The American Society of Interventional Pain Physicians (ASIPP) has published comprehensive, evidence-based guidelines for performing diagnostic and therapeutic facet joint interventions for the management of chronic spinal pain. The guidelines were published in the journal Pain Physician.
An ASIPP panel of experts convened to develop the guidelines. The panel comprised of clinical practitioners with both interest and expertise in interventions applicable to facet joint pain. The ASIPP guideline committee performed a review and synthesis of medical literature related to facet joint interventions. The panel members formulated recommendations based on this review, and offered a consensus on all evidence-based statements prior to inclusion in the guideline. The recommendations were also assigned grades reflecting the strength of evidence (strong, moderate, weak), and indicated the current level of evidence supporting each recommendation (strong, moderate, fair, limited, consensus-based).
The level of evidence is 2 (moderate) with regards to selecting patients for facet joint nerve blocks ≥3 months following the onset of axial pain, tenderness over the facet joints, reduced range of motion, pain reduction with rest, and absence of radicular pattern for physical examination and assessment and failure of conservative management.
The guideline committee made a strong strength of recommendation for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions, based on level of evidence of 1 (strong).
A weak strength recommendation was made for single photon emission computed tomography (SPECT) for identifying painful lumbar facet joints prior to diagnostic facet joint nerve blocks, based on a level of evidence of 3 (fair). The committee made a weak strength recommendation based on consensus-based evidence for scintigraphy, magnetic resonance imaging (MRI), and CT for identifying painful facet joints.
The ASIPP guideline also provided a moderate to strong recommendation for lumbar diagnostic facet joint nerve blocks based on level of evidence 1 to 2. A moderate strength of recommendation was also made for cervical facet joint nerve blocks in the accurate diagnosis of facet join pain. Additionally, a recommendation of moderate strength was made for the use of thoracic facet joint nerve blocks for the diagnosis or confirmation of thoracic facet joint pain.
According to the guideline committee, the preferable strategy for diagnosing facet joint pain is to utilize diagnostic facet joint nerve blocks, using 80% pain relief as the criterion standard to define [p\response]. In terms of therapeutic approaches, the ASIPP committee makes a moderate strength recommendation based on level 2 evidence for lumbar radiofrequency neurotomy and therapeutic lumbar facet joint never blocks. This was based on an analysis of the available literature on the subject.
Only a weak recommendation based on level 4 evidence was made for lumbar intra-articular injections, with the majority of studies demonstrating a lack of efficacy without a local anesthetic.
A recommendation of moderate strength was also made for lumbar radiofrequency ablation, according to data from 11 randomized, controlled studies. A total of 3 randomized controlled trials provided a moderate strength recommendation for therapeutic lumbar facet joint nerve blocks. Thoracic radiofrequency ablation was featured as a therapeutic recommendation with a weak to moderate strength of recommendation based on emerging evidence. In their guideline statement, the committee members also recommended thoracic intra-articular facet joint injections.
Antithrombotic Therapy and Sedation
The guidelines suggested that antithrombotic therapy can be continued based on the patient’s overall general status, as facet joint interventions are typically moderate- to low-risk procedures. In terms of sedation, the guideline committee recommends avoidance of opioid analgesics during the diagnosis of facet joint pain with interventional techniques (moderate strength of recommendation).
Moderate sedation can be used for patient comfort as well as to help curb anxiety during therapeutic facet joint interventions, according to a recommendation of moderate strength.
The guidelines were designed under certain limitations, according to the ASIPP committee. Primarily, a limited number of rigorous studies were available to help form the recommendations. According to the authors, the guidelines offer recommendations based on “the best available evidence and do not constitute inflexible treatment recommendations.”
Manchikanti L, Kaye AD, Soin A, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint interventions 2020 guidelines. Pain Physician. 2020;23(3S):S1‐S127.