BlueCross BlueShield of Tennessee Medical Policy Manual

Diagnosis and Treatment of Facet Joint Pain

DESCRIPTION

A potential source of spinal pain is the posterior zygapophysial joint (facet, Z joint), which adjoins adjacent vertebrae and is innervated by medial branches of the dorsal spinal nerves at two levels; however, there is no single history or physical examination finding that can diagnose facet joint syndrome. 

Diagnosis of facet joint pain can be made when controlled local anesthetic blocks of the medial branches of the posterior rami of the spinal nerves that supply the painful joint(s) provides relief of the target pain.  In dual controlled diagnostic testing, the individual receives an injection of a short-acting anesthetic agent (lidocaine), and if appropriate short-term pain relief is achieved, the individual is then injected with a longer-acting agent (bupivacaine).  Individuals with appropriate longer-term pain relief are considered candidates for therapeutic facet injections, with or without steroid, or nonpulsed facet radiofrequency neurotomy (radiofrequency denervation).

Radiofrequency neurotomy is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves.  The goal of radiofrequency neurotomy is long-term pain relief; however, the nerves regenerate and repeat procedures may be required.

POLICY

Policies with similar titles:  Diagnosis and Treatment of Sacroiliac Joint Pain

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Controlled trials are needed to evaluate laser, chemo, and cryo-denervation. 

SOURCES

American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine. (2010). Practice guidelines for chronic pain management. Retrieved February 21, 2017 from http://www.asahq.org/quality-and-practice-management/standards-and-guidelines.

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2015). Facet joint denervation (7.01.116). Retrieved February 20, 2017 from BlueWeb. (37 articles and/or guidelines reviewed)

Boswell, M., Manchikanti, L., Kaye, A., Bakshi, S, Gharibo, C., Gupta, S., et al. (2015). A best-evidence systematic appraisal of the diagnostic accuracy and utility of facet (zygapophysial) joint injections in chronic spinal pain. Pain Physician, 18, E497-E533. (Level 1 evidence)

Cahaba Government Benefit Administrators, LLC. (2015, October). LCD for Surgery: Lumbar facet blockade (L34293). Retrieved January 5, 2016 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34293&ver=3&Date=02%2f20%2f2017&DocID=L34293&bc=iAAAABAAAAAAAA%3d%3d&.

Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician, 16, S49-S283. (Level 2 evidence)

Manchikanti, L., Boswell, M., Singh, V., Benyamin, R., Fellows, B., Abdi, S., et al. (2009). Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician, 12, 699-802. (Level 2 evidence)

Manchikanti, L., Hirsch, J., Falco, F., & Boswell, M. (2016). Management of lumbar zygapophysial (facet) joint pain. World Journal of Orthopedics, 7 (5), 315-337. (Level 2 evidence)

Manchikanti, L., Kaye, A., Boswell, M., Bakshi, S., Gharibo, C., Grami, V., et al. (2015). A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician, 18 (4), E535-E582. (Level 2 evidence)

National Institute for Health and Care Excellence. (2016, November). Low back pain and sciatica in over 16s: assessment and management. Retrieved February 27, 2017 from www.nice.org.uk/guidance/ng59.

OrthoNet LLC. (2010, October; last updated April 2014). Facet joint block injection. Received from OrthoNet on February 13, 2017.

Poetscher, A., gentil, A., Lenza, M., & Ferretti, M. (2014). Radiofrequency denervation for facet joint low back pain: a systematic review. Spine, 39 (14), E842-E849. Abstract retrieved February 27, 2017 from PubMed database.

Vekaria, R., Bhatt, R., Ellard, D., Henschke, N., Underwood, M., & Sandhu, H. (2016). Intra-articular facet joint injections for low back pain: a systematic review. European Spine Journal, 25 (4), 1266-1281. Abstract retrieved February 27, 2017 from PubMed database.

Watters, W., Resnick, D., Eck, J., Ghogawala, Z., Mummaneni, P., Dailey,A, et al. (2014). Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. part 13: Injection therapies, low-back pain, and lumbar fusion. Journal of Neurosurgery: Spine, 21, 79-90. (Level 2 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, December). Radiofrequency ablation for facet joint denervation for chronic low back pain. Retrieved February 20, 2017 from www.Hayesinc.com/subscribers. (54 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, November). Percutaneous radiofrequency ablation for cervical and thoracic spinal indications. Retrieved February 20, 2017 from www.Hayesinc.com/subscribers  (45 articles and/or guidelines reviewed)

Wu, T., Zhao, W., Dong, Y., Song, H., & Li, J. (2016). Effectiveness of ultrasound-guided versus fluoroscopy or computed tomography scanning guidance in lumbar facet joint injections in adults with facet joint syndrome: a meta-analysis of controlled trials. Archives of Physical Medicine and Rehab, 97 (9), 1558-1563. Abstract retrieved February 27, 2017 from PubMed database.

ORIGINAL EFFECTIVE DATE:  4/1999

MOST RECENT REVIEW DATE:  8/31/2017   

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