Disclosures: Alex D. Schmidt, MD: Nothing to disclose

Case Description: Adjacent level facet synovitis presenting as new low back pain after successful lumbar radiofrequency neurotomy.

Setting: Outpatient spine clinic

Patient: A 62-year-old female presented with worsening of her chronic lower lumbar back pain. After two positive medial branch blocks (MBB) targeting the bilateral L4-5 and L5-S1 facet joints she underwent successful radiofrequency neurotomy (RFN) with greater than 50% pain relief, decreased opioid use, and functional improvement lasting 1 year.

Assessment/Results: One year later she returned to clinic with complaints of lower back pain similar to her initial presentation. After positive MBBs targeting bilateral L4-5 and L5-S1 facet joints she again underwent successful RFN. She returned to clinic 2 months later reporting acute onset of right upper lumbar spine pain that was distinctly different from her prior complaints. Physical exam was positive for pain over the right mid-upper lumbar spine segments while performing facet loading maneuvers. A new MRI revealed new bone marrow edema in the right L1-L2, L2-L3, and L3-L4 facet joints. MBBs targeting these joints were performed with greater than 80% relief temporarily consistent with the presumptive diagnosis of right L1-2 L2-3 and L3-4 facet mediated pain, followed by RFN targeting the same levels with improvement in symptoms.

Discussion: The patient’s symptoms were likely due to increased activity of adjacent segments following RFN given her symptom improvement at the levels initially targeted. This likely represents a unique confluence of events given the temporal relationship of new onset pain following successful RFN of the lower lumbar segments in conjunction with the specific MRI findings of edema within the adjacent facet joints ipsilateral to her pain and absence of these findings in the treated joints.

Conclusion: Acute onset of low back pain with new or different pain characteristics after successful lumbar medial branch RFN shouldn’t be considered treatment failure and may warrant further work up and treatment.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/successful-lumbar-radiofrequency-neurotomy-with-ensuing-adjacent-level-facet-synovitis/