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Effectiveness of Lumbar Facet Joint Blocks and Predictive Value before Radiofrequency Denervation: The Facet
Steven P Cohen1, Tina L Doshi, Octav C Constantinescu
1From the Department of Anesthesiology and Critical Care Medicine (S.P.C., T.L.D., M.A.-W.) the Department of Neurology and Physical Medicine and Rehabilitation (S.P.C.) The Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology (S.P.C., S.R.G.) Department of Physical Medicine and Rehabilitation (S.P.C., M.B.J., W.J.K., P.F.P.) Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany (O.C.C.) Department of Neurology, District of Columbia Veterans Affairs Hospital, Washington, District of Columbia (Z.Z.) Physical Medicine and Rehabilitation Service, Department of Orthopedic Surgery (P.F.P.) Pain Treatment Center, Anesthesia Service, Department of Surgery (A.J.V., C.K., D.E.J., S.R.G.) Walter Reed National Military Medical Center, Bethesda, Maryland; Parkway Neuroscience and Spine Institute, Hagerstown, Maryland (T.M.L., S.E.S.) Puget Sound Veteran's Hospital, Seattle, Washington (T.C.D.) Department of Pain Medicine, David Grant U.S. Air Force Medical Center, Travis Air Force Base, California (R.L.W.) Pain Medicine Center, Department of Anesthesiology, Naval Medical Center-San Diego, San Diego, California (I.M.F.) Department of Anesthesiology, University of Washington, Seattle, Washington (T.C.D.).
What We Already Know About This Topic:
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: With facet interventions under scrutiny, the authors' objectives were to determine the effectiveness of different lumbar facet blocks and their ability to predict radiofrequency ablation outcomes.
Methods:
A total of 229 participants were randomized in a 2:2:1 ratio to receive intraarticular facet injections with bupivacaine and steroid, medial branch blocks, or saline. Those with a positive 1-month outcome (a 2-point or more reduction in average pain score) and score higher than 3 (positive satisfaction) on a 5-point satisfaction scale were followed up to 6 months. Participants in the intraarticular and medial branch block groups with a positive diagnostic block (50% or more relief) who experienced a negative outcome proceeded to the second phase and underwent radiofrequency ablation, while all saline group individuals underwent ablation. Coprimary outcome measures were average reduction in numerical rating scale pain score 1 month after the facet or saline blocks, and average numerical rating scale pain score 3 months after ablation.
Results:
Mean reduction in average numerical rating scale pain score at 1 month was 0.7 ± 1.6 in the intraarticular group, 0.7 ± 1.8 in the medial branch block group, and 0.7 ± 1.5 in the placebo group; P = 0.993. The proportions of positive blocks were higher in the intraarticular (54%) and medial branch (55%) groups than in the placebo group (30%; P = 0.01). Radiofrequency ablation was performed on 135 patients (45, 48, and 42 patients from the intraarticular, medial branch, and saline groups, respectively). The average numerical rating scale pain score at 3 months was 3.0 ± 2.0 in the intraarticular, 3.2 ± 2.5 in the medial branch, and 3.5 ± 1.9 in the control group (P = 0.493). At 3 months, the proportions of positive responders in the intraarticular, medial branch block, and placebo groups were 51%, 56%, and 24% for the intraarticular, medial branch, and placebo groups, respectively (P = 0.005).
Conclusions:
This study establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation.
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