A Systematic Review And Meta-Analysis Of Randomized Trials Of Therapeutic Intraarticular Facet Joint Injections In Chronic Axial Spinal Pain

Abstract

Background: Chronic axial spinal pain remains a leading cause of disability. Therapeutic interventional modalities for managing axial spinal pain of facet joint origin include intraarticular injections, facet joint nerve blocks, and radiofrequency neurotomy.Based on multiple randomized controlled trials (RCTs), systematic reviews, and clinical guidelines, the evidence supporting intraarticular facet joint injections is rated as Level III, with a weak to moderate recommendation for managing spinal facet joint pain.

Objective: To evaluate intraarticular facet joint injections as a therapeutic option for managing chronic axial spinal pain of facet joint origin.

Study design: A systematic review and meta-analysis of RCTs involving intraarticular facet joint injections, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

Methods: A comprehensive literature search was conducted across multiple databases from 1966 through February 2025, including manual searches of bibliographies from known review articles. The methodological quality and risk of bias for the included studies were assessed.Evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. The level of evidence was classified using a modified best evidence synthesis, ranging from Level I to Level V.

Outcome measures: The primary outcome measure was the proportion of patients achieving significant pain relief and functional improvement of more than 50% for a minimum of 3 months. Duration of relief was categorized as short-term (< 6 months) and long-term (> 6 months).

Results: This analysis identified 12 high-quality and 2 moderate-quality RCTs based on Cochrane review criteria, and 11 high-quality and 3 moderate-quality RCTs based on Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) criteria. Based on grade assessment, there were no high quality trials.Evidence synthesis using both qualitative and quantitative analyses, along with GRADE assessment, indicated Level IV (limited evidence), with low certainty and a low level of recommendation.

Limitations: The primary limitation is the continued paucity of high-quality literature.

Conclusion: Based on qualitative analysis and GRADE assessment, intraarticular facet joint injections are supported by Level IV evidence, with limited quality, low certainty, and a low strength of recommendation.

Keywords: facet joint intraarticular injections; facet joint nerve blocks; low back pain; meta-analysis; neck pain; randomized controlled trials; spinal pain; systematic review; Facet joint pain.