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Facet Joint
Injections
What are they? How are they done?
Zygapophysial joints, better known as
facet or “Z” joints, are located on the back (posterior) of the spine
on each side of the vertebrae where it overlaps the neighboring
vertebrae. The facet joints provide stability and give the spine the
ability to bend and twist. They are made up of the two surfaces of the
adjacent vertebrae, which are separated by a thin layer of cartilage.
The joint is surrounded by a sac-like capsule and is filled with
synovial fluid (a lubricating liquid that reduces the friction between
the two bone surfaces when the spine moves and also nourishes the
cartilage.)
Indications
There are basically two reasons for having
a facet joint injection: for diagnosis (to determine the source of
pain) or for therapy (to treat an abnormality that has been detected.)
Most
back pain will improve within a few
weeks by itself, or with conservative treatments such as rest,
anti-inflammatory medications, physical therapy and exercise. If you
suffer from back pain for more than six weeks and conservative
treatments have not helped, or if your pain has increased, your
physician may order diagnostic tests such as magnetic resonance
imaging (MRI) or computerized tomography (CT) scans to look at the
structures of the spine. A problem (such as inflammation, irritation,
swelling or arthritis) in the facet joint may cause low back pain. If
these diagnostic tests show an abnormality in a facet joint, it may be
the source of the pain.
To determine if a facet joint is truly the
source of back pain, an injection (sometimes called a “block”) may be
prescribed. If an injection of a small amount of anesthesia into the
facet joint reduces or removes the pain, your health care provider is
assured that the facet joint is the source of the pain. This is
diagnostic use of the facet injection.
Once a facet joint is pinpointed as a
source of pain, therapeutic injections of anesthesia and
anti-inflammatory medications may give pain relief for longer periods
of time.
Injections
Procedure Overview
Facet joint injections are performed while
you are awake, under a local anesthetic, and able to communicate.
Sometimes, your health care provider may also administer drugs to make
you more comfortable during the procedure. The injection is usually
performed while you are lying on your stomach on an X-ray table. EKG,
blood pressure cuffs and blood-oxygen monitoring devices may be hooked
up prior to the injection process.
During the procedure, you probably will
undergo a fluoroscopic X-ray that allows your health care provider to
place the syringe in the correct facet joint. Your health care
provider or an assistant will clean and sterilize the area of the back
directly over the affected joint. Your health care provider will then
use a local anesthetic to numb the skin over the injection site.
Before your health care provider injects the actual medication into
the joint capsule, he or she will inject the joint with a contrast
(dye) that will show up on the X-ray to ensure he or she has the
proper site for injecting the medications.
Once the proper site has been determined,
your health care provider will inject the anesthetic and the
anti-inflammatory. You may be asked whether you are experiencing pain
relief or not, to make sure the injection is in the right place and
determine if additional injections are needed. This process may then
be repeated depending on the number of affected facet joints. Although
the actual injection takes only a few minutes, the overall procedure
usually takes approximately 30 to 60 minutes.
Special
Preparations
If you are to undergo a facet injection,
you should not take any non-steroidal anti-inflammatory (NSAID)
medications for three days prior to the procedure. You should also not
take any prescription pain relievers for at least four hours before
the injection; check with your health care provider. On the day of the
injection you should have no food or drink (including water) for at
least four hours before the procedure. However, if you are an insulin
dependent diabetic, inform your health care provider; you may not need
to change your normal eating habits prior to the procedure. If you
need to take medication within four hours before the procedure, a sip
of water may be allowed; however, you should check with your health
care provider prior to taking any medication before the injection.
After The Injection
Immediately following the procedure, you
may feel a reduction or complete relief of your back pain. Your health
care provider may ask you to perform a task that would normally cause
pain to assess the level of pain relief. You will be able to walk
immediately after the procedure, although some patients may experience
leg weakness, numbness or tingling for a few hours after the
injection. Because your reaction times may be affected by the
medications, driving is not recommended immediately following the
injection. You probably should have someone who is able to drive you
home following the procedure.
Once home, you can treat any pain you may
have at the injection site with ice or a pain medication prescribed by
your health care provider. It is generally recommended that you take
it easy and not exert yourself for the first day. After the anesthetic
component of the injection wears off, your back pain may return. It
may take seven to ten days for the steroid component of the injection
to relieve the pain. After the first day, you can usually return to
your daily activities as your pain will allow; however, you should
check with your health care provider to get his or her recommendations
on specific activities that will be allowed. In most cases, you can
return to work the day following the injection.
Effectiveness Are Facet Injections
The effectiveness of facet injections for
the treatment of low back pain is controversial. No medical study has
definitively identified the facet joint as the cause of low back pain.
Research has found that facet injections can give relief of lower back
pain for longer than six months in 18-63% of patients who underwent
the procedure. It has been recommended that facet injections be used
as a method to allow the patient to be able to perform other forms of
conservative treatment (such as physical exercise, yoga and stretching
and bending), rather than using it as a stand-alone pain treatment.
If you do not get relief from your pain
following the first therapeutic facet injections, further treatments
by injection are not recommended.
Who Should
Not Receive Facet injections?
You should not undergo facet injections
for the treatment of low back pain if your pain has not been present
for at least four to six weeks and if other forms of conservative
treatment have not been tried. If you are prone to excessive bleeding
or are taking an anticoagulant medication, this procedure is not
recommended; you should notify your health care provider if you are
taking these medications. If your back pain has been diagnosed as a
result of an infection or malignancy, it is also recommended that
other forms of pain relief be used.
Side
Effects
There is a possibility of side effects
with just about any medical procedure and you should always discuss
that possibility with your physician before undergoing any treatment.
Possible side effects from facet injections include pain at the
injection site, bleeding, infection or a worsening of the pain
symptoms. Side effects of the steroid medications used may include
fluid retention, weight gain, elevated blood pressure, mood swings and
insomnia.
Frequently Asked Questions:
-
What
is a Facet Joint Injection?
Facet
Joint Injection is an injection of long lasting steroid
("cortisone") in the Facet joints – which are located in the back
area, as a part of the bony structure.
-
What
is the purpose of it?
The
steroid injected reduces the inflammation and/or swelling of
tissue in the joint space. This may in turn reduce pain, and
other symptoms caused by inflammation / irritation of the joint
and surrounding structures.
-
How
long does the injection take?
The
actual injection takes only a few minutes.
-
What
is actually injected?
The
injection consists of a mixture of local anesthetic (like
lidocaine or bupivacaine) and the steroid medication (triamcinolone
– Aristocort® or methylprednisolone – Depo-medrol®).
-
Will
the injections hurt?
The
procedure involves inserting a needle through skin and deeper
tissues (like a "tetanus shot"). So, there is some discomfort
involved. However, we numb the skin and deeper tissues with a
local anesthetic using a very thin needle prior to inserting the
needle into the joint. Most of the patients also receive
intravenous sedation and analgesia, which makes the procedure
easy to tolerate.
-
Will I
be "put out" for this procedure?
No. This
procedure is done under local anesthesia. Most of the patients
also receive intravenous sedation and analgesia, which makes the
procedure easy to tolerate. The amount of sedation given
generally depends upon the patient tolerance.
-
How is
the injection performed?
It is
done either with the patient lying on the stomach, or for the
cervical (neck area) injections – in sitting position, under
x-ray control. The patients are monitored with EKG, blood
pressure cuff and blood oxygen-monitoring device. The skin in the
back is cleaned with antiseptic solution and then the injection
is carried out. After the injection, you are placed on your back
or on your side.
-
What
should I expect after the injection?
Immediately after the injection, you may feel that your pain may
be gone or quite less. This is due to the local anesthetic
injected. This will last only for a few hours. Your pain will
return and you may have a "sore back" for a day or two. This is
due to the mechanical process of needle insertion as well as
initial irritation form the steroid itself. You should start
noticing pain relief starting the 5th day or so.
-
What
should I do after the procedure?
You
should have a ride home. We advise the patients to take it easy
for a day or so after the procedure. You may want to apply ice to
the affected area. Perform the activities as tolerated by you.
-
Can I
go to work to work the next day?
Unless
there are complications, you should be able to return to your
work the next day. The most common thing you may feel is sore
back.
-
How
long the effect of the medication lasts?
The
immediate effect is usually from the local anesthetic injected.
This wears off in a few hours. The cortisone starts working in
about 5 to 7 days and its effect can last for several days to a
few months.
-
How
many injections do I need to have?
If the
first injection does not relieve your symptoms in about a week to
two weeks, you may be recommended to have one more injection. If
you respond to the injections and still have residual pain, you
may be recommended for a third injection.
-
Can I
have more than three injections?
In a
six-month period, we generally do not perform more than three
injections. This is because the medication injected lasts for
about six months. If three injections have not helped you much,
it is very unlikely that you will get any further benefit from
more injections. Also, giving more injections will increase the
likelihood of side effects from cortisone.
-
Will
the Facet Joint Injection help me?
It is
very difficult to predict if the injection will indeed help you
or not. Generally speaking, the patients who have recent onset of
pain may respond much better than the ones with long standing
pain.
-
What
are the risks and side effects?
Generally
speaking, this procedure is safe. However, with any procedure
there are risks, side effects, and possibility of complications.
The most common side effect is pain – which is temporary. The
other risks involve, infection, bleeding, worsening of symptoms,
spinal block, Epidural block etc. The other risks are related to
the side effects of cortisone: These include weight gain,
increase in blood sugar (mainly in diabetics), water retention,
suppression of body’s own natural production of cortisone etc.
Fortunately, the serious side effects and complications are
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®), or if
you have an active infection going on, you should not have the
injection.
Call The
Pain Treatment Center in Houston,
Texas today to
see how we can help you determine the best minimally-invasive spine
treatment for your specific medical condition.
For appointments please call: 281-556-0001
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