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5/31/2013 Disclosures Lumbar Facet Joint Pain: Evidence I have nothing to disclose David J. Lee, MD Professor Pain Management Center Department of Anesthesia Facet Joint Pain Facet Joint Pain Prevalence 60% with degenerative changes by

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Lumbar Facet Joint Pain: Evidence

David J. Lee, MD Professor Pain Management Center Department of Anesthesia

Disclosures

I have nothing to disclose Facet Joint Pain Prevalence

Spinal pain

54-80% lifetime 80-90% resolve in 6 weeks 5-10% persistent 25-75% recurrent and persistent 60% multiple regions

Facet joint pain

54-67% chronic cervical pain 42-48% chronic thoracic pain 15-45% chronic lumbar pain Facet Joint Pain

60% with degenerative changes by age 30 Clinical history, physical exam and diagnostic imagings

are unreliable for facet joint pain and can not reliably predict response to diagnostic facet injections

There is no tissue diagnosis to confirm facet joint pain

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Lumbar Facet Joint Pain

Diagnostic block (single vs comparative) Therapeutic intervention (intra-articular injection vs

medial branch block vs radiofrequency ablation)

Repeat radiofrequency ablation Spinal fusion

Diagnostic Block Validity of comparative local anesthetic blocks confirmed with placebo controlled diagnostic blocks

Comparative local anesthetic blocks in the diagnosis of

cervical zygapophysial joints pain Barnsley et al 1993 Pain

The utility of comparative local anesthetic blocks versus

placebo controlled blocks for the diagnosis of cervical zygapophysial joint pain Lord et al 1995 Clin J Pain

Barnsley L, Lord S, Bogduk N: Comparative local anesthetic blocks in the diagnosis of cervical zygapophysial joints pain. Pain 1993; 55:99-106 Lord SM, Barnsley L, Bogduk N: The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygopophysial joint pain. Clin J Pain 1995: 11:208-13

Diagnostic Block

False positive rate: high

placebo (18-32%) sedation liberal superficial local anesthetic spread of injectate

False negative rate:11%

Hogan QH, Abram SE: Neural blockade for diagnosis and prognosis: a review. Anesthesiology 1997; 86:216-41 Kaplan M, et al: The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint: a physiologic challenge. Spine 1998; 23:1847-52

Diagnostic Block

Retrospective review 438 patients Comparative local anesthetic blocks Outcome: >=80% pain relief and ability to perform

painful movement

Multiple regions: 38%

Patient Single Double Prevalence False Positive Bilateral Cervical 251 175 97 39% 45% 72% Thoracic 65 38 22 34% 42% 80% Lumbar 303 150 83 27% 45% 79%

Manchukonda R, et al: Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech 2007; 20:539-45

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Lumbar Facet Joint Pain

Diagnostic block (single vs comparative) (2) Therapeutic intervention (intra-articular injection vs

medial branch block vs radiofrequency ablation)

Repeat radiofrequency ablation Spinal fusion

Diagnostic Block

Review of literature 10/2004 to 12/2006 Comparative local anesthetic blocks Outcome: >50% pain relief Cervical:

strong/II

Thoracic:

moderate/III

Lumbar:

strong/II

Intra-articular injections vs medial branch blocks

Sehgal N, et al: Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician 2007; 10:213-28 Marks RC, Houston T, Thulbourne T: Facet joint injection and facet nerve block: a randomized comparison in 86 patients with chornic low back pain. Pain 1992; 49:325-8

Diagnostic Block

Review of literature 1966 to 6/2012 Lumbar medial branch blocks Single or comparative local anesthetic blocks Outcome: 50-74% or 75-100% pain relief and ability to

perform painful movement

Falco F, et al: An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician 2012; 15:869-907

Diagnostic Block

Level of evidence: U.S. Preventive Services Task Force

(USPSTF)

Evidence Single block, 50-74% relief (1) Poor Single block, 75-100% relief (4) Limited Comparative blocks, 50-74% relief (5) Fair Comparative blocks, 75-100% relief (13) Good

Falco F, et al: An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician 2012; 15:869-907

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Level of Evidence

Grade Definition

Good Evidence includes at least 2 consistent, higher quality RCTs or studies of diagnostic test accuracy. Fair Evidence is includes at least 1 higher quality RCT or study of diagnostic test accuracy. Limited

r Poor

Evidence is insufficient to assess effects on health outcome.

Adapted and modified from methods developed by U.S. Preventive Services Task Force (USPSTF)

Diagnostic Block

Retrospective 262 patients Single local anesthetic block Outcome: >=50% pain relief after radiofrequency ablation

persisting >=6 months and Global Perceived Effect (GPE)

Degree of pain relief from medial branch blocks does not

correlate with outcome from radiofrequency ablation

Not to be extrapolated to controlled or comparative local

anesthetic blocks

Patients Pain Relief GPE >=50%<80% 145 52% 67% >=80% 117 56% 66%

Cohen S, et al: Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. The Spine Journal 2008; 8;498-504

Diagnostic Block

Strong evidence for diagnostic accuracy No consensus

Intra-articular injection vs medial branch block >=50% vs >=80%

Comparative blocks: decrease false positive rate, increase

false negative rate Lumbar Facet Joint Pain

Diagnostic block (single vs comparative) Therapeutic intervention (intra-articular injection vs

medial branch block vs radiofrequency ablation) (4)

Repeat radiofrequency ablation Spinal fusion

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Therapeutic Intervention

Review of literature 11/2004 to 12/2006 Outcome: pain relief, functional improvement,

psychological status, and return to work

Intra-articular injections and medial branch blocks

Short term: <6 weeks Long term: >=6 weeks

Radiofrequency ablation

Short term: <3 months Long term: >=3 months

Boswell M, et al: A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10:229-53

Therapeutic Intervention

Level of evidence: Manchikanti et al

Evidence Evidence Short Term Long Term Cervical Intra-articular (1) Limited IV IV MBB (1) Moderate III III RFA (1) Moderate III III Thoracic MBB Moderate III III RFA Indeterminate V V Lumbar Intra-articular (2) Moderate III III MBB (2) Moderate III III RFA (1) Moderate III III

Boswell M, et al: A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10:229-53

Level of Evidence

Level I

Conclusive: Research-based evidence with multiple relevant and high-quality scientific studies or consistent reviews of meta-analyses

Level II

Strong: Research-based evidence from at least 1 properly designed randomized, controlled trial; or research-based evidence from multiple properly designed studies of smaller size; or multiple low quality trials

Level III

Moderate: a) Evidence obtained from well-designed pseudorandomized controlled trials (alternate allocation or some

ther method);

b) Evidence obtained from comparative studies with concurrent controls and allocation not randomized (cohort studies, case-controlled studies, or interrupted time series with a control group); c) Evidence obtained from comparative studies with historical control, 2 or more single-arm studies, or interrupted time series without a parallel control group

Level IV

Limited: Evidence from well-designed nonexperimental studies from more than 1 center or research group;

r conflicting evidence with inconsistent findings in multiple trials

Level V

Indeterminate: Opinions of respected authorities, based on clinical evidence, descriptive studies, or reports

f expert committees

Manchikanti, et al: Methods for evidence synthesis in interventional pain management. Pain Physician 2003; 6:89-111

Therapeutic Intervention

Review of literature 1966 to 12/2008 Diagnostic with controlled local anesthetic blocks

Outcome: >=80% pain relief and ability to perform painful activities

Therapeutic facet intra-articular injections, MBBs and RFA

Primary outcome: pain relief and long-term follow up Secondary outcome: improved functional status, psychological status, return to work, and reduction in opioids

Datta S; et al: Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician 2009; 12:437-60

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Therapeutic Intervention

Level of evidence: USPSTF Grade of recommendation: Guyatt et al

Evidence Recommendation Diagnostic (7) I or II1 Intra-articular Injection III Limited2C/very weak Medial Branch Blocks (2) II1 or II2 Strong 1B/1C Radiofrequency Ablation (1) II2 or II3 Strong 1B/1C

Datta S; et al: Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician 2009; 12:437-60

Level of Recommendation

Grade of Recommendation/Description Benefit vs Risk and Burdens Methodological Quality of Supporting Evidence Implications 1A/strong recommendation, high-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1B/strong recommendation, moderate quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1C/strong recommendation, low-quality or very low quality evidence Benefits clearly outweigh risk and burdens, or vice versa Observational studies or case series Strong recommendation but may change when higher quality evidence becomes available 2A/weak recommendation, high-quality evidence Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ or societal values 2B/weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ or societal values 2C/weak recommendation, low-quality or very low quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Observational studies or case series Very weak recommendations;

ther alternatives may be equally

reasonable Adapted from Guyatt G et al. Grading strength of recommendations and quality of evidence in clinical guidelines. Report from an American College of Chest Physicians task force. Chest 2006; 129:174-181 (104).

Therapeutic Intervention

Review of literature 1966 to 6/2012 Therapeutic facet intra-articular injections, MBBs and RFA Primary outcome: >=50% pain relief or >=3 VAS change

Short term: <=6 months Long term: >6 months

Secondary outcome: >=40% functional improvement,

psychological status, return to work, and reduction in

pioids

Falco F, et al: An Update of the Effectiveness of Therapeutic Lumbar Facet Joint

Interventions. Pain Physician 2012; 15:909-53

Therapeutic Intervention

Level of evidence: U.S. Preventive Services Task Force

(USPSTF)

Evidence Evidence Short Term Long Term Intra-articular (2) Limited Limited MBB (3) Fair to Good Fair to Good RFA (7) Good Good

Falco, F, et al: An Update of the Effectiveness of Therapeutic Lumbar Facet Joint

Interventions. Pain Physician 2012; 15:909-53

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Level of Evidence

Grade Definition

r Poor

Evidence is insufficient to assess effects on health outcome.

Adapted and modified from methods developed by U.S. Preventive Services Task Force (USPSTF)

Therapeutic Intervention

Recommendation: Guyatt et al, adapted by van Kleef et al Radiofrequency ablation: recommended Intra-articular steroid injection: reserved for nonresponders

to RFA

Comparative local anesthetic blocks: false negative rate

Recommendation Radiofrequency Ablation 1B+ Intra-articular steroid injection 2B+/-

van Kleef M, et al: Evidence-based medicine: pain originating from the lumbar facet joints. Pain Practice 2010; 10: 459-69

Level of Recommendation

Score Description Implication 1 A+

Effectiveness demonstrated in various RCTs of good quality. The benefits clearly outweigh risk and burdens Positive recommendation

1 B+

One RCT or more RCTs with methodologic weaknesses, demonstrate effectiveness. The benefits clearly

utweigh risk and burdens

Positive recommendation

2 B+

One or more RCTs with methodologic weaknesses, demonstrate effectiveness. Benefits closely balanced with risk and burdens Positive recommendation

2 B+/-

Multiple RCTs, with methodologic weaknesses, yield contradictory results better or worse than the control

treatment. Benefits closely balanced with risk and burdens, or uncertainty in the estimates of benefits, risk

and burdens Considered, preferably study-related

2 C+

Effectiveness only demonstrated in observational studies. Given that there is no conclusive evidence of the effect, benefits closely balanced with risk and burdens Considered, preferably study-related There is no literature or there are case reports available, but these are insufficient to suggest effectiveness and/or safety. These treatments should only be applied in relation to studies Only study-related

2 C-

Observational studies indicate no or too short-lived effectiveness. Given that there is no positive clinical effect, risk and burdens outweigh the benefit Negative recommendation

2 B-

One or more RCTs with methodologic weaknesses, or large observational studies that do not indicate any superiority to the control treatment. Given that there is no positive clinical effect, risk and burdens outweigh the benefit Negative recommendation

2 A-

RCT of a good quality which does not exhibit any clinical effect. Given that there is no positive clinical effect, risk and burdens outweigh the benefit Negative recommendation van Kleef M, et al: Evidence based guidelines for interventional pain medicine according to clinical diagnoses. Pain Pract. 2009; 9:247–51

Lumbar Facet Joint Pain

Comparative blocks: best available diagnostic method Radiofrequency ablation: best available treatment Intra-articular injection: reserved for non-responders to

RFA

Diagnostic Intra-articular MBB RFA Sehgal et al 2007 II Falco et al 2012 Good Boswell 2007 III III III Datta et al 2009 I or II1 III II1 or II2 II2 or II3 Falco et al 2012 Limited Fair to Good Good

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Therapeutic Intervention

RCT
151 patients
Zero, single and comparative local anesthetic blocks
0.5 ml 2% Lidocaine and 5 mg Depomedrol prior to

radiofrequency ablation

Outcome: >=50% pain relief persisting >=3 months and Global

Perceived Effect (GPE)

Cohen P, et al: Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology 2010; 113:395-405

Therapeutic Intervention

RFA without diagnostic injection: highest success rate
0.5 ml 2% Lidocaine and 5 mg Depomedrol prior to RFA
Comparative local anesthetic block: more reliably predict
utcome from RFA with lower pain and disability scores

Patients Outcome RFA Pain Disability Medications GPE RFA 51 17(33%) 33% 6.3 21 36% 74.2% 1 MMB + RFA 50 8(16%) 39% 4.5 15.5 81.8% 91.7% 2 MMBs + RFA 50 11(22%) 64% 2 10 87.5% 100%

Therapeutic Intervention

RFA without diagnostic injection: most cost effective

1st Level Subsequent Level MBB $350 $170 RFA $650 $325 Cost (>=3 Months) RFA $6286 1 MBB + RFA $17142 2 MBBs + RFA $15241

Lumbar Facet Joint Pain

Diagnostic block (single vs comparative) Therapeutic intervention (intra-articular injection vs

medial branch block vs radiofrequency ablation)

Repeat radiofrequency ablation (3) Spinal fusion

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Radiofrequency Ablation Success with repeat facet radiofrequency ablation

Effectiveness of repeated radiofrequency neurotomy for

lumbar facet pain Schofferman et al 2004 Spine

The effect of repeated zygapophysial joint radiofrequency

neurotomy on pain, disability, and improvement duration Rambaransingh et al 2010 Pain Med 10 months duration, same when repeated

Schofferman J, Kine G: Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine 2004; 29:2471-3 Rambaransingh B, Stanford G, Burnham R: The effect of repeated zygapophysial joint radiofrequency neurotomy on pain, disability, and improvement duration. Pain Med 2010; 11:1343-7

Radiofrequency Ablation

Review of literature Outcome: Duration of pain relief after initial and

repeated radiofrequency ablation

Initial: 7 to 9 months Repeat: 6 to 12.7 months

Smuck M, et al: Success of initial and repeated medial branch neurotomy for zygopophysial joint pain: a systematic review. PM R 2012; 4:686-92

Lumbar Facet Joint Pain

Diagnostic block (single vs comparative) Therapeutic intervention (intra-articular injection vs

medial branch block vs radiofrequency ablation)

Repeat radiofrequency ablation Spinal fusion

Diagnostic Block Before Lumbar Fusion

Evidence does not support using diagnostic lumbar facet

blocks as a predictive tool before spinal fusion

Cohen et al 2007 Anesth Analg

Cohen S, Hurley R: The ability of diagnostic spinal injections to predict surgical outcomes. Anesth Analg 2007; 105:1756-75

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Low Back Pain After Lumbar Fusion

Most common source is sacroiliac joint, followed by disc,

facet joint, and soft tissue irritation by hardware

Sacroiliac joint pain prevalence: 13% in non-fused, 43%

in fused

Disc pain prevalence: 45% in non-fused, 25% in fused

DePalma M, et al: Etiology of chronic low back pain in patients having undergone lumbar fusio Pain Medicine 2011; 12:732-39

Radiofrequency Ablation After Lumbar Surgery

479 had microsurgical lumbar disc surgery 120 had persistent back pain Comparative local anesthetic and steroid blocks with

>=80% pain relief

34 had positive response to diagnostic block Outcome: >50% pain relief for at least 6 months 20 had positive outcome Radiofrequency ablation success rate: 58.8%

Klessinger S: Zygapophysial joint pain in post lumbar surgery syndrome. The efficacy of medial branch blocks and radiofrequency neurotomy. Pain Medicine 2012; 12:732-39

Conclusion

Facet joint pain: prevalent, bilateral, multiple regions History, physical exam and diagnostic imaging: unreliable Diagnostic block: high false positive rate (45%) and false

negative rate (11%)

Comparative blocks: best available standard, decrease false

positive rate, increase false negative rate

Debate: Intra-articular injection vs medial branch block,

>=50% vs >=80% Conclusion

Radiofrequency ablation: recommended Intra-articular injection: reserved for non-responders to

RFA

Repeat radiofrequency ablation: duration of pain relief

maintained

Diagnostic block as a predictive tool before spinal fusion:

not supported by evidence

Source of pain after spinal fusion: sacroiliac joint (43%),

followed by disc (25%), and facet joint

Radiofrequency ablation after lumbar surgery: success rate