The effectiveness of fluoroscopically guided lumbar facet steroid joint injections: A systematic review.

Summary of background data: Facet joint degeneration is a known source of chronic axial low back pain, and intra-articular steroid injections (IASI) have been used as a treatment. Objectives: To systematically review the evidence of the effectiveness of fluoroscopically guided lumbar IASI for the treatment of lumbar facet joint pain. Methods: The primary outcome was ≥50 % pain reduction at ≥ 1 month, measured by Visual Analog Scale and/or Numeric Rating Scale. Secondary outcomes included ≥30 % functional improvement on a validated functional scale. Studies including group mean improvements in pain/function without categorical reporting were also considered. Two reviewers independently screened Embase, Cochrane, PubMed Medline, Ovid Medline, Web of Knowledge, and Google Scholar. The risk of bias was assessed using the Cochrane Risk of Bias Tool, and evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Results: Of the 701 publications screened, 21 met the inclusion criteria. Success rates for clinically significant pain reduction (≥50 % pain relief) ranged from 13 to 74 %, and functional improvement (≥30 % improvement) was 29 % at ≥ 1 month, based on only one study. Overall, mean improvement ranged from 11 to 59 % for pain relief and 8-58 % for function at ≥ 1 month. In the seven studies selecting patients with facet or medial branch blocks, success rates for clinically significant pain reduction (≥50 % pain relief) are reported as 13-74 % at ≥ 1 month. In this subgroup, mean pain improvement rates ranged from 23 to 67 % and functional improvement from 15 to 58 % at ≥ 1 month. According to GRADE, the overall quality of the evidence is very low due to the high risk of bias, study heterogeneity, and inconsistent methodologies. Discussion/conclusion: Pragmatic and observational studies suggest IASI may reduce pain and disability, while sham-controlled trials have not demonstrated efficacy. Given the very low quality of evidence, the true effect of IASI is highly uncertain. Further high-quality, placebo-controlled studies using standardized diagnostic criteria are needed.