Facet - Padda Institute Center for Interventional Pain Management

Whiplash Injury (Nagging neck pain after an accident)

Following a car accident, your nagging neck pain may not be just “soft tissue.”  Neck pain is one of the most common chronic pain conditions in modern medicine and can lead to depression, sleep disturbance, and inability to work.  Even though there may be minimal damage to your car, you can still sustain significant whiplash.  In fact, even at low speeds, occupants can experience severe whiplash, the video above demonstrates whiplash injury with a 5 mph collision.

 

 

 

 

 

The rapid motion of the neck during a crash can result in a number of injuries, with the majority of these injuries involving “soft tissue”:

  • Muscles
  • Tendons
  • Ligaments
  • Nerves
  • Discs
  • Micro fractures
  • Facet subluxation
  • Hemorrhage or edema of the pariarticular tissues (facet joints)
Soft tissue ligaments involved in whiplash

The term “soft tissue” is frequently tossed around as if it is an insignificant injury; this could not be farther from reality, as even the brain, liver, and heart are soft tissue, and it doubtful you could survive long with any of these structures damaged.

Nerves involved in whiplash injury

Soft tissue injuries are difficult to see on x-rays or MRI, and frequently require a diagnostic interventional workup to define.  Soft tissue injuries can lead to significant permanent impairments, and should be treated in a timely and medically appropriate manner in order to mitigate long-term consequences.

 

Injuries to bony structures are less common, but are usually apparent on x-rays

  • Rim Lesions
  • Endplate avulsions
  • Tears of the anterior longitudinal ligament
  • Uncinate process
  • Articular subchondral fractures
  • Articular pillar
  • Articular processes

 

 

 

Whiplash affects the cervical vertebrae of the neck as well as the first few upper thoracic vertebrae, and is most commonly caused by car accidents when the force of a blow from the rear causes the head to whip backward and forward.  The most common facets to be injured are at C2/C3 and C5/C6, which frequently results in referred pain at the locations indicated. As a result of facet joint injury, whiplash patients frequently encounter, headaches, back and shoulder pain in addition to neck pain.

Referred pain from facet injury

This action can cause tears in the muscles, tendons or ligaments of the neck. It can also cause a nerve to become pinched between two vertebrae, resulting in pain or numbness that may radiate down to the shoulder, arm and hand.

 

The neck is a particularly vulnerable part of the spine because:

  • The head is a free floating weight attached to the fixed thorax like a pendulum
  • The neck has relatively little muscular support
  • During an accident the head is moved with tremendous force back and forth, concentrating the biomechanical forces to just a few cervicothoracic vertebral bodies and their limited support

 

 

When the neck is moved quickly and forcefully, it places tremendous strain on the facet joints of the spine — which are located at the rear of the spine. The facet joints normally allow the spine to move in a very flexible manner through flexion, extension and rotation.

 

Xray of facet joints, range of motion
Normal motion of cervical facets
Damage to facet with whiplash

 

Injured people with cervical facet syndrome usually present with severe posterior neck pain and muscle spasms. Outpatient to the neck produces pain over the cervical facets. The pain typically increases with extension of the neck with symptoms of pain overlying the cervical facet joints or regionally to the head, neck or shoulder region.

 

Unfortunately radiographic diagnoses of these injuries are very difficult. Cervical spine x-rays may reveal focal or diffuse cervical spondylosis or loss of normal lordosis, but will not reveal the facet injury itself. The medial branch of the dorsal ramus transmits the pain from inflamed facet joints. Stimulation of the facet nerves often results in referred pain.

 

 

Cervical facet blocks at the appropriate level are frequently necessary in the accurate diagnosis of cervical facet pain. The cervical facet block at the appropriate level usually brings immediate relief to the injured person, with pain relief lasting four to six hours after injection being diagnostic.  If successful diagnosis with facet blockade is made, then a more permanent solution may be radiofrequency neurolysis.

 

Low back pain with lumbar facet involvement can also be diagnosed similarly. However, lumbar facet joint injuries are far less likely to occur following an auto accident; because the lower back (lumbar spine) is generally supported and not subject to fast and extreme range of motion following a rear end car accident. This is different than the neck (cervical spine), which can only rely on a headrest for protection from these quick acceleration injuries (whiplash).

 

 

Facet Joint Radiofrequency (RF)

A patient with primary facet pain, proven with either one or more blocks, may be a candidate for a facet rhizotomy using radiofrequency (RF). The patients selected for rhizotomy are those who are not surgical candidates and who have failed other conservative measure.

By using the radiofrequency rhizotomy, the surgeon denervates the medial branch nerve which runs along the posterior spine near the facet joints.

Radiofrequency ablation or lesioning is a term used when radio waves are used to produce heat to destroy tissue, usually a nerve. It has been used for several years with great success in patients who have abnormally fast heartbeats. More recently, it is being used to destroy tumors. It is also a non-surgical option to treat your spine pain.

Spine pain is the second most frequent pain complaint. It occurs in 65 to 80 percent of the population at one time or another, and can be disabling and frightening. Its costs to society are great.

In the case of spinal pain, radiofrequency waves are transmitted through a needle placed into the facet joint under x-ray guidance. This procedure is also known as rhizotomy.

 

 

 

 

 

Radiofrequency (RF)

For chronic cases of facet joint syndrome, where the pain relief from the injections is short lived a procedure called Radiofrequency Rhizotomy or facet neurotomy or simply RF can be performed.  There are nerves that arise from the facet joints that carry the painful impulses to the brain. Heating these nerves by radiofrequency waves can block this transmission.

 

What is RF?

Facet neurotomy is a procedure which results in interruption of the nerve supply to a facet joint. A radio-frequency probe that heats the 2 small nerve branches to each facet joint accomplishes this interruption known as denervation. These nerves are called the medial branches.

 

How is RF done?

With the patient in a prone position [laying on your stomach] and under local anesthesia and fluoroscopic guidance, a radio-frequency needle is advanced to the base of the transverse processes. The needle is placed along the course of the medial branch. The needle is heated to 80° C for 90 seconds. At least 2 branches for each joint are treated in this same manner.  Sometimes a cold radio frequency is done, especially for cervical facets, which does not involve heating, but does involve a special pulsed radio wave.  Frequently, a small does of IV anesthesia medication is given for sedation.  However, this medication is not intended to make you unconscious.  You must be awake and responsive during the procedure.

 

How long does RF take?

The neurotomy takes 10 to 45 minutes, depending on the number of levels to be done. The patient is then recovered in the observation area for 30 minutes to 1 hour.

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk and try to imitate something that would normally bring about your usual pain. You will then report the percentage of pain relief and record the relief you experience during the next week.

 

You should not drive the day of the procedure. Your legs may feel weak or numb for a few hours.

 

General Pre/Post Instructions

  • You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).
  • Do not take pain medications or anti-inflammatory medications the day the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief or lessen your usual pain. These medications can be restarted after the procedure if they are needed.
  • If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will be at the clinic for approximately 1-3 hours for your procedure.
  • You will need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

Risks of RF?

Increased localized back pain and/or leg pain can be expected from several days to several weeks and rarely several months. Destabilization of the facet joint is a risk and post injection training to strengthen the extensor muscles can prevent this possibility.  There is a rare risk of permanent injury to nerve tissue with weakness or loss of sensation.  There is also a rare risk of complication from anesthesia used to make you feel more comfortable during the procedure.

 

As with any procedure, there is a risk of significant complications. The most common side effects from the RF include (but are not limited to):

 

  • Allergic reactions to medications
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of an unexpected motor or sensory nerve in the path of the radiofrequency needle
  • Bleeding, nerve injury, organ injury and death are rare but possible
  • Neuritis with inflammation of the nerve with pain and tenderness that lasts three to six weeks. This can occur in 10 to 15 percent of patients.
  • Neuroma is a tumor from a nerve made of nerve cells and fibers. It forms around the area destroyed during radiofrequency ablation and can itself cause pain.
  • Numbness-nerve damage
  • Lack of pain relief  even though a test block was beneficial.

 

 

Expected Outcome of RF?

Following the neurotomy, there is a 60 to 80% chance of pain relief. This typically last for 3 months to 2 years. The nerve eventually grows back and the procedure can be repeated. While the patient is experiencing pain relief, vigorous physical therapy is necessary to try and strengthen the involved facet joint(s).  You should expect no pain relief for the first 72 hours, with peak relief occurring 6 weeks later.

 

Facet Joint Injection (zygapophyseal joint injection)

What are facet joints and why are facet joint injections helpful?

The spine is designed to bend and turn. Along with the intervertebral discs, facet joints (also referred to as Z joints or zygapophyseal joints) enable the spine to bend and twist. Each vertebra has two sets of facet joints. One set of facet joints is located at the top and a corresponding set is at the bottom.

Facets joint are small joints a little larger than the size of your thumbnails located in pairs on the back of your spine. They provide stability and guide motion in your back. If the joints become painful they may cause pain in your neck, shoulder, low back, abdomen, buttocks, groin or legs.   The pattern and location of pain helps to determine the likely facet joints involved.

 

Working like a hinge, the articulating surfaces of each facet joint are coated with smooth cartilage allowing friction free movement. Although the facet joint bones fit snugly together, there is a lubrication system. The lubricating ‘oil’ is called synovial fluid and resembles uncooked egg whites. This fluid also nourishes the cartilage tissues.

A block that is performed to confirm that a facet joint is the source of pain and decrease pain and inflammation in a facet joint or joints.

 

I. Introduction

 

  • The Facet Joint injection (FJI) procedure targets the facet joint thought to be responsible for a patient’s back pain. The joint is injected and anesthetized with the intent of relieving this pain.
  • The facet injection procedure delivers a low volume of concentrated medication directly into the affected joint.
  • Back Pain is often multifactorial and difficult to diagnose because the symptoms overlap considerably with those of other degenerative disorders of the spine.
  • The FJI is useful in both the diagnosis and the treatment of back pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected joint space and the pain improves, we are fairly confident that this joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this joint is likely not responsible for the pain.

 

II. The Facet Joints

 

  • The Facet Joints are the joints of the spine (cervical, thoracic, and lumbar). They contain joint fluid and are lined by cartilage. There are two facet joints at each level of the spine, one on the right and one on the left.
  • The function of the facet joints of the spine is to allow movement (flexion, extension, bending side-to-side) and rotation.
  • Like any other joint in the body, facet joints can become diseased, and thereby become painful.
  • By far the most common disease affecting the facet joints is arthritis. This is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself.  Facet joints are also damaged by trauma, and frequently are the source of pain after whiplash type injuries.  Facet injury can also occur with disc height loss, in front of the disc.
  • The facet joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.
  • The primary role for imaging studies prior to the procedure is to evaluate for other possible causes of back pain.

 

 

III. Facetogenic Pain (‘Facet Syndrome’)

 

Just as imaging studies demonstrate typical patterns of facet joint degeneration, patients with facetogenic pain often have a typical history and physical examination suggestive of this disease. This is sometimes referred to as “Facet Syndrome”.

The exact definition and what constitutes the ‘Facet Syndrome’ is somewhat controversial, but includes the following:

 

Cervical

  • Unilateral or bilateral neck pain
  • Decreased range of motion
  • Tenderness over the affected facet joint(s)
  • Headaches
  • ‘Referred’ pain, or pain which is referred to other areas, such as the shoulder, or upper arm

Lumbar

  • Unilateral or bilateral low back pain, often worsened by rest in any position
  • Deep pain which may radiate to the hip, thigh and upper leg
  • Pain worsened by twisting or rotation, and exacerbated by moving from sitting to standing
  • Improvement of pain by standing, walking, or repeated activity
  • Morning stiffness
  • Pain directly over involved facet joint

 

 

IV. Patient Selection

 

  • Oftentimes more than one facet joint is inflamed or degenerated. In addition, there are other factors, which may be contributing to a patient’s back pain, including disc disease, referred pain, as well as psychological factors. This can make the exact site and level responsible for the facet pain more challenging to localize and diagnose.
  • Unfortunately, while imaging studies (X-RAYs, MRI and CT scans) are helpful in screening the spine for potential causes of back pain, they are often unreliable in determining whether or not a given facet joint may be the source of pain.
  • They help in identifying and characterizing the extent of facet degeneration, but like any other joint in the body, the extent of degeneration doesn’t necessarily correlate with the amount of pain. In other words, some patients may show severely degenerated facet joints on imaging studies, but be relatively asymptomatic.
  • Conversely, some patients experiencing severe pain from the facet joints (facetogenic pain) may show relatively mild degenerative findings on imaging studies. For this reason, the patient’s history and physical exam are very important in helping to clarify the source and level responsible for pain.

 

 

V. Procedure: Lumbar, Thoracic or Cervical Facet Joint Injection

 

What will happen to me during the procedure?

The procedure is explained to the patient, questions are answered and informed consent is obtained.

 

You will be placed on the x-ray table on your stomach in such a way that your doctor can best visualize these joints in your back using x-ray guidance. The skin on your back will be scrubbed using a sterile scrub (soap). Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds.

 

After the numbing medicine has been given time to be effective, your doctor will direct a very small needle using x-ray guidance into the joint. A small amount of contrast (dye) is then injected to insure proper needle position inside the joint space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

 

One or several joints may be injected depending on the location of your usual pain.

 

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk and try to imitate something that would normally bring about your usual pain. You will then report the percentage of pain relief and record the relief you experience during the next week.

 

You should not drive the day of the procedure. Your legs may feel weak or numb for a few hours.

 

General Pre/Post Instructions

  • You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).
  • Do not take pain medications or anti-inflammatory medications the day the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief or lessen your usual pain. These medications can be restarted after the procedure if they are needed.
  • If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will be at the clinic for approximately 1-3 hours for your procedure.
  • You will need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

 

What if I don’t get any relief from the facet joint injections?

If you don’t get relief from the facet joint injections, it is unlikely that this is a source of your pain.  You should then consider with your physician the other possible sources of your pain.  This may include other diagnostic blocks or imaging studies.

 

What happens if I get relief from the injection, but my pain comes back after a few hours or days?

This is the most common scenario with facetogenic pain.  Typically the local anesthetic wears off over the next six hours and the pain may return.   After a series of successful diagnostic facet blocks, the next step is usually to proceed with a Radiofrequency Neurolysis (RF).

 

Potential Risks of  Joint Injections

 

As with any procedure, there is a risk of significant complications. The most common side effects from the joint injection include (but are not limited to):

 

  • Allergic reactions to medication or dye used
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after the corticosteroid injection)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Rupture of a tendon or capsule located in the path of the injection
  • Bleeding, nerve injury, organ injury and death are rare but possible