Ask the Experts: Which Treatment Is Best for Lumbar Facet (Low Back) Pain?
The first time it happened, you twisted to reach for something behind your desk at work and—suddenly—there was a sharp pain in your lower back. The pain subsided when you twisted back around, so you figured you just overextended yourself and put it out of your mind.
A month later, you were in a yoga class. As you twisted your torso into a pose, you felt a similar sharp pain in your lower back—only, this time, the pain radiated down into your right buttock and groin. “I’ve never had back problems,” you thought to yourself. “I take great care of myself—I’m one of the most fit and flexible people I know.”
Caught off guard by the pain, you quickly excused yourself from class.
It’s been a year, now, and you’ve had low back pain on and off, especially when twisting, and sometimes when standing. You see a spine specialist, who suspects that your low back pain may be caused by a problem with your lumbar facet joints. The doctor will need to run some additional tests to be sure.
Low-Back Pain Is Common
Fitness and flexibility aside, lumbar facet pain can affect anyone, but it’s especially common in older people. Facet joint disorders are some of the most common recurrent low-back and neck problems.
We’ll briefly describe the facet joints of the lumbar spine (the source of lumbar facet pain) and available treatments before hearing the experts weigh in on which treatment they believe is best for treating this kind of low-back pain.
The Lumbar Facet Joints
The spinal column is divided up into four segments (or levels); from top to bottom, they include the cervical, thoracic, lumbar, and sacral spine segments. Each level has two facet joints and a large disc in front that make up each intervertebral segment.
The facet joints keep the spinal vertebrae aligned; they are located at the top of the cervical spine in the neck, all the way down to the lumbar spine in the lower back. Each facet joint has two small spinal nerve branches called medial nerves.
What Causes Lumbar Facet Pain?
An injury or accident can cause lumbar facet pain, but the most common cause is the degeneration of or arthritis of the facet joints. The pain is usually confined to the lower back, but it can travel into the buttocks and down the back of the thigh. It’s rare for the pain to travel below the knee, as commonly happens with disc herniation.
Most people with lumbar facet joint problems experience lower back pain that becomes worse with twisting, standing, or bending backward.
How Is Lumbar Facet Pain Treated?
There are several options for treating the pain and symptoms caused by facet joint problems. They include:
- Oral anti-inflammatory medications to help reduce pain and inflammation.
- Physical therapy to help improve the strength and endurance of the muscles in the lumbar spine.
- Epidural steroid injections (ESIs) to help relieve some of the pain and discomfort of facet joint problems, by reducing inflammation. Read more about ESIs.
- Medial branch (nerve) blocks to help doctors confirm that facet problems are, in fact, the cause of the pain. The spine doctor injects anesthetic near the small medial nerves, which are connected to the facet joint. If the patient experiences pain relief immediately after the injection, then the facet joint is determined to be the source of the pain. Nerve blocks provide only short-term relief.
- Radiofrequency neurotomy (RFN) is also called radiofrequency ablation, and it is a minimally-invasive procedure in which a heat lesion (burn area) is created on the irritated nerve tissue in order to interrupt the pain signals to the brain, thus eliminating pain.
Radiofrequency currents are applied through an electrode placed near the target nerve to interrupt the pain signal to the brain.
- With conventional RFN, radiofrequency currents generate heat of 80-90°C (176-194°F) around the nerve to create the lesion.
- With cooled RFN, water-cooled radiofrequency (60°C/140°F) is used to create the lesion.
- Spine Surgery may be necessary to relieve nerve root compression from disorders of the lumbar spine, such as degenerative disc disease, spinal instability, or spinal stenosis.
A Case of Intermittent Low Back Pain
Let’s look at a case study of a patient with lumbar facet (low back) pain and hear what the experts have to say about the best treatment plan for her.
(Unless otherwise indicated, the remainder of this article is based on the point/counterpoint discussion referenced under source #1 at the end of this article).
Fifty-nine-year-old Selena has been experiencing low back pain on her right side, on and off, for the last several years. She has no history of trauma or injury. The pain gets worse when she stands in place but improves when she walks or sits. She tells the doctor at the spine clinic that the pain is only on her right side in the lower back and buttocks area.
The spine doctor performs a physical exam on Selena and finds that her sensor, motor, and muscle stretch reflexes are all normal. Selena tells the doctor she experiences pain when she extends or twists her spine. Selena’s doctor knows this indicates an issue with her lumbar (lower) spine. Selena’s doctor orders an MRI (magnetic resonance imaging) of her lower spine, which shows mild disc degeneration and evidence of problems with the facet joints (facet arthropathy).
Selena is diagnosed with lumbar facet-mediated pain and is treated with medial branch blocks (which involve injecting anesthesia to numb the pain). She responds well to two sets of medial branch blocks, experiencing an 80% reduction in pain.
Since medial branch blocks only relieve pain temporarily, she returns to the clinic to find out what her next step is. Selena recently saw an advertisement for cooled radiofrequency neurotomy (RFN) and would like to consider this option.
Which Treatment Approach Is Most Appropriate for Selena? A Q&A with the Experts
Four doctors weigh in on which treatment they feel is best for Selena. All of the doctors agree that radiofrequency neurotomy (RFN), which uses heat lesions on nerve tissue to interrupt pain signals, is the best option for Selena, but they don’t all agree on whether cooled RFN or conventional RFN is the best option.
Two of the doctors advocate for cooled RFN, arguing that this procedure is safe and results in good outcomes for patients.
The other two doctors argue that there is limited evidence showing the benefits of cooled RFN, and that the cost of this procedure does not justify its use.
Let’s drill down on how they made their assessments and arrived at their conclusions.
Q: Which type of RFN do you recommend, and why?
Physicians #1 & #2:
Selena has a common condition that is widely seen throughout pain practices in the U.S. Selena received two medial nerve branch blocks (the most reliable and valuable tool for diagnosing facet joint problems), which reduced her pain by more than 80%. Selena’s positive response to the diagnostic medial blocks confirmed her arthropathy diagnosis.
Typically, patients like Selena who have facet arthropathy that has been confirmed by medial nerve branch blocks are good candidates for RFN, assuming that other treatments, such as physical therapy and anti-inflammatory medications, have not resolved the issue.
For many years, pain physicians have used conventional RFN to reduce pain from facet joints, but it’s important to understand the limitations of conventional RFN. We must also take into consideration that many patients with chronic low-back pain from facet arthropathy also have significant disc degeneration in the spine with bone spurs and calcium build-up that make it difficult to access the problem area.
We believe cooled RFN is preferable for the following reasons:
- Cooled RFN creates a sphere-shaped lesion that covers a greater area than conventional RFN, increasing the chances for pain relief.
- Cooled RFN is a more efficient, faster procedure.
- Cooled RFN is better for patients with a low pain tolerance, as it uses lower temperatures for a shorter period of time than conventional RFN.
Our clinic recently completed a small study of 60 patients and found that the imaging time of conventional RFN was significantly longer than that of cooled RFN. Additionally, a 2012 review found stronger evidence for the therapeutic benefits of cooled RFN than conventional RFN; this was largely attributable to the larger burn area with cooled RFN.
In summary, we believe that cooled RFN is as safe as conventional RFN for treating low-back pain, has better results due to the larger burn area, and has shorter procedure times. Therefore, we recommend cooled RFN for treating Selena’s lumbar facet pain.
Physicians #3 & #4:
Selena’s case of chronic low-back pain is a common one, and her MRI indicates facet arthropathy, a diagnosis that is further confirmed by two diagnostic medial branch blocks.
Numerous studies and clinical trials confirm the safety and effectiveness of conventional RFN, which is considered the standard treatment for facet pain and can provide pain relief for 6-12 months.
Cooled RFN is thought to create a bigger lesion, which can help address anatomical differences in patients. Even so, we suggest using conventional RFN in Selena’s case for the following reasons:
- Conventional RFN allows the electrodes to be placed parallel to the target nerve, which allows for the creation of a smaller, more precise lesion—ultimately, the goal is not to make a larger lesion, but a more precise one.
- The safety of using cooled RFN (which the other physicians are recommending) for low-back pain caused by lumbar facet arthropathy has never been evaluated. We are not aware of a single study that has been published on the use of cooled RFN for lumbar facet pain.
- RFN is more cost-effective than cooled RFN; looking beyond Selena’s case, alone, the routine use of cooled RFN will increase health care costs in the U.S.
- It is concerning to create a large lesion (as with cooled RFN) in the spinal canal area, which is filled with complex neural (nerves) and vascular (blood transport) structures.
We prefer to use conventional RFN to achieve precise, controlled lesions. Conventional RFN is one of the most commonly performed procedures in the U.S. and has an excellent safety record. No such record exists to support the safety, efficacy, and cost-effectiveness of cooled RFN for this type of low-back pain.
In summary, conventional RFN is the standard of care for lumbar facet pain. It is safe and effective, and it is our recommendation for Selena.
While each of the two treatment options presented here has its advantages and disadvantages, both can help alleviate low-back pain caused by lumbar facet arthropathy. While the spine specialists do not agree on the best treatment for Selena, all four physicians have her best interest at heart and will do their best to provide her with the best spinal care possible.
Pain Management Strategies: Dr. Singh’s Minimally Invasive Treatment Plans
As a board certified sports and pain specialist, Dr. Jaspal Ricky Singh, M.D. provides interventional pain management treatment for patients who suffer from lower back pain. In addition to patient education, his practice specializes in procedures ranging from acupuncture and injections to nerve blocks and regenerative medicine. Dr. Singh relies on state-of-the-art diagnostic tests to deliver targeted and minimally invasive treatments to each of his patients.
Visit the website to read more about Dr. Singh’s approach to pain management and the procedures he performs.
- Cooled Versus Conventional Thermal Radiofrequency Neurotomy for the Treatment of Lumbar Facet–Mediated Pain, http://www.pmrjournal.org/article/S1934-1482(15)00990-9/fulltext
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