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 typically receives injections of anesthetics with different, predictable durations of action (comparative anesthetic blocks). Alternatively, the diagnostic testing can be done using true placebos (inactive substances) as well as the active agent in a double-blind manner. The underlying premise for these injections is that the facet joints have been shown to be the source of neck and back pain using reliable methods.

Individuals with appropriate longer-term pain relief are considered candidates for therapeutic facet injections, with or without steroid, or conventional radiofrequency ablation (RFA), also known as nonpulsed or thermal RFA or RF neurotomy. Conventional RFA involves the constant application of energy usually at 80 - 85 degrees Celcius via an image-guided needle electrode inserted through the skin (percutaneously) to the affected nerve. Higher temperatures result in larger lesions, risking the surrounding tissues.  

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Controlled trials are necessary to evaluate non-conventional radiofrequency ablation (laser, chemical, low-grade thermal energy and cryo-denervation). 

SOURCES

Al-Najjim, M., Shah, R., Rahuma, M., & Gabbar, O. (2018). Lumbar facet joint injection in treating low back pain: radiofrequency denervation versus SHAM procedure. Systematic review. Journal of Orthopaedics, 15, 1-8. (Level 2 evidence)

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. (11:2017). Facet joint denervation (7.01.116). Retrieved May 4, 2018 from BlueWeb. (38 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)

Lee, C.H., Chung, C.K., & Kim, C.H. (2017). The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine Journal, 17 (11), 1770-1780. Abstract retrieved May 7, 2018 from PubMed database.

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)

OrthoNet LLC. (2018, February). Facet joint block injection. Received from OrthoNet on April 24, 2018.

Palmetto Government Benefit Administrators. (2018, February). Local Coverage Determination (LCD): Facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy (L36471). Retrieved May 7, 2018 from www.cms.org.

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; last update search November 2017). 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; last update search October 2017). 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:  10/24/2018         

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