Facet joint injection

A facet joint injection involves injecting local anesthetics and sometimes steroids into or around a facet joint also called zygapophyseal joint, which are the small joints located between each vertebra on the back of your spine that provide stability and help guide motion (see Figures 1 and 2 below). Facet joints (zygapophyseal joints) are found in your neck (cervical), upper back (thoracic) and lower back (lumbar). Facet joints can become painful as a result of arthritis, injury or mechanical stress. However, this is not necessarily the sole cause of long term back pain. Two nerves called “medial branches” supply each facet joint. These nerves carry pain signals to the spinal cord and these signals will eventually reach the brain. Facet joint injections are often used when pain is caused by degenerative or arthritic conditions or injury. Facet joint injections are used to treat neck, middle back, or low back pain. The pain does not have to be exclusively limited to the midline spine, as these problems can cause pain to radiate into the shoulders, buttocks, or upper legs. The local anesthetics numb the nerves to the facet joint to give pain relief. The steroids reduce inflammation and may make the pain relief last longer. A facet joint injection usually takes less than 30 minutes. Your doctor may use an x-ray to guide them while they give the injection.

Your doctor will carefully insert the needle for the facet joint injection. They may inject dye (colorless contrast fluid) and take an x-ray to help them to check that the needle is in the right position. Sometimes your doctor will use an ultrasound scanner to help guide them while they insert the needle.

The facet joints and/or medial branch nerves can be injected with a local anesthetic and/or steroid for both diagnostic and therapeutic reasons.

1. Diagnosis: If the local anesthetic in the injection relieves your pain then it suggests that the facet joints are a source of your pain. Repeating the procedure a second time improves accuracy of the diagnosis. This can guide future treatment such as “radio frequency ablation” of medial branch nerves. There is strong scientific evidence to support this ¹.
2. Therapy: The steroid in the injection can reduce inflammation, reduce medial branch nerve sensitivity and provide long lasting pain relief. The duration of pain relief may vary from weeks to months. There is limited to moderate scientific evidence to support this ².

For diagnostic purposes, facet joints can be injected in two ways: injecting anesthetic directly into the joint or anesthetizing the nerves carrying the pain signals away from the joint (medial branches of the nerve). If the majority of pain is relieved with anesthetic into the joint, then a therapeutic injection of a steroid may provide lasting neck or low back pain relief.

If anesthetic injections indicate that the nerve is the source of pain, the next step is to block the pain signals more permanently. This is done with radiofrequency ablation, or damaging the nerves that supply the joint with a “burning” technique.

Figure 1. Cervical facet joint

Figure 2. Lumbar spine facet joints

What happens after facet joint injection procedure?

• You will be monitored in a recovery area until you are ready to go home (usually 20-60 minutes).
• It is preferable to have someone take you home and stay with you for the next 24 hours.
• If you have received any sedation during your procedure, the effects of these medications may last for up to 24 hours. You may not remember some of the information given during the procedure. This is a normal side effect of the medication. For the next 24 hours you should not drive a vehicle, drink alcohol, operate machinery, make important decisions, sign legal documents or travel unaccompanied
• You will be given a pain relief chart to fill out. Please bring this to show the doctor at your next consultation.
• Remove the dressing the day after the procedure, when you next wash.
• The pain may return when the local anesthetic wears off. Some people experience an initial increase in pain and stiffness that may continue for several days. If necessary, an ice pack can be applied to the area, 20 minutes at a time, for 1-2 days following the procedure.
• If steroids are injected then it may take several days for the benefits to be noticed. Additionally, you may feel flushed in the face and/or notice a change in your mood for a few days. Diabetic patients may notice a rise in their blood sugar levels.
• After the procedure, care must be taken to avoid a rapid increase in your activities. Gradually increase your daily activities as tolerated. Discuss this with your doctor.
• If you notice any swelling or bleeding from the site or have any other concerns, please contact your doctor, the Pain Management Unit, or the Emergency Department of your local hospital.

Are there any alternatives to the facet joint injection?

An x-ray or scan can show if you have osteoarthritis in one or more of your facet joints.

If you decide not to have an injection, your doctor may be able to suggest other methods of pain relief. You may need more painkillers that are more likely to make you feel sick or drowsy.

Facet joint injection benefits

Lumbar facet joint degeneration is a source of chronic low back pain, with an incidence of 15% to 45% among patients with low back pain ³. A facet joint injection can be used to find out if your pain is caused by your facet joints. The gold standard for diagnosis of facet joint mediated pain is a local anesthetic block of the facet joint ⁴. This randomized, double-blind, controlled trial revealed that relief of lumbar facet joint-related low back pain and functional improvement can be achieved by radiofrequency denervation and intraarticular facet joint injection steroid injections. No significant differences were noted between the 2 procedures ⁵.

Treatment of chronic lower back pain usually begins with conservative management, such as physical therapy is the first line in management. This is true for facet joint pain, even in the absence of confirmation via a diagnostic block. Physical therapy is a cornerstone of the treatment of chronic lower back pain and should include postural education, stretching, and exercises tailored to strengthen the core musculature ⁶. Pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, are widely considered the first line for treatment of lower back pain. Adjuvant medications, such as antidepressants in chronic back pain and muscle relaxants in acute back pain have also demonstrated effectiveness.

Patients who fail trial conservative management are considered candidates for a diagnostic facet joint block ⁶. If the diagnostic facet joint block is successful, more invasive treatment can be considered. Intra-articular steroid injections are a controversial treatment, with level 3 evidence to support their use ⁷. Radiofrequency neurotomy via continuous high-temperature medial branch radiofrequency ablation, carries level 2 evidence ⁸. Due to axonal regeneration, pain may return requiring repetition of the procedure, typically between 6 months to 1 year ⁶. Other reported interventions include pulsed radiofrequency ablation, cryo-denervation, and phenol neurolysis; however, these studies are uncontrolled and require further evaluation.

Facet joint pain is rarely an indication for surgical intervention in itself. Studies have not demonstrated evidence for surgical intervention except in cases of traumatic dislocation ⁶. However, due to facet arthropathy, osteophytes or large synovial cysts may impinge upon other surrounding structures and lead to stenosis, nerve root impingement, and radiculopathy. In such cases, lumbar facetectomy may be performed. Medial facetectomy is the most commonly performed form of facetectomy and is often performed in conjunction with laminectomy. Complete facetectomy may be performed in the setting of lumbar fusion.

How soon will I recover after a facet joint injection?

After a short while you should be able to go home. Rest if you feel tired.

You should be able to return to normal activities the next day.

Facet joint injection complications

Spinal injection procedures are generally safe procedures. If complications occur, they are usually mild and self-limited. The risks of spinal injections include, but are not limited to the following:

• Failure of the injection to relieve your pain
• Worsening pain
• Backache
• Allergic reaction
• Seizures
• Infection around your spine
• Nerve damage (due to direct trauma, the medication, infection or bleeding).
• Short-term nerve injury
• Visual disturbance or loss of vision
• Long-term nerve injury
• Bleeding and blood clot around your spine
• Arachnoiditis
• Paralysis
• Avascular necrosis
• Spinal headache
• Muscle weakness

Common side effects from steroids include:

• Facial flushing
• Increased appetite
• Menstrual irregularities
• Nausea
• Diarrhea
• Increased blood sugar

Some people are not good candidates for spinal injections. These include people with:

• Skin infection at the site of needle puncture
• Bleeding disorder or anticoagulation
• Uncontrolled high blood pressure or high blood sugar levels (especially in diabetic patients)
• Allergy to contrast, anesthetics, or steroids
• The manufacturer did not specifically design most steroid solutions for facet joint injection procedure. Despite this, these medications have been widely used, over many years, for this procedure without significant complications.

Some facet joint injection complications can be serious and can even cause death. Serious complications of facet intervention are rare. Intraarticular steroid injections carry the risk of metabolic and endocrine side effects related to elevated glucose levels and suppression of the hypothalamic-pituitary-adrenal access; however, there have been no studies reported to date. There have been case reports of infection following intraarticular steroid injection, including septic arthritis, epidural abscess, and meningitis. Other complications include dural puncture and spinal anesthesia.

References

1. Sehgal N, Dunbar EE, Shah RV, Colson J. Systematic review of the diagnostic utility of facet (zygoapophysial) joint injections in chronic spinal pain: an update. Pain Physician 2007; 10: 213-228.
2. Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. A Systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10: 229-253.
3. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg. 2013 Jul;117(1):228-35. doi: 10.1213/ANE.0b013e3182910c4d. Epub 2013 Apr 30. https://journals.lww.com/anesthesia-analgesia/fulltext/2013/07000/A_Comparison_of_Intraarticular_Lumbar_Facet_Joint.34.aspx
4. Manchikanti L, Hirsch JA, Pampati V. Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions? Pain Physician. 2003 Oct;6(4):399-405.
5. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation (radiofrequency neurotomy) in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg. 2013 Jul;117(1):228-35. doi: 10.1213/ANE.0b013e3182910c4d. Epub 2013 Apr 30. https://journals.lww.com/anesthesia-analgesia/fulltext/2013/07000/A_Comparison_of_Intraarticular_Lumbar_Facet_Joint.34.aspx
6. Mann SJ, Singh P. Lumbar Facet Arthropathy. [Updated 2019 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538228
7. Manchikanti L, Kaye AD, Boswell MV, Bakshi S, Gharibo CG, Grami V, Grider JS, Gupta S, Jha SS, Mann DP, Nampiaparampil DE, Sharma ML, Shroyer LN, Singh V, Soin A, Vallejo R, Wargo BW, Hirsch JA. A Systematic Review and Best Evidence Synthesis of the Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. Pain Physician. 2015 Jul-Aug;18(4):E535-82.
8. Civelek E, Cansever T, Kabatas S, Kircelli A, Yilmaz C, Musluman M, Ofluoglu D, Caner H. Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain. Turk Neurosurg. 2012;22(2):200-6.