An Update of Evaluation of Therapeutic Thoracic Facet Joint Interventions

Abstract

Background: Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of patients based on responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain, moderate evidence for therapeutic thoracic medial branch blocks, and limited evidence for radiofrequency neurotomy of thoracic medial branches. Study Design: Systematic review of therapeutic thoracic facet joint interventions. Objective: To determine the clinical utility of therapeutic thoracic facet joint interventions in the therapeutic management of chronic upper back and mid back pain. Methods: The available literature for the utility of facet joint interventions in the therapeutic management of thoracic facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this systematic review, 13 studies were identified. Of these, 7 studies were excluded, and a total of 4 studies (after removal of duplicate publication) met inclusion criteria for methodological quality assessment with one randomized trial and 3 non-randomized studies. The evidence is fair for therapeutic thoracic facet joint nerve blocks, limited for thoracic radiofrequency neurotomy, and not available for thoracic intraarticular injections. Limitations: The limitation of this systematic review includes a paucity of literature. The only positive studies were of medial branch blocks performed by the same group of authors. Conclusion: The evidence for therapeutic facet joint interventions is fair for medial branch blocks, whereas it is not available for intraarticular injections, and limited for radiofrequency neurotomy due to lack of literature. Key words: Chronic thoracic pain, mid back or upper back pain, thoracic facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, therapeutic thoracic medial branch blocks, thoracic radiofrequency neurotomy, thoracic intraarticular facet joint injections