found similar evidence for the effectiveness of radi- able to detect real-­time intravascular uptake, but may
ofrequency in facet joint pain. be especially useful in the performance of IA injections
A pragmatic controlled study estimated the added where it has been shown to have a higher technical suc-
value of radiofrequency to a standardized exercise pro- cess rate than fluoroscopically-­g uided injections.88
gram for patients with chronic mechanical low back pain The use of ultrasound has garnered dramatic interest
(facet joint pain, sacroiliac joint pain, and a combina- over the past 15 years since it is not associated with ra-
tion group). The primary outcome parameter was pain diation exposure, it provides real-­time visualization of
intensity at 3 months. The study on facet joint pain did targeted tissues and is portable and relatively inexpen-
not find a statistically significant difference in pain re- sive. Disadvantages include limited field visualization,
duction, defined as ≥2 points on Numeric Rating Scale especially in obese patients, a lengthy learning curve,
(NRS, 0–­10) between the 2 groups. The outcomes show the potential for unrecognized inadvertent vascular up-
that the mean difference in pain intensity between the ra- take, and the need to count lumbar vertebral levels, es-
diofrequency procedure group and controls at 3 months pecially in patients with transitional lumbar anatomy, to
was NRS (−0.18 [95% CI −0.76 to 0.40]). There were also avoid treating non-­targeted levels.89 A systematic review
no differences in other outcomes or at other follow-­up and meta-­analysis (n = 22 studies) compared ultrasound-­
moments.57 This study was the subject of numerous criti- guided MBB and IA injections using fluoroscopy and
cisms regarding design, technique, and analysis.79–­81 CT as the reference standards, respectively, Ashmore
et al. found pooled risk differences for inaccurate needle
Biopsychosocial factors influencing outcome of placement of 11% for MBB and 13% for IA injections,
radiofrequency with slightly longer procedure times.5,90
Consistent with the biopsychosocial model of pain,
studies have shown that some psychological, social fac- Alternative radiofrequency administration possibilities
tors and biological factors (previous surgery, radicu- The small size of the target nerves and the limited size
lar signs, predominantly midline pain) have a greater of radiofrequency ablation zone necessitates the need for
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VAN den HEUVEL et al.     | 167

optimizing radiofrequency, which can be performed using subpopulations experiencing acute facet joint inflamma-
conventional, cooled or bipolar ablation, or pulsed ra- tion respond better to IA blocks.99 Ackerman and Ahmad
diofrequency (PRF). During conventional radiofrequency found that IA lumbar injections were more effective than
nerve tissue is ablated by increasing the temperature of MBBs in SPECT-­positive patients (n = 46).100 The study
nerve tissue which interrupts nociceptive signaling. Cooled found ≥50% pain relief in 14/23 IA group vs. 6/23 MBB
radiofrequency, wherein water is circulated through the group and greater disability reduction at 12 weeks in the
probe tip to regulate temperature at the tissue-­tip inter- IA group.100 Another important issue is the high technical
face and reduce tissue charring that can limit lesion ex- failure rate for IA injections which ranges between 29%
pansion, creates a spherical, forward-­ projecting lesion. and 38% per joint, and 46% and 64% per procedure.58,101
Bipolar radiofrequency utilizes two symmetrically situ- In addition to corticosteroids, lumbar facet joint injec-
ated electrodes serving as the anode and cathode, through tion using autologous platelet-­r ich plasma,102 hyaluronic
which current flows to heat the intervening tissue. Similar acid,103 and medical ozone104 have yielded mixed results
to cooled radiofrequency, bipolar radiofrequency creates based on low-­quality studies, and are currently not recom-
large lesions that may increase the nerve capture rate com- mended outside of clinical studies.5,105 Other treatments
pared to conventional radiofrequency, but requires preci- for lumbar facet joint pain such as fluoroscopy-­g uided
sion placement and involves greater tissue trauma. PRF high-­intensity focused ultrasound and percutaneous fix-
utilizes brief pulses of radiofrequency current to induce ation techniques are also devoid of high-­quality data and
voltage fluctuations at the treatment site, thereby mini- are not recommended at this time.106,107
mizing neurotrauma. In multiple randomized trials, con-
ventional radiofrequency has been shown to be superior to
PRF for lumbar facet joint pain.91,92 In a meta-­analysis of COM PL ICAT ION S
21 studies comparing the effectiveness of pulsed, cooled, or
conventional radiofrequency for lumbar facet joint or sac- MBB have a low complication rate, in part because no
roiliac joint pain, Shih et al. found cooled radiofrequency vulnerable structures lie near the target region or along
to be superior to conventional radiofrequency, with PRF the intended track of the needle. Nevertheless, side ef-
providing the least benefit through 12 months follow up. fects/complications can occur and may be related to
No serious complications were reported after receiving general procedural interventions, or lumbar facet inter-
treatment using the three techniques.93 Another system- ventions in particular including equipment malfunction.
atic review confirmed that PRF is less effective than con- All described side effects and complications should be
ventional radiofrequency in reducing pain and functional discussed with the patient.
deficits in patients with lumbar facet pain.94 Patients commonly report some postprocedural
New application forms of radiofrequency are cur- pain, which can be from performing the procedure it-
rently under investigation (eg, cooled RF and multi-­tined self, or post-­procedure neuritis, which can last several
electrodes).95,96 weeks and occurs in between 1% and 10% of individu-
als.108 The cervical and lumbar facet guidelines found
mixed evidence for prevention with gabapentin, and
Other treatment options Grade C evidence for the use of post-­radiofrequency
perineural steroids or oral NSAIDs.5,109 Patients can
Intra-­articular injections also experience a vasovagal (less common than in the
The evidence for IA facet joint injections in low back cervical region) or allergic reactions, and one should
pain is limited, with most systematic reviews failing to be prepared for its treatment.
demonstrate therapeutic utility because of high study het- Temporary paresthesia in the legs and loss of motor
erogeneity and a very small effect size.5,97,98 A systematic function can be caused by extravasation of local anes-
review evaluated 6 RCTs comparing IA facet joint injec- thetics to the segmental nerves or a needle inadvertently
tions with (various) active drug or placebo/inactive injec- placed into a foramen. As noted above, inadvertent
tion and found significant between-­group differences for intravascular injection or overflow of local anesthetic
pain, disability, and outcomes in only 2 of the included can be responsible for false-­negative diagnostic/prog-
studies.98 However, there was a wide range in quality (eg, nostic block but the low volumes injected have not been
only two studies provided information on sample size cal- reported to cause systemic toxicity.47,49 In rare cases,
culation) and no consistent pattern of benefit among the puncturing a blood vessel may result in bleeding and a
6 trials, with most patients improving with or without the retroperitoneal hematoma. After radiofrequency numb-
intervention.98 A recent meta-­analysis included 7 studies ness and/or neuropathic-­type pain in the skin overlying
comparing IA corticosteroid injection versus radiofre- the lumbar paraspinal muscles separate from medial
quency ablation.97 They found lower pain scores at 3, 6, branch neuritis has been reported, possibly resulting
and 12 months and improved functioning at 6 months in from transection of the lateral branches of the lumbar
patients treated with radiofrequency. Despite the concep- dorsal rami.110,111 Unintentional spinal nerve root pares-
tual plausibility, there is little evidence that suggests some thesia or foot drop have been described in medicolegal
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168 |    LUMBAR FACET JOINTS

cases after radiofrequency.112 Improper needle place- When the proximity of the electrode is confirmed with
ment, insertion of multiple electrodes simultaneously sensory stimulation, it is important that a near-­parallel/
with no motor testing, and performing the procedure parallel positioning of the electrode is achieved to envelop
under deep sedation and general anesthesia are factors the targeted nerve in the radiofrequency, as randomized
that contribute to permanent nerve injury.112 and large retrospective studies have found superiority to a
Infection is a risk common to all invasive procedures, perpendicular approach for lumbar facet joint pain118,119
though severe infections like epidural abscess, and verte- (Figure 4). In addition to a greater nerve capture rate (es-
bral osteomyelitis are rare after radiofrequency and have pecially in cases where the medial branch is trapped be-
only been described in case reports.113 neath the mamillo-­accessory ligament) and effectiveness,
Multifidus atrophy has been observed following ra- animal studies suggest that larger lesions result in longer-­
diofrequency. A small study (n = 5) observed diffuse lasting structural changes, which may translate to longer
lumbar multifidus atrophy on a MRI 17–­26 months after benefit.5,120 Lesions expand in a spheroid shape around
radiofrequency; however, radiologists could not reliably the active tip of the electrode; hence perpendicular place-
determine the laterality and levels of treatment.114 A ret- ment has the highest chance of missing the nerve. Strict
rospective study (n = 27) found a trend (p = 0.06) toward parallel placement to the nerve can theoretically produce
measurable segmental changes in multifidus morphol- the largest lesions, though it is important that sensory
ogy after lumbar medial branch radiofrequency. The thresholds are tested because if the electrode is placed
notable change in cross-­sectional area measured with exactly parallel to but adjacent to the nerve outside of
MRI was <10% and more pronounced in females and the lesion circumference, it can miss it altogether.5 Insert-
the elderly.16 Another retrospective study (n = 20) found ing electrodes at an oblique and cephalad angle results
no differences in the paraspinal intramuscular adipose in a larger active tip-­bony target interface and therefore
tissue volume and distribution before and after RFN.115 greater chance of nerve capture, but the precise angle that
An analysis of aforementioned studies on behalf of the optimizes electrode contact has yet to be determined (and
Spine Intervention Society Patient Safety Committee may differ based on individual anatomy).121 Although in-
concluded that despite inconclusive evidence for multif- direct results of randomized trials also support a near-­
idus atrophy after MBB radiofrequency, some degree of parallel approach, these results should be interpreted
atrophy is plausible but requires further study.116 with caution considering the differences in patient selec-
tion, criteria for designating the diagnostic/prognostic
blocks as positive, and other technical parameters.119
Recommendations

Well-­selected individuals with chronic low back origi- Procedure for diagnostic medial branch block
nating from the facet joints may benefit from lumbar me-
dial branch radiofrequency. Patients should be treated in The patient is positioned in a prone position, with a pil-
accordance with guidelines, and stringent interventional low placed under the abdomen to reduce lumbar lordosis,
techniques should be used to reduce technical treatment if necessary. Routinely, 3 lumbar levels are treated at the
failure (i.e., missed nerves) and complications.5 The rec- same time. These are identified by counting downward
ommendations are summarized in Table 2. from Th12. The C-­arm is then angled approximately 15–­
20° obliquely to the ipsilateral side until the joint line be-
tween the SAP and inferior articular process opens up.
Clinical practice algorithm For the L5 dorsal ramus, the C-­arm can be turned less
oblique (0–­10°). The entry point on the skin is marked a
A practice algorithm for the management of lumbar few millimeters caudad to the junction between the SAP
facet pain is illustrated in Figure 3. and transverse process (L1–­L4), or sacral articular pro-
cess and ala (L5).122
The procedure is performed in a sterile manner and
T E C H N IQU E S the skin is anesthetized before needle (10-­c m 22-­G needle
with connection tubing) placement. The needle is slowly
Procedure for diagnostic/prognostic block and advanced in a co-­axial (tunnel) view until bony contact
radiofrequency of the lumbar medial branch is achieved, with regular use of lateral, oblique, and an-
teroposterior fluoroscopic images to ensure safe and ac-
There are several ways to perform lumbar facet radiof- curate needle manipulation. In a lateral view, the needle
requency, and this section elaborates on one technique should be at the base of the SAP posterior to the middle
that has been previously described.1,8,26 We also refer to of the facet line. True lateral images occur when the ilio-
the book “Interventional Pain: A step-­by-­step guide for pectineal lines overlap. In an AP view, the needle should
FIPP exam”.117 touch the base of the SAP.
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VAN den HEUVEL et al.     | 169

TA BL E 2 Summary of recommendations from Cohen et al.5 with permission of the publisher.

Topic Recommendation/findings Level of evidence and certainty

Value of history and physical There are no examination or historical signs that reliably Grade C, low level of certainty
examination to select predict response to lumbar facet blocks. Paraspinal
patients for blocks tenderness and radicular symptomatology may be weakly
predictive of positive and negative blocks, respectively.
The levels targeted should be based on clinical
presentation (eg, tenderness, pain patterns, imaging if
available)
Correlation between imaging There is moderate evidence for SPECT before MBB Grade C, moderate level of certainty
and facet block and RF There is weak evidence for SPECT before IA blocks Grade D, low level of certainty
outcomes, and whether
imaging is necessary before There is weak evidence for MRI, CT, and scintigraphy before Grade D, low level of certainty
blocks MBB and IA blocks

Requirement of conservative Consistent with clinical practice guidelines, we recommend a Grade C, low level of certainty
treatment including 3-­month trial of different conservative treatments before
physical therapy before facet joint interventions
facet blocks
Necessity of image guidance We recommend CT or preferably fluoroscopy be used for Grade C, low level of certainty
for lumbar facet blocks and lumbar MBB, although ultrasound may be considered in
RFA certain contexts. For IA injections, we recommend CT,
although fluoroscopy can be considered in some cases
For RF, we recommend using fluoroscopy Grade B, low level of certainty
Diagnostic and prognostic IA injections are theoretically more diagnostic than MBB, Grade B, low level of certainty
value of facet blocks although they are characterized by a high technical
failure rate and poorer predictive value before RF. Both
MBB and IA injections are better than saline injections as
prognostic tools before RFA
MBB vs. IA injections before MBB should be the prognostic injection of choice before Grade C, moderate level of certainty
RF RF. IA injections may be used for both diagnostic and
therapeutic purposes in some individuals (eg, young
people with inflammatory pain, people at risk of RFA
complications)
Effect of sedation on diagnostic Consistent with guidelines, sedation should not be routinely Grade B, low-­to-­moderate level of
and prognostic utility used in the absence of individual indications certainty
Ideal volume for facet blocks Lumbar MBB should be performed with a volume <0.5 mL to Grade C, low level of certainty
prevent spread to adjacent structures, and IA injections
should be done with a volume <1.5 mL to prevent aberrant
spread and capsular rupture
Therapeutic benefit from MBB We recommend against the routine use of both therapeutic Grade D, moderate level of certainty
and IA injections MBB and IA injections, although we acknowledge
there may be some contexts in which these can be
useful (eg, prolonged relief from prognostic blocks,
contraindications to RF)
Cut-­off for designating a We recommend that >50% pain relief be used as the Grade B, moderate level of certainty
prognostic block as positive threshold for designating a prognostic block as positive
and use of non-­pain score but recognize that using higher cut-­off values may result
outcome measures in higher RF success rates. Secondary outcomes such
as activity levels may also be considered when deciding
whether to proceed with RFA
Number of prognostic blocks We recommend a single block. Although using multiple Grade C, low-­to-­moderate level of
performed before RF blocks may improve RFA success rates, it will also result certainty
in patients who might benefit from RFA being denied
treatment
Evidence for large RF lesions There is indirect evidence, and limited direct evidence, Grade C, low level of certainty that
that techniques that result in larger lesions (eg, larger larger lesions increase the chance of
electrodes, higher temperatures, longer heating times, capturing nerves
proper electrode orientation, fluid modulation) improve Grade I, low level of certainty that larger
outcomes lesions increase the duration of pain
relief

(Continues)
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170 |    LUMBAR FACET JOINTS

TA BL E 2 (Continued)

Topic Recommendation/findings Level of evidence and certainty

Electrode orientation We recommend positioning the electrode in an orientation Grade B, low level of certainty
near parallel to the nerve
Use of sensory and motor Sensory stimulation should be used when single lesions are Grade C, low level of certainty
stimulation before RFA anticipated.
When multiple lesions are planned, the evidence for sensory Grade I, moderate level of certainty
stimulation is inconclusive
Motor stimulation may be beneficial for safety and Grade B, low level of certainty
effectiveness purposes
Mitigating complications Intravascular uptake can adversely affect the validity of Grade C, low level of certainty
MBB and we recommend aspiration and real-­time
contrast injection
Anticoagulation medications should be continued for Grade B, moderate level of certainty
facet blocks and RF, and cases that might warrant
discontinuation should be discussed with relevant
healthcare providers
Injection of steroids after RFA may prevent neuritis Grade C, low level of certainty
Confirming electrode placement in multiple views and using Grade B, low level of certainty
sensorimotor testing may reduce the risk of nerve root
injury
RF can result in paraspinal muscle degeneration and Grade C, low level of certainty
possibly disc degeneration, though the clinical relevance
of this is unclear. We recommend a discussion of this
possibility with patients, and consideration of physical
therapy before and after RF to reduce the risk
Interference with implanted electrical devices can occur, Grade C, low level of certainty
and physicians should consult with relevant healthcare
teams regarding recommendations (eg, programming
pacemakers to asynchronous mode, turning off
neurostimulators). Bipolar modes may be safer than
monopolar, and grounding pads should be placed away
from implanted cardiac devices, but not too close to
the neurotomy site (risk of tissue burn). Avoid excessive
sedation
Burns may occur from equipment malfunction or lesion Grade B, moderate-­to-­h igh level of
extension to the skin (less likely). Checking equipment, certainty
and properly positioning the grounding on a dry, clean-­
shaven lower extremity devoid of scars may minimize this
risk
Spine surgery is associated with lower RFA success rates, Grade C, low level of certainty
and physicians should check the placement of RF probes
in multiple fluoroscopic views and avoid contact with
hardware to prevent thermal injury
Difference in standards Providers involved in clinical trials and clinical practice Grade A, moderate level of certainty
between clinical trials and may have different goals that warrant different selection
clinical practice and performance criteria. Areas that might warrant
discrepancies include the use of contrast during MBB,
number of blocks performed, prognostic block cut-­off
for identifying an RF candidate, and use of sensorimotor
stimulation
Repeating RF We recommend repeating RFA in individuals who obtained Grade B, moderate level of certainty
at least 3 (and preferably 6) months of relief, up to two
times per year. The success rate for repeat RFA decreases
for successive procedures but remains above 50%
Repeating prognostic blocks is not routinely necessary in Grade C, low level of certainty
patients who experience a recurrence of their baseline
pain in a physiological timeframe
Abbreviations: IA, intra-­articular; LA, local anesthetic; MBB, medial branch block; RF, radiofrequency; SPECT, single photon emission computed tomography.
 15332500, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/papr.13287 by Instituto Aragones De Ciencias, Wiley Online Library on [03/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VAN den HEUVEL et al.     | 171

FIGURE 3 Clinical practice algorithm for the treatment of lumbar facet pain.

Sensory stimulation is applied after confirming electrode is slowly wiggled over the transverse process.
the proper needle position and checking impedance. To prevent spinal nerve root injury, the trajectory of
Needle position is generally deemed adequate if con- the electrode is kept over bone as it is advanced. In the
cordant stimulation is obtained at ≤0.5 V for the lower lateral view, the electrode tip should lie at the base of
back. After confirmation of correct needle position, SAP and approximately 1 mm to the posterior border
intravascular needle placement needs to be ruled out of the foramen intervertebral. In anteroposterior view,
with real-­time contrast injection and fluoroscopic ob- the electrode should touch down along the lateral neck
servation. After negative aspiration and administra- of the SAP, just cephalad to the superior border of the
tion of contrast have confirmed a lack of vascular (or transverse process.
intramuscular) uptake, a low volume of local anesthetic Sensory stimulation is performed as discussed above,
is administered. with most studies using concordant stimulation at ≤0.5
volts as the cutoff threshold. In one prospective study,
no correlation was found between sensory stimula-
Procedure for radiofrequency ablation of the tion and lumbar medial branch radiofrequency abla-
lumbar medial branch tion outcomes, which was attributed to numerous other
confounding factors (eg, sedation, age, presence of
Imaging for radiofrequency can either be similar to that neuropathy) mitigating any small effect.123 Next, motor
used for a diagnostic MBB, but a co-­axial view is desira- stimulation at 2 Hz is performed, usually up to 1.5–­2 V
ble, the image intensifier is rotated sharply caudally (30°) or at least 3× the sensory threshold, to confirm suffi-
so that the electrode can be positioned in a near-­parallel cient proximity to the medial branch as well as to rule
orientation to facilitate a cephalad trajectory. The inser- out proximity to the exiting nerve-­root by confirming the
tion point for radiofrequency is at the junction between absence of lower extremity muscle stimulation. In one
SAP and transverse process, or sacral articular process retrospective study, a higher success rate was observed
and ala (L5). when paraspinal muscle contraction was observed at all
The electrode is slowly advanced in a co-­a xial (tun- treated levels than when no twitches were observed.124 At
nel) view until bony contact is achieved, with inter- the L5 level (ramus dorsalis) 2 Hz stimulation does not
mittent use of fluoroscopic images. Once on bone, the always produce prominent contraction of the multifidus
 15332500, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/papr.13287 by Instituto Aragones De Ciencias, Wiley Online Library on [03/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
172 |    LUMBAR FACET JOINTS

at least 90 s, which reduces lesion variability.125,126 The

goal of radiofrequency is to capture the medial branch
with an adequate lesion size and avoid unnecessary in-
jury to non-­t argeted tissues. Medial branches can vary
in location and even in the number of branches that
innervate the facet joint. Some practitioners perform
multiple lesions.127 The effect of temperature and dura-
tion of lesioning were studied in 96 patients with lum-
bar facet joint pain using a single block. No difference
was found in categorical outcomes at 1 and 6-­month
follow-­ups between lesioning at 90°C for 50 s, 85°C for
60 s, or 70°C for 90 s.84 However, this study was under-
powered and experimental studies have found larger
lesions when higher temperatures and longer heating
times are employed, as recommended in the lumbar
facet guidelines.5,126

SU M M A RY

Lumbar facet joint pain is a common source of low back

pain in which controversy exists regarding prevalence,
diagnosis, and treatment, including radiofrequency
parameters. There is no gold standard for diagnosing
pain originating from the lumbar facet joints. Unilat-
eral localized back pain without referral to the lower
leg, worsened with movement, and with paravertebral
tenderness on palpation are suggestive for diagnosis. A
single diagnostic/prognostic MBB (and in selected cases
an IA block) should be used to confirm the diagnosis.
If ≥50% pain reduction is achieved, radiofrequency can
be performed. As for all patients with chronic low back
pain, patients should be treated using a step-­w ise, mul-
tidimensional approach before moving to interventional
F I G U R E 4 Insets illustrate closeup views of the bony and neural techniques.
anatomical landmarks and a schematic representation of the effect
electrode orientation has on nerve ablation. Artistic renditions by
Joe Kanasz ([email protected]). (A) Parallel insertion of electrodes. AU T HOR S C ON T R I BU T ION S
Parallel placement may result in a higher likelihood of missing the Sandra van den Heuvel performed the literature search
nerve than with near-­parallel orientation. (B) Near-­parallel insertion and wrote the manuscript. Van Zundert Jan, Koen Van
of electrodes. This may result in the highest likelihood of medial Boxem, and Kallewaard Jan Willem assisted in the se-
branch nerve ablation. (C) Perpendicular insertion of electrodes.
lection of the literature and revised the manuscript. Jan
This theoretically results in the highest chance of missing the nerve,
which may be more likely when the medial branch is entrapped Van Zundert is the final responsible for this manuscript.
beneath the mammillo-­accessory ligament. From Cohen et al.5 With Cohen Steven and Javier de Andrès Ares, revised and ed-
permission of the publisher. ited the manuscript.

F U N DI NG I N F OR M AT ION
muscle. If leg movement is observed, the needle must be The authors have no sources of funding to declare for
repositioned. this manuscript.
After confirmation of correct electrode placement,
local anesthetic is administered. Before radiofrequency, C ON F L IC T OF I N T E R E ST STAT E M E N T
higher volumes than those administered during diag- The authors declare no conflicts of interest.
nostic/prognostic blocks are sometimes used since local
anesthetic may not only reduce procedure-­related pain, DATA AVA I L A B I L I T Y STAT E M E N T
but has also been shown to enhance radiofrequency This narrative review is based on the existing literature,
lesion size. After a brief time interval waiting for the therefore, data on the used publications are available
local anesthetic to take effect, an 80° burn is created for through PubMed and libraries.
 15332500, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/papr.13287 by Instituto Aragones De Ciencias, Wiley Online Library on [03/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VAN den HEUVEL et al.     | 173

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