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.
THERAPEUTIC FACET JOINT INTERVENTIONS
- 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.
- 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.
- Diagnostic blocks must be repeated if the patient has received no treatment in 2 years.
- Only light sedation is permitted for diagnostic blocks. Moderate sedation, or MAC are permitted for radiofrequency neurotomy.
- Opioids cannot be used for diagnostic blocks.
- Facet joint interventions, as of now, are contraindicated in patients with anterior lumbar interbody fusion or ALIF.
CHECKLIST FOR FACET JOINT INTERVENTIONS
It would be appropriate to utilize a checklist to assure that these procedures are performed properly: https://asipp.org/checklist-for-facet-joint-interventions/