In his practice he first screens for red flags in patients who present with low back pain. Next, he gets an X-ray to look for alignment issues, and he "heavily considers – if the clinical picture fits" – whether facet joint OA might be the cause of the pain.
"I’ll talk to them about it, and then almost always, I’ll send them for an empiric trial of physical therapy plus or minus some analgesics – Tylenol or NSAIDs," he said.
If patients experience improved function and a decrease in symptoms within 6-8 weeks, he recommends that they begin a more interesting (than their home physical therapy regimen) exercise program, such as yoga or Pilates to help them maintain those gains; if they remain symptomatic, he images them.
He starts with SPECT/CT rather than MRI if facet joint OA is high on his differential list for the patient, and if that’s positive, he will consider intra-articular steroid injections. If the injections are effective he recommends yoga and/or Pilates for maintaining the gains.
In rare cases a patient doesn’t respond to the injections, and then he will consider more aggressive treatment, such as medial branch block or radiofrequency denervation.
Understanding of facet joint OA has been slow to emerge, but progress is being made, Dr. Gellhorn said.
For example, the work with SPECT/CT and STIR MRI is very exciting, he said.
"I think this is going to give us a number of things to work with: first and foremost, it’s going to give us better criteria to diagnose patients and enroll them in treatment studies," he said.
Serum, urine, and genetic biomarkers, on the other hand, are interesting and on the horizon, "but we’re not really there yet," he added.
"But I think we will be able to at least use imaging studies to monitor some response to treatment," he said.
Additional study is also needed with respect to conservative treatments. Studies comparing different exercise programs, including studies comparing strength vs. flexibility and extension vs. flexion, are needed.
Regenerative treatments, such as platelet rich plasma and autologous stem cells are another area of interest, he said.
Dr. Gellhorn reported having no disclosures.