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An Algorithmic Approach to Facet Joint Interventions

The algorithmic approach describes diagnostic block procedure, as well as therapeutic interventions. For diagnostic blocks, the following 4 components should be met:


  • The assessment as it relates to the complaint for that visit
  • Relevant medical history and physical examination
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report
  • Documentation to support the medical necessity of the procedure(s)


  • Axial pain above 5
  • 3 months duration of pain
  • Failed conservative treatment modalities (chiropractic, physical therapy, structured exercise program, NSAIDs, and other drugs) with duration and results.
  • No untreated radiculopathy or radiculitis.
  • Once these criteria are met, 2 diagnostic blocks, initially utilizing 0.5 mL lidocaine 1% or if you desire, 2%, may be performed.
  • To qualify as a positive response, you must document ≥ 80% relief with an ability to perform previously painful movements. If negative, please stop interventions.
  • If positive, you may proceed with a second block utilizing 0.5mL of either 0.25% or 0.5% bupivacaine and document ≥ 80% pain relief with an ability to perform previously painful movements.

If negative, stop facet joint interventions.
If positive, you can proceed with therapeutic facet joint interventions.


  1. The diagnostic blocks are performed with the intention to perform radiofrequency neurotomy unless it is contraindicated and documented appropriately such as for a patient with pseudoarthrosis, implant. radiofrequency is not recommended for patients who were intolerance of a previously performed radiofrequency neurotomy and is contraindicated for patients who demonstrated a previous lack of response, or others where a physician/patient shared decision-making is made.
  2. Radiofrequency neurotomy may be repeated after 6 months of appropriate pain relief with improvement in functional status. Therapeutic facet joint blocks may be repeated after 3 months of pain relief and improvement in function.
  3. Diagnostic blocks must be repeated if the patient has received no treatment in 2 years.


  1. Only light sedation is permitted for diagnostic blocks. Moderate sedation, or MAC are permitted for radiofrequency neurotomy.
  2. Opioids cannot be used for diagnostic blocks.
  3. Facet joint interventions, as of now, are contraindicated in patients with anterior lumbar interbody fusion or ALIF.

It would be appropriate to utilize a checklist to assure that these procedures are performed properly:

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