Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions.

BACKGROUND Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of the patients based on the 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 therapeutic facet joint nerves. OBJECTIVES To determine the clinical utility of diagnostic and therapeutic thoracic facet joint interventions in diagnosing and managing chronic upper back and mid back pain. STUDY DESIGN Systematic review of diagnostic and therapeutic thoracic facet joint interventions. METHODS Review of the literature for utility of facet joint interventions in diagnosing and managing facet joint pain was performed according to the Agency for Healthcare Research and Quality (AHRQ) criteria for diagnostic studies and observational studies and the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by United States Preventive Services Task Force (USPSTF) for therapeutic interventions. Recommendations were based on the criteria developed by Guyatt et al. Data sources included relevant literature of the English language identified through searches of Medline and EMBASE from 1966 to July 2008 and manual searches of bibliographies of known primary and review articles. Results of the analysis were performed for diagnostic and therapeutic interventions separately. OUTCOME MEASURES For diagnostic interventions, studies must have been performed utilizing controlled local anesthetic blocks. For therapeutic interventions, the primary outcome measure was pain relief (short-term relief = up to 6 months and long-term relief > 6 months) with secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS Based on the controlled comparative local anesthetic blocks, the evidence for the diagnosis of thoracic facet joint pain is Level I or II-1. The evidence for therapeutic thoracic medial branch blocks is Level I or II-1. The recommendation is IA or 1B/strong for diagnostic and therapeutic medial branch blocks. CONCLUSION The evidence for the diagnosis of thoracic facet joint pain with controlled comparative local anesthetic blocks is Level I or II-1. The evidence for therapeutic facet joint interventions is Level I or II-1 for medial branch blocks. Recommendation is 1A or 1B/strong for diagnostic and therapeutic medial branch blocks.