The following article has been accepted for presentation at the first joint meeting of the North American Spine Society and The American Pain Society in April 1998 in Charleston, South Carolina.

MODIFIED PROTOCOL FOR DIAGNOSIS AND TREATMENT OF FACET JOINTS PAIN SYNDROME 

Y. Eugene Mironer, M.D., Judson J. Somerville, M.D.
Carolinas Center For Advanced Management Of Pain,
Spartanburg-Greenville, SC 

Facet joints pain syndrome is a well recognized entity, that presents in patients of different age and gender with or without previous surgery. Selection of the patients for RF facet denervation is still the center of debate. We tested a modified 3-step protocol for diagnosis and treatment of facet joints pain.

Methods. 148 patients with suspected facet joints pain were included in the protocol. Average age was 52. 59.5% were female and 40.5% male. 35.8% had undergone previous back surgery, 31.8% had unilateral pain and received unilateral treatment. The levels of injection varied from 1 to 3. Intraarticular injections and medial branch nerve blocks were performed using techniques described elsewhere. Each joint was injected with 1 ml of 0.5% bupivacaine and 5 mg of Depomedrol. Patients with at least 60% improvement that lasted longer than 2 months were observed and reinjected in the same fashion as needed. Those who experienced 60% relief of pain for less than 2 months underwent medial branch nerve block with 1 ml of 0.5% bupivacaine. Reduction of pain level by 60% or more was the indication for RF. Denervation was carried out with Leskell RF generator (Electa) using standard protocol. Follow-up interval ranged from 4 to 15 months. 

Results. Of 148 patients who received facet joints injection of bupivacaine and steroid, 28.4% had relief of at least 60% that lasted longer than 2 months. Those were observed and 8 had reinjection on the average 4.8 months later with good results. 34.5% didn't have adequate relief and were treated with other modalities. 48 received medial branch nerve block. 15 patients didn't meet the criteria of pain relief after procedure, while 33 had 60% or better relief. 29 out of this 33 patients underwent RF. Only 6 didn't have significant or prolonged improvement. Of the rest 23, two had repeated and successful RF 7 months later. As a result of our treatment 67.0% patients, who responded to initial injection, received prolonged and significant relief of pain. Statistical analysis revealed two noticeable associations: increased number of negative responses to initial injection in patients with unilateral pain and patients with previous back surgery, as well as reduced number of long-term improvement after steroids in the last group.

Discussion. There is no adequate protocol of diagnosis and treatment of facet joints pain in the literature. Intraarticular steroids have not been proved statistically effective, but still endorsed by multiple authors as valid modality of treatment. More than 1 in 4 patients in our study obtained prolonged relief after this procedure. We strongly feel that it should be a part of the treatment protocol. Review of literature showed that any single procedure is not enough to adequately screen for false-positive results. In our study 31.2% of the patients who "passed" the first test were eliminated after second diagnostic block. In our opinion, using medial branch block as the only type of injection will put in disadvantage those who obtain sustained improvement after intraarticular injection. Suggested by many authors consecutive use of short and long-acting local anesthetics to eliminate false-positive results has our strong objection. Many patients were reported to have prolonged decrease in pain even after normal saline injections. We are concerned that by "labeling" patients, who couldn't differentiate local anesthetics by the length of their action, as false positives, we will be losing good candidates for RF. The protocol used in the study worked by providing extended improvement to significant number of patients and helping with elimination of false-positive results judging by nearly 80% success of RF. In our opinion a larger population study for a more prolonged period of time needed to confirm the efficacy of the suggested protocol.