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. 2025 Nov;35(11):6958-6966.
doi: 10.1007/s00330-025-11651-9. Epub 2025 May 8.

Image-guided injections for facet joint pain: evidence-based Delphi conjoined consensus paper from the European Society of Musculoskeletal Radiology and European Society of Neuroradiology

Luca Maria Sconfienza  1   2 , Danoob Dalili  3 , Miraude Adriaensen  4 , Domenico Albano  5   6 , Georgina Allen  7   8 , Maria Pilar Aparisi Gomez  9   10   11 , Giacomo Aringhieri  12 , Francesco Arrigoni  13 , Alberto Bazzocchi  14 , Miguel Oliveira Castro  15 , Roberto Luigi Cazzato  16 , Miriam De Dea  17 , Aldo Eros De Vivo  18 , Elena Drakonaki  19 , Fernando Facal de Castro  20 , Dimitrios Filippiadis  21 , Jan Fritz  22   23 , Inês Gil  24 , Salvatore Gitto  5   25 , Hannes Gruber  26 , Harun Gupta  27 , Amanda Isaac  28 , Andrea S Klauser  29 , Thomas Le Corroller  30 , Alexander Loizides  29 , Salvatore Marsico  31 , Giovanni Mauri  5 , Eugene McNally  32 , Kalliopi Melaki  33 , Carmelo Messina  25   34 , Rebeca Mirón Mombiela  35 , Cyprian Olchowy  36 , Davide Orlandi  37 , Ricardo Moutinho  38   39 , Riccardo Picasso  40 , Mahesh Prakash  41 , Nicolas Theumann  42 , Violeta Vasilevska Nikodinovska  43   44 , Evangelia E Vassalou  45 , Jelena Vucetic  46 , David Wilson  7   8 , Federico Zaottini  40 , Marcello Zappia  47 , Chiara Zini  48 , Žiga Snoj  49
Affiliations

Image-guided injections for facet joint pain: evidence-based Delphi conjoined consensus paper from the European Society of Musculoskeletal Radiology and European Society of Neuroradiology

Luca Maria Sconfienza et al. Eur Radiol. 2025 Nov.

Abstract

Objectives: To perform a Delphi-based consensus on published evidence on image-guided injections for facet joint pain (FJP) and provide clinical indications.

Methods: We report the results of an evidence-based Delphi consensus of 38 experts from the European Society of Musculoskeletal Radiology and the European Society of Neuroradiology, who reviewed the published literature for evidence on image-guided injections for FJP. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when ≥ 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the consensus were used to write the paper.

Results: Twenty statements on image-guided FJP treatment have been drafted. Eighteen statements received strong consensus, while two received broad consensus. Three statements reached the highest level of evidence, all of them regarding the lumbar spine. All radiological methods are used for image-guided injections for FJP, and regardless of the radiological method used, all show good safety and efficacy. Facet joint injections and medial branch blocks are used in all spinal regions to treat FJP, and both show similar clinical outcomes. Advanced technological solutions have been studied in the field of lumbar FJP; however, the level of evidence for these is low.

Conclusion: Despite promising results reported by published papers on image-guided injections for FJP, there is still a lack of evidence on injection efficacy, appropriateness of imaging methods, and optimal medication.

Key points: Question Image-guided injections to treat facet joint pain (FJP) are performed throughout the spine; however, the highest level of evidence exists for the lumbar spine. Findings Regardless of the imaging method used, image-guided injections for facet joint pain treatment are safe, with only minor adverse events in rare cases. Clinical relevance All imaging methods are used for injection guidance to treat FJP, each with advantages and disadvantages. These statements on image-guided injections for FJP provide a concise and up to date overview on the topic, serving as a list of clinical indications.

Keywords: Delphi process; Facet joints; Injection; Interventional radiology; Spine.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Luca Maria Sconfienza MD PhD. Conflict of interest: A.B. is a member of the Advisory Editorial Board of European Radiology (European Society of Musculoskeletal Radiology). As such, they have not participated in the selection or review processes for this article. The remaining authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Statistics and biometry: No complex statistical methods were necessary for this paper. Informed consent: Written informed consent was not required for this study because it does not involve patients directly. Ethical approval: Institutional Review Board approval was not required because it does not involve patients directly. Study subjects or cohorts overlap: Not applicable. Methodology: Literature-based Delphi process

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