Facet Joint Injection
Approximately two-thirds of all adults will experience difficulties associated with back or neck pain; a common form of chronic spine pain. A cervical, thoracic or lumbar facet joint injection involves injecting a small amount of local anesthetic (numbing agent) and/or steroid medication, which can anesthetize the facet joints and block the pain. The pain relief from a facet joint injection is intended to help a patient better tolerate a physical therapy routine to rehabilitate his or her injury or back condition.
Facet joint injections usually have two goals: to help diagnose the cause and location of pain and to provide pain relief:
-Diagnostic goals: By placing numbing medicine into the facet joint, the amount of immediate pain relief experienced by the patient will help determine if the facet joint is a source of pain. If complete pain relief is achieved while the facet joint is numb, it means that joint is likely a source of pain.
-Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release steroid (cortisone) into the facet joint to reduce inflammation, which can sometimes provide longer-term pain relief.
The injection procedure may also be called a facet block, as its purpose is to block the pain.
-To confirm disabling non-radicular low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as documented in the medical record based upon all of the following:
– history, consisting of mainly axial or non-radicular pain, and
– physical examination, with positive provocative signs of facet disease (pain
exacerbated by extension and rotation, or associated with lumbar rigidity).
-Lack of evidence, either for discogenic or sacroiliac joint pain
-Lack of disc herniation or evidence of radiculitis
-Intermittent or continuous pain with average pain levels of ≥ 6 on a scale of 0 to 10 or
functional disability; AND
-Duration of pain of at least 2 months; AND
-Failure to respond to conservative non-operative therapy management.
-All procedures must be performed using guidance (Fluro, CT, or Ultrasound)
Patients may notice a slight increase in pain lasting for several days as the numbing medicine wears off and before the cortisone starts to take effect. In the week following the injection, common recommendations include:
-If the area is uncomfortable in the first two to three days after the injection, carefully applying ice or a cold pack to the general area of the injection site will typically provide pain relief.
-Patients may continue to take their regular pain medicine after the procedure.
-On the day after the procedure, patients may return to their regular activities.
-Patients may be referred for physical therapy or manual therapy after the injection while the numbing medicine is effective and/or over the next several weeks while the cortisone is working.
When the pain is improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to increase activities gradually over one to two weeks to avoid recurrence of pain.
If the facet joints that were treated are the source of the pain, the patient will have immediate pain relief from the local anesthetic and may notice longer lasting pain relief from the steroid starting two to five days after the injection.
If the patient has immediate relief with the numbing medication, but does not have any longer lasting improvement with the steroid, further diagnostic tests (medial branch nerve injection) or treatments (radiofrequency neurotomy) might be performed.
If the patient does not have any relief with the numbing medication, further diagnostic tests may be needed to accurately diagnose the patient’s pain.
Ideally, patients should record the levels of pain relief during the first several hours, and during the next several days, in a pain diary. A pain diary is helpful to clearly inform the treating physician of the injection results and in planning future tests and/or treatment, as needed.
The facet joints are paired joints in the back and neck, one pair at each vertebral level (one joint on each side of the vertebrae). These joints have opposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule that is filled with synovial fluid, which reduces the friction between bones that rub together. Cervical facet joints are located on the back or side of the neck. Thoracic facet joints are in the upper back and lumbar facet joints are in the lower back.
Depending on which joints are affected, pain can be in different areas of the body:
-Cervical facet joints. Pain caused by cervical facet joints (in the neck) is usually felt in the head, neck, shoulder, and/or arm.
-Thoracic facet joints. Pain caused by thoracic facet joints (in the upper spine) is typically felt in the upper back, chest, and/or arm (rarely).
-Lumbar facet joints. Pain cause by lumbar facet joints (in the lower spine) is typically felt in the lower back, hip, buttock, and/or leg.
Facet joint injection can be used to diagnose the facet joint as the pain generator of back pain. After the injection, if the complete pain relief is achieved immediately while the facet joint is numb, it means that joint is likely a source of pain.
Diagnosis is done by injecting anesthetic agent like lidocaine.
For this, steroid is injected along with anesthetic agent. Steroids work on reducing the inflammation and provides long-term pain relief.
A facet joint injection is a relatively simple, straightforward procedure, and is usually performed in an office based procedure suite or in an ambulatory surgical center.
As with many spinal injections, facet joint injections are best performed using fluoroscopy (live X-ray) for guidance to properly target and place the needle (and to help avoid nerve injury or other injury).
The injection procedure includes the following steps:
Commonly, the procedure is performed without any sedation, however, an IV line can be started if relaxation medicine is needed.
The patient lies on a procedure table, and the skin over the area to be tested is well cleansed.
The physician treats a small area of skin with a numbing medicine (anesthetic), which may sting for a few seconds.
The physician uses X-ray guidance (fluoroscopy) to direct a very small needle into the facet joint.
A small amount of contrast dye is then injected to confirm that the needle is in the joint and that medication is contained inside the joint. Following this confirmation, a small mixture of anesthetic (such as lidocaine) and anti-inflammatory medication (steroid/cortisone) is then slowly injected into the joint.
After the procedure, the patient typically remains resting in the recovery area for twenty to thirty minutes, and then is asked to perform some movements or activities that would usually provoke their pain.
Patients may or may not obtain pain relief in the first few hours after the injection, depending upon if the joints targeted are the main source of their pain. If the joint or joints being targeted are not causing their pain, a patient will not obtain immediate relief from injection.
On occasion, patients may feel numb or have a slightly weak or odd feeling in their neck or back for a few hours after the injection.
As with all invasive medical procedures, there are potential risks and complications associated with facet joint injections. However, in general, the risk is low and complications are rare.
Potential risks and/or complications that may occur from a facet joint injection include:
-Allergic reaction. Usually, the allergy is to the X-ray contrast or steroid; rarely to local anesthetic. Life threatening or severe allergies are rare.
-Bleeding. A rare complication, bleeding is more common for patients with underlying bleeding disorders or in patients on blood thinners.
-Infection. Minor infections occur in less than 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
-Discomfort at the point of the injection or worsening of pain symptoms. These symptoms are usually mild and short-lived. Long lasting increases in pain are rare.
-Nerve or spinal cord damage or paralysis. While very rare, damage to the spinal cord or spinal nerves can occur from direct trauma from the needle, or secondarily from infection, bleeding resulting in compression, or injection into an artery causing blockage.
In addition to risks from the injection, some patients will experience side effects from the steroid medication, such as:
-Transient flushing with a feeling of warmth (‘hot flashes’) for several days
-Fluid retention, weight gain, or increased appetite
-Elevated blood pressure
-Mood swings, irritability, anxiety, insomnia
-High blood sugar – diabetic patients should inform their primary care physicians about the injection prior to their appointment