Lumbar/Cervical Facet Joint Injections

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 (see illustration) 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.
• 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 contribute 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 or Cervical Facet Joint Injection

• The procedure is explained to the patient, questions are answered and informed consent is obtained.
• The patient is placed prone (stomach down) on the fluoroscopic table, and the lower back is sterilely cleansed with povidone-iodine (Betadine) and alcohol.
• The exact level is located with the fluoroscope, and the skin overlying this area is anesthetized (numbed) with lidocaine.
• A needle is sterilely advanced into the facet joint, which typically causes a mild degree of pain. It is important for us to know whether the pain elicited is similar to the patient’s pain (concordant response), or dissimilar (discordant response).
• Typically, as small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.
• Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected.
• The needle is slowly withdrawn
• This procedure may be performed with either CT or Fluoroscopic guidance.