FR Facet Joint Injections

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Facet Joint Injections

Panel findings and recommendations:

- Facet joint injections are invasive and not recommended for use in the treatment of patients with low back problems. (Strength of Evidence = C.)

In treatment of low back problems, facet joint injections involve the injection of local anesthetics and/or corticosteroids into or around facet joints of the lumbar spine, with needle placement aided by fluoroscopy. The theoretical basis is that some patients with low back problems have a "facet syndrome" with pain arising from facet joints. The facet syndrome reportedly involves patients with primarily low back pain (unilateral or bilateral) and no root tension signs or neurologic deficits, the pain usually being aggravated by extension of the spine.191 The therapeutic objective of facet joint injections is temporary relief from motion-limiting pain so the patient may proceed into an appropriate exercise program.198

Facet Joint Injections

Literature Reviewed Evidence on Efficacy Potential Harms and Costs Summary of Findings Author's Example

Facet Joint Injections

Literature Reviewed. Of 17 articles screened for this topic, 5 RCTs met review criteria.191,192,193,194,195 Other articles contained information used by the panel, but did not meet criteria.196,197

Evidence on Efficacy. No articles were found evaluating patient groups who had only low back problems of less than 3 months' duration. One study evaluated a mixed group of acute and chronic patients with pretreatment symptom durations ranging from 1 to 12 months. 191 Three articles evaluated patients with low back pain of over 3 months' duration. 192, 193, 194 One study did not specify symptom duration before treatment.195

Injections were made either into facet joints or into pericapsular areas around facet joints. The latter type of injection was also referred to as a "facet nerve block" when a local anesthetic was used. Medications injected included steroids, local anesthetics, and saline (either alone or in combination).

Three studies evaluated a combination of steroid and local anesthetic injected into either facet joints or pericapsular areas.193, 194, 195 Three studies evaluated groups receiving facet joint injections in which steroid was compared with saline,192 or local anesthetic was compared with saline,191 or a combination of steroid and local anesthetic was compared with saline.193

None of the five studies that met review criteria found any significant differences between groups for patient-rated pain relief or global improvement scores during followup periods of up to 3 months after treatment. The only study with followup beyond 3 months found significantly greater improvement in pain and functional disability ratings at 6 months followup for the group receiving steroid facet injections compared with saline facet injections, but no significant differences between groups in number of patients who had sustained improvement over the entire 6-month followup period.192

Potential Harms and Costs. Some of the articles reviewed noted transient local pain at the injection sites. The risks of facet joint injections include potential infection, hemorrhage, neurologic damage, and chemical meningitis,196,187 as well as x-ray exposure from fluoroscopy. Facet injections are considered a moderate- to high-cost treatment.

Summary of Findings. No studies have adequately investigated the efficacy of facet injections for patients with low back problems. However, there were an adequate number of studies evaluating facet injections for chronic low back problems.192, 193, 194, 195 One study evaluated a mix of acute and chronic problems.191 Neither the type of agent injected (steroid, local anesthetic, saline, or a combination of these) nor the location of the injection (intrafacet or pericapsular) made a significant difference in patient outcomes during the first 3 months after treatment or in the percentage of patients with sustained improvement over 6 months.

Based on limited research evidence, facet joint injections appear to be associated with rare potential serious complications and do not appear to be effective for treating low back problems.

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