Facet Joint Injection

• The facet joints are the joints of the spine (cervical, thoracic, and lumbar). They hold joint fluid and are lined with cartilage. There are two facet joints at each level of the spine, one on the right and one on the left.
• The facet joints let the spine move (flexion, extension, bending side-to-side) and rotate.
• Like any other joint in the body, facet joints can wear down and become painful.
• By far the most common disease of the facet joints is arthritis. It is a wear-and-tear, inflammatory condition. Over time it wears away joint cartilage. It grows extra bone (‘osteophytes’ or ‘spurs’). It eats into the joint. In the end the joint itself turns unstable. Injuries also damage facet joints. They are often the source of pain after whiplash-type injuries. Facet injury can also happen when the disc in front of the joint loses height.
• The facet joints and the tissue around them are lined with nerves. As the wear-and-tear and inflammation get worse, the nerve endings get irritated and inflamed. That is what you feel as pain. Any part of this wearing-down process may hurt.
• The main job of scans before the procedure is to check for other possible causes of back pain.

Scans show typical patterns of facet joint wear. In the same way, patients with facet pain often have a typical history and exam that point to this disease. This is sometimes called “Facet Syndrome”. Experts still argue over the exact definition of the ‘Facet Syndrome’. But it includes the following:

• Neck pain on one side or both sides
• Less range of motion
• Tenderness over the affected facet joint(s)
• Headaches
• ‘Referred’ pain, or pain felt in other areas, such as the shoulder or upper arm

• Low back pain on one side or both sides, often worse with rest in any position
• Deep pain that may spread to the hip, thigh and upper leg
• Pain made worse by twisting or turning, and by moving from sitting to standing
• Pain that improves with standing, walking, or repeated activity
• Morning stiffness
• Pain right over the involved facet joint

• Often more than one facet joint is inflamed or worn. Other factors may also add to back pain. These include disc disease, referred pain, and mental and emotional factors. All of this makes it harder to pin down the exact joint and level causing the facet pain.
• Scans (X-rays, MRI and CT scans) help screen the spine for possible causes of back pain. But they often cannot tell whether a given facet joint is the source of pain.
• They show how worn the facet joints are. But like any other joint in the body, the amount of wear doesn’t always match the amount of pain. Some patients have badly worn facet joints on their scans but feel little or no pain.
• On the flip side, some patients with severe pain from the facet joints (facetogenic pain) show only mild wear on their scans. That is why your history and physical exam matter so much. They help pin down the source and level of the pain.

It fits when the pain sits on one or both sides of the spine, gets worse when you arch backward or twist, eases when you lean forward or sit, and stays above the knee. That pattern points at the facet joints. Pain that shoots down the leg with numbness points at a nerve root instead, and an epidural or nerve root block fits that better.

The injection settles the question. If numbing the joint takes the pain away, the joint is confirmed, and when the relief fades, radiofrequency ablation of its nerves makes it last longer. Back pain that gets worse when you arch and twist.

What Will Happen To Me During The Procedure?

We explain the procedure, answer your questions and get your informed consent. You will lie on your stomach on the x-ray table. This lets your doctor see the joints in your back clearly with x-ray guidance. The skin on your back is cleaned with a sterile scrub (soap). Next, the physician numbs a small patch of skin with numbing medicine. This medicine stings for several seconds.

Once the numbing medicine takes effect, your doctor guides a very small needle into the joint using x-ray. A small amount of contrast (dye) is injected to make sure the needle is inside the joint space. Then a small mix of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected. One or several joints may be injected, based on where your usual pain is.

What Will Happen After The Procedure?

Right after the procedure, you will get up, walk and try something that normally brings on your usual pain. Then you will report the percentage of pain relief. You will also record your relief over the next week. Your legs may feel weak or numb for a few hours. If they do, have someone else drive until that wears off; most patients drive themselves home.

How Do I Prepare for the Procedure?

• Eat a light meal a few hours before your procedure. If you are a diabetic on insulin, do not change your normal eating pattern before the procedure. Take your usual medicines (for example, blood pressure and diabetes medicines).
• Do not take pain medicines or anti-inflammatory medicines the day of your procedure. You need to be hurting before this procedure. Do not take any medicine that may ease your usual pain. You can restart these medicines after the procedure if you need them.
• If you take Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetes medicine Glucophage, you must tell this office. We will explain when to take them. You will be at the clinic for about 1-3 hours for your procedure.
• You will be awake under local anesthetic, with no sedation, so most patients drive themselves home. Arrange a driver only if your arm or leg feels weak or numb, and only until that wears off. Normal activity, including work, resumes within two to four hours.

What If I Don’t Get Any Relief From The Facet Joint Injections?

If the facet joint injections bring no relief, that joint is unlikely to be a source of your pain. You and your physician should then look at other possible sources. This may mean other diagnostic blocks or more scans.

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 pattern with facet pain. The local anesthetic (numbing medicine) usually 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 a Radiofrequency Neurolysis (RF).