Facet Joint Injections
A Facet Joint is a small joint located in pairs on the back of your spine from rhe neck to the base of your spine. A Facet Joint Injection is:
- An injection of a local anesthetic into facet joints (needles on the right in Fig. 1 areshown in position to inject into the three lower right facet joints) or …
- An injection of local anesthectic around the nerves that supply the joint (the needles on the left in Figure 1 are shown in position to inject anesthetic onto the nerves supplying two lower left lumbar facet joints, or…
- An injection of local anesthetic into joints and around the nerves going to the joints, together, at the same time.
WHAT DIAGNOSIS IS THIS PROCEDURE FOR?
1) Cervical, thorax or lumbar spondylosis (osteoarthritis, degeneration) 2) Spinal arthritis.
WHAT IS THE PURPOSE OF THIS PROCEDURE?
Diagnostic (95% of facet injections are diagnostic injections): This is a diagnostic test to see if the injected joints are causing your back or neck pain. Only local anesthetic (usually Bupivicaine) is injected into the joint and/or onto the nerves supplying the joint. The intent of the injections is to numb up the joint long enough (2-4 hours) to allow you to do activities that normally provoke back or neck pain and to see if the back or neck pain occurs during those activities or not. If the injected joints ARE causing your back or neck pain, then you will feel much less back or neck pain for 2-4 hours after the injection, while the painful joints are numb. Your pain log will show less back or neck pain during the 2-4 hours after the injection. If the injected joints are NOT causing your back or neck pain, you will notice no difference in back or neck pain in the 2-4 hours after the injection. Your pain log will show minimal change in back or neck pain severity in the 2-4 hours after the injection. Therapeutic injection (rarely done at IPCA): A small (5 mg methylprednisolone usually) amount of steroid is added to the local anesthetic and the injection is made into the joint, not onto the nerves going to the joint. This is rarely done, only special circumstances justify its use. The intent is to reduce joint inflammation related to arthritis, much as an injection into the knee or shoulder joint can do when arthritis is severe. The results are temporary (2 weeks to 6 months of pain relief)
IF I HAVE A DIAGNOSTIC INJECTION, WHAT IS THE POINT? WHAT WILL WE DO WITH THE INFORMATION OBTAINED FROM THE DIAGNOSTIC INJECTIONS?
There are special treatments available for painful facet joints: if the diagnostic injections show that you have one or more painful facet joints, there is a relatively simple procedure that can be done to make the painful joints numb permanently. See the patient education handout titled “Permanent Anesthetic Block Of Spinal Facet Joints” If the joints are NOT causing your pain, treatment has to be focused elsewhere, not on the joints. Finally, once we know that the joints are a cause of pain we may, your doctors may want to modify surgical treatment plans to include treatment of facet joint pain, should you ever need surgery.
WHY IS THE INJECTION SOMETIMES IN THE JOINT, AND SOMETIMES ON THE NERVE TO THE JOINT?
We usually anesthetize only the nerves to the joint. But if we place a needle into the joint because the doctor wants to get a diagnostic picture of the joint using liquid contrast dye that can be seen on the fluoroscope, we inject local anesthetic into the joint rather than move the needle to the nerves, to reduce the number of needle sticks (for our patient’s comfort).
WILL THE FACET JOINT INJECTION(S) HELP ME?
Diagnostic injections: NO! They are not meant to help your pain; they are intended only to diagnose if your back or neck/neck pain is coming from facet joints, and if so which joint(s) are painful. If pain goes away after the injection, it WILL return when the local anesthetic wears off. Therapeutic injections are supposed to help, but it is impossible to know ahead of time if they will. The chance that they will is roughly 50%. However, unless the doctor has specifically told you that he is doing a therapeutic injection, this does not apply to you. 95% of facet injections are diagnostic injections.
WHY CAN’T WE USE BACK OR NECK X-RAYS, CT SCANS, OR MRIs TO TELL WHICH JOINT IS HURTING?
These imaging tests will show joint abnormalities such as changes of arthritis. However, arthritis of facet joints does not always cause pain. Joints may look bad on X-ray but not hurt. Also, joints may look almost normal yet hurt very badly. The x-rays tell us where the arthritis is but not which one (if any) of the arthritic joints is hurting.
HOW LONG DOES THE INJECTION TAKE?
The actual injection takes only a few minutes.
WHAT IS ACTUALLY INJECTED?
The injection consists of local anesthetic (usually bupivicaine). Occasionally (for therapeutic injections) steroid medication (triamcinolone-Aristocort , methylprednisolone-Depo-medro, or celestone-Betamethasone ) will be injected into the facet joints to try for longer term relief (therapeutic injection, see above). This is rarely done, however.
WILL THE INJECTION(S) HURT?
The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). There is some discomfort involved. We use a very thin needle, just like the one used for injecting local anesthetic.
WILL I BE “PUT OUT” FOR THIS PROCEDURE?
No. We usually want you to be able to tell if your pain has been relieved by the local anesthetic injected into the joint right after the injection is finished. The key time is the first two-four hours after the injection. If you were sedated during the injection, the effect of the sedative might interfere with your ability to decide how much the injection helps in the two-four hours right after the injection.
HOW IS THE INJECTION PERFORMED?
You will be checked in for the procedure and the nurse will ask some routine questions and help you change if this is necessary. You will review and sign the consent to treat forms. If you are bringing x-rays that the doctor has not already seen, please inform the nurse who helps you get ready for the procedure – she will bring them to the doctor’s attention. Position: For thoracic and lumbar facet blocks you will be lying on your stomach, for cervical facet blocks you will be lying on your back. An X-ray machine called a “fluoroscope” will be positioned over you and it will show the doctor doing the injection exactly where to place the needle. X-ray pictures are taken during the procedure, using this fluoroscope. The skin over the injection site is cleaned with antiseptic solution (betadine, unless you are allergic to iodine. If you are, tell the nurse who helps you get positioned for the injection and the nurse will use a special antiseptic soap without iodine) and then the injection is carried out. You will walk to and from the injection unless you normally use a wheelchair.
WHAT SHOULD I EXPECT AFTER THE INJECTION?
Immediately after the injection you may feel that your pain may be gone or considerably less for 2-4 hours. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return in a few hours. Regardless, you may have a “sore back or neck” for a day or two. This is due to the mechanical process of needle insertion.
WHAT SHOULD I DO AFTER THE PROCEDURE, DO I HAVE LIMITATIONS?
You should not drive for 2 hours after the injection. In the first 4 hours you should test the injection by doing things that usually provoke back or neck pain, so we definitely do not want you to rest and take it easy right after the injection. If you are sore after the anesthetic wears off (and you may be for 1-2 days like with any shot), avoid activity that hurts a lot for comfort’s sake. You are not at increased risk of hurting yourself, however.
CAN I GO TO WORK?
You should be able to return to work. The most common thing you may feel is a sore back or neck.
WILL THE INJECTION NEED TO BE REPEATED?
Diagnostic injections are usually done in sets of 2 injections on 2 different days, although sometime 3 different days and occasionally all on one day. It depends on how many joints need to be tested. The IPCA scheduling staff will go over the specific plan with you when it is time to schedule.
WHAT SHOULD I DO WITH THE PAIN LOG I AM GIVEN?
For all diagnostic injections you will be asked to rate your pain every thirty minutes for a while, then every one hour, for about 6 hours on a written pain log..Rate only your typical pain, do not include soreness from the injection! The nurse who discharges you will provide you with the pain log. The specific instructions as to how to return it to your doctor will be given to you in writing on your discharge paperwork.
WHAT ARE THE RISKS AND SIDE EFFECTS?
Generally speaking, this procedure is very safe. However, with any procedure there are risks, side effects and the possibility of complications. The most common side effect is pain – which is temporary. The other very rare risks involve infection, bleeding, worsening of symptoms, spinal block, epidural block, etc. There are possible side effects of steroid, if it is used (for therapeutic blocks), but the dose is so small in these injections that these temporary side effects are very unlikely to occur: weight gain, temporary weight gain, increased blood sugar (mainly in diabetics ), water retention, suppression of the body’s own natural production of cortisone etc. Fortunately the serious side effects and complications are very, very uncommon.
WHO SHOULD NOT HAVE THIS INJECTION?
If you are allergic to any of the medications to be injected, if you are on a blood thinning medication ( e.g. Coumadin, Heparin, Plavix), if you are or could be pregnant, or if you have an active infection going on, you should not have the injection.
WHAT ABOUT MY PAIN MEDICINES … DO I TAKE THEM THE DAY OF THE PROCEDURE?
What not to take:
On the morning of the procedure try not to take short acting pain “as needed” medications such as Percocet, Roxicet, Roxicodone, oxycodone. Oxy IR, Vicodin, Lortab, Norco, hydrocodone, immediate release morphine, Dilaudid, codeine, propoxyphene, or Darvocet. Also avoid ibuprofen, Motrin, naprosyn, naproxen, Aleve, Tylenol, and other over the counter remedies for back or neck pain before the procedure.
What is OK to take:
It is OK to take you regular dose of long-acting pain medicine such as MS Contin, morphine ER, OxyContin, oxycodone SR, oxycodone 12hr, Avinza, Kadian, and methadone. We do not want you to be skipping these because that causes withdrawal symptoms that make it hard for you to concentrate on the results of the injections.
After the procedure:
Take any medications that you usually take for pain if there is severe back or neck pain. If you have to take pain medicine right after the injection, please note on your Pain Log that you took pain medicine, and note the time that you took the medicine as well.