Chronic low back pain doesn’t necessarily have to be just one thing or another; there can be a variety of reasons why people have it Facet-mediated pain is considered one of the more frequent things that we see when it comes to chronic low back pain reasons, accounting for anywhere from 15 to 45 percent of cases. I’d like front-line practitioners to keep facet-mediated pain in their differential diagnosis and if they do suspect that, rather than resort necessarily to opioid therapy, it would be good to consider referring to a specialist.
Many patients who come in with facet-mediated back pain will talk about how they predominantly have low back pain, but it doesn’t necessarily radiate down their legs. If it does radiate, there are referral patterns and those referral patterns typically go down to the level of their knee. They’re not in a dermatomal distribution. They don’t seem to follow a radicular pattern, so you can go down the pathway of axial facetogenic low back pain in that kind of a situation. With respect to the physical exam, we were classically taught that facet loading and bending sideways or extension maneuvers would help bring out the diagnosis of facet pain. The reality is that the evidence behind facet loading is actually not that great when you look at the larger studies. The one most consistent thing in your physical exam finding is if you have paraspinal muscle tenderness.
First-line therapy for facet-mediated pain can be NSAIDs or acetaminophen and there’s really no evidence to suggest one is better than the other. I would use the patient’s history and comorbidities to help you decide which you’re going to use first. Physical therapy is very important, and I can’t stress enough how important multimodal approaches to therapy are. A diagnostic block can be used to see whether or not their pain is relieved with some local anesthetic to a specific nerve. If the medial branch when numbed at the location of the transverse process and the superior articulate process, produces a good amount of relief--50, 70, 90 percent or so--then there’s a pretty good indication that they will do very well with radiofrequency ablation. Typically radiofrequency ablation treatment can last anywhere from six months to a year. You can give significant quality of life back to these patients who would otherwise have been put on opioid therapy. Facet-mediated pain is typically more in the adult older population who are prone to osteoarthritis and wear and tear. So these are patients you don’t necessarily want to be putting on high doses of opioids.