Are Facet Joint Injections Any Good?

Useless Back Pain Jab Costs NHS £40 Million Per Year

Facet joint injections with cortisone have been offered as a treatment for mechanical low back pain for at least 60 years. More recently however, this practice has been becoming increasingly controversial on both clinical efficacy and cost effectiveness grounds. This uncertainly has led to a number of UK health trusts de-funding the procedure and insurers withdrawing recognition.

The most recent NICE guidelines for management of low back pain and sciatica in adults (NICE NG59) were published on 30th November 2016. This guideline recommended not to offer this procedure on grounds of cost and unreliable efficacy.

One would have to say that this is pretty clear advice and does not leave much room for interpretation. The same guideline also suggests that the only spinal procedure to offer is lumbar medial branch radiofrequency ablation. This should only be performed after successful diagnostic medial branch blocks.

So is this the death sentence for lumbar facet joint injections? Well it would seem that this is not actually the case. A recent article in the Times suggested that this practice, despite doubts around the efficacy is still widely practised. This article, published on 9th April 2019, (over 2 years after publication of NG59) suggests that the practice is alive and well and costs the NHS up to £40 Million per year. This does not include the further sum spent in private practice, despite de-recognition of the procedure by several insurance companies.

Useless Back Pain Jab Costs NHS £40 Million Per Year

3rd April 2019

Tens of thousands of patients every year are being given a useless back pain injection, costing the NHS almost £40 million despite doctors being told to stop using it, The Times can reveal

To read the full article CLICK HERE

Should we Abandon Facet Joint Injections Completely?

The obvious answer here would appear to be a clear yes. Lumbar facet medial branch radiofrequency denervation appears to be a much superior procedure, in terms of pain relief, duration of action and by the fact that no cortisone is involved. However, it is a highly skilled procedure that only a relatively small amount of pain specialists can perform. Furthermore, NICE NG59 states that it is necessary to perform diagnostic medial branch blocks prior to the procedure. This adds to the overall cost. A negative result with medial branch blocks, however, suggests that the pain is not coming directly from facet joints and therefore ablation would not be successful. This also implies that facet joint injections will also not be successful, saving the patient future unnecessary injections.

I still believe that there is a limited scope for facet joint injections with cortisone. While they are not particularly effective within study populations, there is a small subset of individuals who gain significant benefit from these injections for up to 6 months. Within this group it may be arguable that it is easier to do a set of facet joint injections twice that a set of medial branch blocks and a radiofrequency ablation once. Furthermore, some individuals may have residual sacro-iliac pain. Radiofrequency ablation, I do not believe, has proven to be reliable in the management of sacro-iliac pain, an in this group, cortisone injections are at least equally effective.

So overall, I believe that the facet joint injection is not completely written off as a procedure, but the indications should be very limited. Radiofrequency ablation is the way forward for now, but the is still some room for facet injections in some circumstances.

Your opinion may differ.