This article is part of a series written by Dr. Kevin Pauza
Yesterday, my kind and inquisitive patient from Colorado, who previously suffered from low back pain before I treated her discs, asked: “Why did my spine doctors do so many facet joint injections, knowing they weren’t helping?” Her question resonated because it was the same question posed by many others over the years. Her concern was valid, and after seeking an answer for her, I was disheartened to learn what’s happening out there in the Wild West with facet joint treatments. It’s a big problem, and others might feel as disturbed as me if they knew.
In medicine, few things are binary, but healthcare dollars are a zero-sum game, and the $87 billion we spend annually treating spines takes away from other diseases ranging from cancer to COVID-19. That’s 17% of our U.S. economy, and several billions of that went towards treating facet joints. Potential misuse of facet procedures strikes a chord with me, especially after I wrote my Specialty’s facet treatment Guidelines, and headed an International Spine Society’s Standards Committee for 8 years. There’s a time and place for facet treatments, but not like we’re seeing in the Wild West.
I’m grateful for my opportunity to routinely meet patients from throughout the world, even during these COVID-19 times. My patients tell me what other doctors are doing everywhere (barring Antarctica). Admittedly, I see a skewed population because almost all went to multiple doctors before seeing me.
Recently, I’ve seen more and more stem cell facet and ligament injection failures.
By exploring further, I learned that doctors are treating facets at explosively increasing rates; so much so that the Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) shared my concern and initiated an inquiry. The OIG-DHHS stated there was often a lack of medical necessity or indication for facet joint injections and other facet joint treatments. They felt that there is a lack of efficacy in all facet joint treatments ranging from ablations to stem cell injections. So what’s behind this growing trend of repetitive facet joint treatments? And why don’t these facet joint treatments work?
No controlled study demonstrates sustained relief from any facet joint treatment. Even the most rigorous study performed under the most meticulous conditions which evaluated cervical facet nerve ablation (RF Neurotomy) showed only partial relief, with all pain returning in less than a year.
But doctors and hospitals still make billions of dollars from repetitively treating facet joints. They inject them with steroids, lidocaine, Platelet Rich Plasma (PRP), or stem cells. If that’s not enough, they burn them using a procedure called “rhizotomy, or nerve ablation” (radiofrequency neurotomy).
Today, many ever-expanding stem cell franchises promote repetitive stem cell injections into facet joints, ligaments, and surrounding structures. Franchisee physicians harvest stem cells from bone marrow, fat, or placentas for every procedure, and those treatments subject patients to repetitive stem cell injections. A patient said “My facet joint treatments reminded me of Albert Einstein’s words: ‘The definition of insanity is repeating the same thing, hoping for a different outcome.’” Their invoices, in the tens of thousands of dollars, were equally disconcerting. Sadly, one patient underwent so many stem cell injections before a successful disc treatment that he was forced to delay college because of his tuition shortfall.
So I wondered if doctors performing repetitive facet joint injections understood why they weren’t providing sustained relief?
I believe it’s easy to understand why facet treatments fail to help many with low back pain. It’s because discs, both directly and indirectly, cause the majority of low back pain and neck pain. Discs also cause sciatica leg pain. Now here’s the curveball: discs often cause facet joint and ligament pain by indirectly damaging those structures. I’ll break it down so it’s easily understood.
Discs are made of two parts, their inner gel (Nucleus Pulposus) and their outer ring (Annulus Fibrosis.) The Annulus Fibrosis cumulatively tears over the years, especially with forward flexion and rotation. Multiple tears cause discs to leak and dry out, and when they dry out, they flatten. Every person who lives beyond their teenage years develops annular tears, causing their spinal discs to flatten.
Each disc is associated with two facet joints, one connecting the bone from above the disc and one connecting the bone from below the disc. Therefore, when discs flatten, their facet joints compress together and this causes most facet arthritis. That’s why most facet joint treatments are for naught unless the discs are concurrently repaired. We’re learning that people previously thought to have facet joint pain experienced sustained relief after treating their discs.
It may take time for some to realize, but no matter how often one treats facets and their adjacent structures, most patients can’t be helped without correcting their associated discs.
- Dieleman, J. L., Baral, R., & Birger, M. (2016, December 27). Spending on US Health Care, 1996-2013. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2594716
- Manchikanti, L., Pampati, V., Singh, V., Boswell, M. V., Smith, H. S., & Hirsch, J. A. (2010, March 30). Explosive growth of facet joint interventions in the Medicare population in the United States: A comparative evaluation of 1997, 2002, and 2006 data. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907752/