Lumbar Facet Joint Injections: Difference between revisions

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<div class="editorbox">'''Original Editors '''- [[User:Georg Baker|Georg Baker]], [[User:Michelle harvey|Michelle Harvey]], [[User:Tommy Pearson|Tommy Pearson]], [[User:Joe Wakefield|Joe Wakefield]]  
<div class="editorbox">'''Original Editors '''- [[User:Georg Baker|Georg Baker]], [[User:Michelle harvey|Michelle Harvey]], [[User:Tommy Pearson|Tommy Pearson]], [[User:Joe Wakefield|Joe Wakefield]] as part of the [[Nottingham University Spinal Rehabilitation Project]]<br>
 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
<br> '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
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== Introduction  ==
== Introduction  ==
[[File:Facet joint injection.png|right|frameless]]
[[File:Facet joint injection.png|right|frameless]]Facet (zygapophyseal) joint injections are performed primarily for the diagnosis and differentiation of facet syndrome and [[Lumbar Radiculopathy|radicular pain syndrome]], and are one of the spinal interventional procedures.
LBP affects roughly 80% of the UK population and is the 2nd most common cause of long-term sickness from work <ref name="Walker. B, 2000">Walker. B, 2000, The prevalence of low back pain: a systematic review, School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia, Journal of spinal disorders, Volume 13, Edition 3, Pages 205-217.</ref>. A study released in 1999 revealed that the economic burden low back pain (LBP) produces onto the UK economy is £10,668 million, making it the most financially costly condition in the UK <ref name="Maniadakis. N, Gray. A, 1999">Maniadakis. N, Gray. A, 1999, The economic burden of back pain in the UK Global Health Outcomes, Searle Division of Monsanto, P.O. Box 53, High Wycombe, Bucks HP12 4HL, UK, Journal of Pain, Volume 84, Edition 1, Pages 95-103.</ref>. This figure is likely to have risen in recent years due to a larger number of LBP cases becoming chronic <ref name="Freburger et al, 2009">Freburger. J, Holmes. G, Agans. R, Jackman. A, Darter. J, Wallace. A, Castel. L, Kalsbeek. W, Carey. T, 2009, The rising prevalence of chronic low back pain, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King, Jr Blvd, Chapel Hill, NC, Archives of internal medicine, Volume 169, Edition 3, Pages 251-258</ref>.  
* They can be performed under fluoroscopic, or [[CT Scans|CT]] image guidance (cervical, thoracic or most commonly lumbosacral facet joints can be injected)
 
* One or multiple joints can be injected during one procedure<ref name=":1">Radiopedia [https://radiopaedia.org/articles/facet-joint-injection Facet joint injections] Available from:https://radiopaedia.org/articles/facet-joint-injection (last accessed 10.9.2020)</ref>.
Spinal injections are one of the many varieties of treatments considered when an individual presents with chronic LBP. As well as a treatment method some spinal injections are also used as a diagnostic tool. An example of one such injection is facet joint injections; which in 2010-2011 made up 36% of all spinal injections (fig. 1.1) <ref name="Hospital Episode Statistics, 2011">NHS Hospital Episode Statistics, 2011. main Procedures and Interventions: Outpatient Statistics[excel]Available at: http://www.hesonline.nhs.uk [Accessed 20 November 2012]</ref>.  
* Spinal injections are one of the many varieties of treatments considered when an individual presents with chronic LBP <ref name="Hospital Episode Statistics, 2011">NHS Hospital Episode Statistics, 2011. main Procedures and Interventions: Outpatient Statistics[excel]Available at: http://www.hesonline.nhs.uk [Accessed 20 November 2012]</ref>.
 
The effectiveness of facet joint injections is largely unknown but despite this, the procedure is still commonly performed by clinicians <ref name="Eckel. T, 2004">Eckel. T, 2004, Facet Joint Injections, Department of radiology, Lewis-Gale medical centre, 1900 Electric road, Salem, Virginia, USA, Journal of spinal pain, Volume 21, Edition 1, Pages 123-129</ref>.
The effectiveness of facet joint injections is largely unknown but despite this, the procedure is still commonly performed by clinicians <ref name="Eckel. T, 2004">Eckel. T, 2004, Facet Joint Injections, Department of radiology, Lewis-Gale medical centre, 1900 Electric road, Salem, Virginia, USA, Journal of spinal pain, Volume 21, Edition 1, Pages 123-129</ref>. The Physiotherapy profession is required to remain up to date with all available procedures each patient has available to them in treating their condition. Consequently, background knowledge regarding this treatment should be known by every clinician who regularly sees LBP patients. Therefore this Physiopedia page aims to use current literature to shine a light on the main areas surrounding this popular intervention, including:
* Although early studies reported reasonable long term relief of symptoms (20-54%), more recent studies have suggested that steroid injection "is of little value". However, short term relief is common (59-94%) and therefore it remains a useful procedure, especially to confirm the diagnosis<ref name=":1" />.  
# The different procedures used for a [[Facet Joints|facet joint]] injection
== Lumbar Facet Joints ==
# The risks facet joint injections cause
[[File:Lumbar vertebra.png|right|frameless]]
# The variety of conditions that lead to facet joint injections being used<br>
Lumbar Facet (zygapophysial) joints are formed of the superior and inferior articulating processes of adjacent vertebra <ref name="Strayer,A. 2005">Strayer,A., 2005. Lumbar Spine: Common Pathology and Interventions. The Journal of Neuroscience Nursing. 37(4) pp 181-193.</ref>.  
The effectiveness of facet joint injections coupled with some suggestions for future research/Physiopedia pages will be included in the conclusion.  
* Classed as plane synovial joints <ref name="Palastanga, Field and Soames, 2006">Palastanga,N.,Field,D.,Soames,R.,2006. Anatomy and Human Movement: Structure and Function. Butterworth Heinemann Elsevier:London</ref>.  
 
* Orientated in a vertical projection <ref name="Palastanga, Field and Soames, 2006" />.  
== Lumbar Facet Joint ==
* Articular surfaces are covered by hyaline cartilage, surrounded by a thin fibrous joint capsule that contains a synovial membrane that secretes synovial fluid into the joint space <ref name="Peh,2009">Peh,W.C.G., 2009. Image-guided Facet Joint Injection. [online] Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107686/pdf/biij-07-e4.pdf[Accessed 27 December 2012]</ref> <ref name="Palastanga, Field and Soames, 2006" />.  
 
* Free and encapsulated nerve endings supplied by the medial branches of the dorsi rami, innervate the facet joints <ref name="Sehgal et al, 2007">Sehgal,N., Dunbar,E.E., Shah,R.V., Colson,J., 2007. Systematic Review of Diagnostic Utility of Facet (Zygopophysial) Joint Injections In Chronic Spinal Pain: An Update. Journal of Pain Physician [online] Available at:http://www.painphysicianjournal.com/2007/january/2007%3B10%3B213-228.pdf[Accessed 29 Nov 2012].</ref><ref name="Manchikanti et al, 2004">Manchikanti, L., Boswell,M.V., Singh,V., Pampati,V., Damron,K.S., Beyer,C.D., 2004. Prevalence of Facet Joint Pain in Chronic Spinal Pain of Cervical, Thoracic, and Lumbar Regions, [online] Available at:http://www.biomedcentral.com/content/pdf/1471-2474-5-15.pdf[Accessed 27 December 2012].</ref>.
Facet (zygapophysial) joints are formed of the superior and inferior articulating processes of adjacent vertebra <ref name="Strayer,A. 2005">Strayer,A., 2005. Lumbar Spine: Common Pathology and Interventions. The Journal of Neuroscience Nursing. 37(4) pp 181-193.</ref>. They are classed as plane synovial joints <ref name="Palastanga, Field and Soames, 2006">Palastanga,N.,Field,D.,Soames,R.,2006. Anatomy and Human Movement: Structure and Function. Butterworth Heinemann Elsevier:London</ref>. Within the Lumbar spine they are orientated in a vertical projection <ref name="Palastanga, Field and Soames, 2006" />. The articular surfaces are covered by hyaline cartilage, surrounded by a thin fibrous joint capsule that contains a synovial membrane that secretes synovial fluid into the joint space <ref name="Peh,2009" /> <ref name="Palastanga, Field and Soames, 2006" />. Free and encapsulated nerve endings supplied by the medial branches of the dorsi rami, innervate the facet joints <ref name="Sehgal et al, 2007">Sehgal,N., Dunbar,E.E., Shah,R.V., Colson,J., 2007. Systematic Review of Diagnostic Utility of Facet (Zygopophysial) Joint Injections In Chronic Spinal Pain: An Update. Journal of Pain Physician [online] Available at:http://www.painphysicianjournal.com/2007/january/2007%3B10%3B213-228.pdf[Accessed 29 Nov 2012].</ref><ref name="Manchikanti et al, 2004" />.<br>
 
[[Facet Joints|Facet joints]] have been recognised as a possible source of chronic LBP since the early 1900's <ref name="Peh,2009">Peh,W.C.G., 2009. Image-guided Facet Joint Injection. [online] Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107686/pdf/biij-07-e4.pdf[Accessed 27 December 2012]</ref><ref name="Manchikanti et al, 2004">Manchikanti, L., Boswell,M.V., Singh,V., Pampati,V., Damron,K.S., Beyer,C.D., 2004. Prevalence of Facet Joint Pain in Chronic Spinal Pain of Cervical, Thoracic, and Lumbar Regions, [online] Available at:http://www.biomedcentral.com/content/pdf/1471-2474-5-15.pdf[Accessed 27 December 2012].</ref>.  


== Facet Joint Injection  ==
== Facet Joint Injection  ==
* [[Facet Joints|Facet joints]] have been recognised as a possible source of chronic LBP since the early 1900's <ref name="Peh,2009" /><ref name="Manchikanti et al, 2004" />.
* Facet joint injections have two main purposes; one to relieve pain both short and long term and the other to be used conjunctively with the physical examination as a diagnostic tool to determine whether the facet joint is the source of pain <ref name="Peh,2009" /><ref name="Manchikanti et al, 2004" /><ref name="Sehgal et al, 2007" />. <br>
{{#ev:youtube|https://www.youtube.com/watch?v=FJq68eIx4KM|width}}<ref>Facet injections Facet Injections - Pain Management Available from: https://www.youtube.com/watch?v=FJq68eIx4KM Last accessed 14.11.2019)</ref>
# '''Diagnostic Facet Joint Injection'''
The following two-step response pattern is the current gold standard which is used to diagnose '''facet joint syndrome''', which may indicate a need for a '''therapeutic''' facet joint injection<ref>Sehgal, N., Shah, R., McKenzie-Brown, A. and Everett, C. (2005) Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician 8(2): pp.211–224.</ref>


Facet joint injections have two main purposes; one to relieve pain both short and long term and the other to be used conjunctively with the physical examination as a diagnostic tool to determine whether the facet joint is the source of pain <ref name="Peh,2009" /><ref name="Manchikanti et al, 2004" /><ref name="Sehgal et al, 2007" />. <br>  
1. Saline is injected causing distension of the problematic facet joint - this should reproduce/increase the patients’ pain.<br>2. Injection of local anaesthetic into the facet joint - this should reduce/relieve the patients’ pain<ref>Murtagh, F. (1988) Computed tomography and fluoroscopy guided anesthesia and steroid injection in facet syndrome. Spine 13(6): pp.686–689.</ref>.
{{#ev:youtube|https://www.youtube.com/watch?v=FJq68eIx4KM|width}}<ref>Facet injections Facet Injections - Pain Management Available from: https://www.youtube.com/watch?v=FJq68eIx4KM Last accessed 14.11.2019)</ref>
===  Diagnostic Facet Joint Injection ===
 
The following two-step response pattern is the current gold standard which is used to diagnose '''facet joint syndrome''', which may indicate a need for a '''therapeutic''' facet joint injection<ref>Sehgal, N., Shah, R., McKenzie-Brown, A. and Everett, C. (2005) Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician 8(2): pp.211–224.</ref> Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as Therapeutic Facet Joint Injection or neurolysis (by radiofrequency or cryoablation)<ref name=":0">Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A, Heck O, Boubagra K, Grand S, Krainik A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206372/ Facet joint syndrome: from diagnosis to interventional management.] Insights into imaging. 2018 Oct 1;9(5):773-89.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206372/ (last accessed 14.11.2019)</ref>
 
Neurolysis is the application of a chemical or physical destructive agent to a nerve to create a long-lasting or permanent interruption of neural transmission.<ref>Hanania MM, Argoff CE. [https://www.sciencedirect.com/science/article/pii/B9780323040198000391 PERMANENT NEURAL BLOCKADE AND CHEMICAL ABLATION.] Pain Management Secrets E-Book. 2009 Jul 31:296. Available from: https://www.sciencedirect.com/science/article/pii/B9780323040198000391 (last accessed 14.11.2019)</ref>


1. Saline is injected causing distension of the problematic facet joint - this should '''reproduce/increase '''the patients’ pain.<br>2. Injection of local anaesthetic into the facet joint - this should '''reduce/relieve''' the patients’ pain<ref>Murtagh, F. (1988) Computed tomography and fluoroscopy guided anesthesia and steroid injection in facet syndrome. Spine 13(6): pp.686–689.</ref>.  
Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain.  
 
* These patients may benefit from specific interventions to eliminate facet joint pain such as Therapeutic Facet Joint Injection or neurolysis (by radiofrequency or cryoablation)<ref name=":0">Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A, Heck O, Boubagra K, Grand S, Krainik A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206372/ Facet joint syndrome: from diagnosis to interventional management.] Insights into imaging. 2018 Oct 1;9(5):773-89.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206372/ (last accessed 14.11.2019)</ref>
=== Therapeutic Facet Joint Injection ===
* Neurolysis is the application of a chemical or physical destructive agent to a nerve to create a long-lasting or permanent interruption of neural transmission.<ref>Hanania MM, Argoff CE. [https://www.sciencedirect.com/science/article/pii/B9780323040198000391 PERMANENT NEURAL BLOCKADE AND CHEMICAL ABLATION.] Pain Management Secrets E-Book. 2009 Jul 31:296. Available from: https://www.sciencedirect.com/science/article/pii/B9780323040198000391 (last accessed 14.11.2019)</ref>
'''2. Therapeutic Facet Joint Injection'''


A local anaesthetic is initially given to decrease the nociceptive signals in and around the facet joint. This is followed by the therapeutic injection which typically contains a mixture of a long-acting steroid (e.g. Triamcinolone) and local anaesthesia (e.g. Bupivacaine).  
A local anaesthetic is initially given to decrease the nociceptive signals in and around the facet joint. This is followed by the therapeutic injection which typically contains a mixture of a long-acting steroid (e.g. Triamcinolone) and local anaesthesia (e.g. Bupivacaine).  
 
* Early studies reported reasonable long term relief of symptoms (20-54%)
The local anaesthetic will provide immediate pain relief, however, the steroids may not start to take effect until 2-6 days post-injection. Pain relief following the injection varies. A study showed that 22%-78% of patients experienced some form of pain relief at 2 weeks. However, long-term relief (3-6 months) varies between 28%-62% of patients, with 38% of patients experiencing no pain relief at 3-months follow-up, increasing to 44% at the 6-month follow-up<ref name="Lynch 1986">Lynch, M. and Taylor, J. (1986) Facet joint injection for low back pain: a clinical study. Journal of Bone and Joint Surgery, British Volume 68(1): pp.138-141.</ref>.  
* More recent studies have suggested that steroid injection "is of little value".
* Short term relief is common (59-94%) <ref name=":1" />.  


== Procedures  ==
== Procedures  ==
* The patient is given the opportunity to ask any questions to relevant doctors
Facet joint injections: Minimally-invasive - outpatient procedure can be performed in just a couple hours. The procedure itself usually takes less than 15 minutes.
* Sedation is not normally required for the procedure, but some patients can request sedation.  
* To start, patients usually only receive a local anesthetic, but in some cases they may opt for general sedation.  
* Consent forms are signed by the patient.  
* To begin the procedure, patients will lie face down on the examining table. The area to be injected will be cleaned and numbed with a topical numbing agent before a local anesthetic is administered.
* The patient will be asked to lie in supine whilst a plastic needle cannula will be inserted into the back of the hand.  
* The doctor inserts a needle using fluoroscopy to ensure proper placement.  
* The patient will then be asked to lie in prone. The back is cleaned with an antiseptic solution and local anaesthetic will be injected into the skin. The patient may experience ‘stinging’ during this stage.  
* Once the needle is in place, guided also by a fluoroscopic dye, an anesthetic and a steroid will be injected into the facet joint.  
* X- Ray machine will be used during the procedure to help guide and identity the facet joint site.  
* The steroid reduces inflammation and irritation and the anesthetic numbs the pain.  
* When the site is located the local anaesthetic and steroid solution is injected. The patient may also experience increased local pressure resulting in pain.  
* The combination medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation.<ref>Pain Dr [https://paindoctor.com/treatments/facet-joint-injections/ Facet jt injections] Available from:https://paindoctor.com/treatments/facet-joint-injections/ (last accessed 10.9.2020)</ref>
* The needle will then be removed and a dressing applied to the injection area.  
* The needle will then be removed and a dressing applied to the injection area.
* The patient is then taken to a recovery area where blood pressure is monitored regularly for thirty minutes.
* Post-procedure care
**pain score assessed immediately and 15-20 minutes post-procedure
**observe for 20 minutes for any immediate complications
**advise to complete pain diary for the next two weeks<ref name=":1" />
* In normal circumstances, the patient is able to return home via escort two hours post-procedure. Under no circumstances is the patient allowed to drive home 2 hours post-treatment.<ref name="NHS, 2012">NHS Evidence 2012. Lumbar facet joint injection. [online] Available at: http://www.royalberkshire.nhs.uk/pdf/Lumbar_facet_joint_injection_dec10.pdf [Accessed 04 January 2013].</ref>  
* In normal circumstances, the patient is able to return home via escort two hours post-procedure. Under no circumstances is the patient allowed to drive home 2 hours post-treatment.<ref name="NHS, 2012">NHS Evidence 2012. Lumbar facet joint injection. [online] Available at: http://www.royalberkshire.nhs.uk/pdf/Lumbar_facet_joint_injection_dec10.pdf [Accessed 04 January 2013].</ref>  


== Implications for Treatment  ==
== Implications for Treatment  ==


Facet injections are generally offered as a last resort after failure to improve following a period of conservative treatments, such as physiotherapy, drug therapy, bed rest, chiropractic manipulations and exercise. Studies have shown the interval of 6 weeks post-injection, when pain is ideally 80-100% elimintated<ref name=":0" />  physiotherapy treatments (including land-based lower back mobility exercise and soft tissue massage) may be of benefit to improve the longer-term outcomes of patients with chronic low back pain.<ref name="Staal, 2008" /><br>These injections might be used in conditions were facet joints may become susceptible to becoming painful such as;
Facet injections are generally offered following failure to improve from a period of conservative treatments eg physiotherapy, drug therapy, bed rest, and [[Back Education Program|exercise]].
* Studies have shown the interval of 6 weeks post-injection, when pain is ideally 80-100% elimintated<ref name=":0" />  physiotherapy treatments (eg land-based lower back mobility exercise, [[Manual Therapy Techniques For The Lumbar Spine|Manual Therapy Techniques]] For The Lumbar Spine, [[McKenzie Method]]) may be of benefit to improve the longer-term outcomes of patients with [[Chronic Low Back Pain|chronic low back pain]].<ref name="Staal, 2008" />  
The following are examples of when injections may be used


#[[Lumbar Facet Syndrome|Lumbar Facet Syndrome]]  
#[[Lumbar Facet Syndrome|Lumbar Facet Syndrome]]: both diagnostic (i.e. relief of pain after injection of local anaesthetic) and therapeutic chronic low back pain.
#[[Spondylolisthesis|Spondylolisthesis]]  
#[[Spondylolisthesis|Spondylolisthesis]]  
#[[Spondylolysis|Spondylolysis]]  
#[[Spondylolysis|Spondylolysis]]  
#[[Ankylosing Spondylitis|Ankylosing Spondylitis]]  
#[[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing Spondylitis]]  
#[[Spinal Stenosis|Spinal Stenosis]]  
#[[Spinal Stenosis|Spinal Stenosis]]  
#Trauma (e.g. road traffic accidents or&nbsp;sports/work with repetitive forceful hyperextensions)
#Trauma (e.g. road traffic accidents or&nbsp;sports/work with repetitive forceful hyperextensions)<ref name="Peh,2009" /><ref name="Harvey, 1991">Harvey,J., Tanner, S., 1991. Low Back Pain in Young  Athletes. Journal of Sports Medicine. 12(6) pp.394-406.</ref>
 
#Low back pain (+/- [[sciatica]]) with normal imaging findings
<ref name="Peh,2009" /><ref name="Harvey, 1991">Harvey,J., Tanner, S., 1991. Low Back Pain in Young  Athletes. Journal of Sports Medicine. 12(6) pp.394-406.</ref>  
#Post-laminectomy syndrome<ref name=":1" />
 
== Risks  ==
 
In general, this procedure carries low-risk complications <ref name="Peh,2009" /><ref name="Cheng and Adbi, 2007">Cheng,J., Adbi,S.A., 2007. Complications of Joint, Tendon and Muscle Injections. National Institutes of Health. [online] Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2084363/pdf/nihms27149.pdf[Accessed 28 December 2012]</ref> and these risks are based on; single case studies, injection procedure reviews and hospital procedure information.
 
== Side Effects    ==
 
Side effects from the '''procedure''' include; 
 
#Localised tenderness
#Bleeding
#Pain at the injection site <ref name="BUPA, 2009">BUPA,2009. Facet Joint Infection. [online] Available at:http://www.bupa.co.nz/fact_sheets/Factsheet.aspx?fs=cnt_facet_joint_injections.html[Accessed 30 December 2012]</ref><ref name="Sehgal et al, 2007" />
#Fainting <ref name="Sehgal et al, 2007" />
#Paraesthesia (duration few minutes-hours) <ref name="Peh,2009" />


Side effects from the '''steroids''' include;
== Complications ==
 
Rare:
#Fluid retention
* Infection, including [[Septic (Infectious) Arthritis|septic arthritis]] and discitis-[[osteomyelitis]]
#Weight gain
* Allergic/anaphylactic reaction
#High blood pressure
* Local reaction to [[Therapeutic Corticosteroid Injection|steroid injection]] (usually >48 hours)
#Increase in blood sugar (mainly diabetics) <ref name="BUPA, 2009" />
* Bleeding<ref name=":1" />
 
== Complications   ==
 
#Unexpected allergic reaction to anaesthetic or steroid medication <ref name="BUPA, 2009" />
#Spondylo discitis, (very rare) occurred in a 78 year old male at L2-L4, this emphasised the importance of proper sterilisation before procedures <ref name="Sehgal et al, 2007" />.
#Septic arthritis <ref name="Cheng and Adbi, 2007" /><ref name="Peh,2009" />  
#Chemical meningism associated with an inadvertent dural puncture
#Excessive Bleeding <ref name="BUPA, 2009" />
#Transient paraplegia and tetraplegia found in two separate case studies following cervical facet injections without image guidance <ref name="Peh,2009" /><ref name="Sehgal et al, 2007" />


== Contraindications  ==
== Contraindications  ==
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#Progressive neurological disorders that may be masked by the procedure  
#Progressive neurological disorders that may be masked by the procedure  
#Pregnancy (due to exposure to radioactive material, eg x-ray)  
#Pregnancy (due to exposure to radioactive material, eg x-ray)  
#Uncontrolled diabetes and heart disease
#Uncontrolled [[diabetes]] and [[Coronary Artery Disease (CAD)|heart disease]]<ref name="Peh,2009" /><ref name="MedCentral Health System, 2012">MedCentral Health System, 2012. Facet Injections. [online] Available athttp://www.medcentral.org/Main/FacetInjections.aspx[Accessed 30 December 2012].</ref>
 
<ref name="Peh,2009" /><ref name="MedCentral Health System, 2012">MedCentral Health System, 2012. Facet Injections. [online] Available athttp://www.medcentral.org/Main/FacetInjections.aspx[Accessed 30 December 2012].</ref>  
 
== Effectiveness of Facet Joint Injections  ==
== Effectiveness of Facet Joint Injections  ==
On conclusion, the evidence on the effectiveness of facet joint injections is inconclusive due to wide variation between studies that limits the number of comparable studies.&nbsp;


A recent Cochrane review <ref name="Staal, 2008">Staal. B, Bie. R, De Vet. H, Hildebrandt. J, Nelemans. P, 2008, Injection therapy for subacute and chronic low back pain, Department of Epidemiology and Caphri Research Institute, Maastricht University, Maastricht, Netherlands, The Cochrane database of systematic reviews, Volume 16, Edition 3</ref> evaluated lumbar facet injections random controlled trials used in sub-acute (&lt; 6 weeks) and chronic (&gt; 3 months) participants suggested the effectiveness of lumbar facet injections is widely debated. They stated due to a lack of inconsistency between studies in terms of area, drugs, dosage and outcome measures statistical pooling was not possible and as such performed a best-evidence synthesis.<br>
A recent Cochrane review <ref name="Staal, 2008">Staal. B, Bie. R, De Vet. H, Hildebrandt. J, Nelemans. P, 2008, Injection therapy for subacute and chronic low back pain, Department of Epidemiology and Caphri Research Institute, Maastricht University, Maastricht, Netherlands, The Cochrane database of systematic reviews, Volume 16, Edition 3</ref> evaluated lumbar facet injections random controlled trials used in sub-acute (&lt; 6 weeks) and chronic (&gt; 3 months)  
 
* They stated due to a lack of inconsistency between studies in terms of area, drugs, dosage and outcome measures statistical pooling was not possible and as such performed a best-evidence synthesis.
They used 7 random clinical trial studies and found the following:<br>
NICE guidelines (2009) for LBP recommends
 
* Further comparable research is required into this area before reliable conclusions can be made (including research into which demographic groups respond more favourably).<ref name="NICE 2009">NICE clinical guidelines, CG88, Low Back Pain, 2009</ref>
=== Corticosteroid Facet Injection vs Placebo ===
Based on two studies comparing corticosteroid facet injections with placebos, the short term effects on pain relief and disability maybe not differ from placebos, however, intermediate and long-term had conflicting results.
 
Carette et al study <ref name="Carette et al, 1991">Carette. S, Marcoux. S, Truchon. N, Grondin. C, Gagnon. J, Allard. Y, Latulippe. M, 1991, A controlled trial of corticosteroid injections into facet joints for chronic low back pain, Laval University, Quebec City, Quebec, Canada, New England Journal of Medicine, Volume 325, Edition 1, Pages 1002-1007.</ref>showed both the placebo and facet injection group both showed improvement in function and pain relief at 1, 3 and 6 months, yet statistically, differences were only found at 6 months. However, the prescript analgesics in addition to these injections might account for improvements in pain relief.
 
=== Corticosteroid Facet Injection vs Other Treatments ===
<br>A 2013 study looking at available evidence of lumbar facet joint injections and the physiotherapy treatments, concluding that lumbar facet joint injections create a short period when pain is reduced. Physiotherapy treatments including land-based lower back mobility exercise and soft tissue massage may be of benefit during this time to improve the longer-term outcomes of patients with chronic low back pain.<ref>Chambers H. Physiotherapy and lumbar facet joint injections as a combination treatment for chronic low back pain. A narrative review of lumbar facet joint injections, lumbar spinal mobilizations, soft tissue massage and lower back mobility exercises. Musculoskeletal Care. 2013 Jun;11(2):106-20. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/pubmed/23468052</nowiki> (last accessed 13.11.2019)</ref>
 
When used in conjunction with home exercise programmes no significant differences were found between those who had the injections and those who did not in terms of pain and disability (Mayer 2000 cited <ref name="Staal, 2008" />).
 
3 studies showed no or little significant differences between groups who had corticosteroid injections or ones with a mixture of anaesthetics. None of these studies had controls in addition the injection type, substances and or dosages differed.<br>The last study gave peri-articular corticosteroid facet injections with or without a local anaesthetic and showed a small difference in reported short term pain relief.
 
Based on these limited number of studies they concluded the effectiveness of facet injection is still debatable and that more consistent research is needed to draw any conclusions.
 
Another paper (Lynch and Taylor <ref name="Lynch 1986" />) gave 50 participants diagnosed with facet joint pain an intra-articular injection to investigate the short and long term effects on pain perception. They found short term (at 2 weeks) 78% had either total or partial pain relief and long term (at 3 and 6 months) between 56-62% had either total or partial relief. However this study had no control, did not specify whether these participants were receiving any additional treatments during the study and a lack of pain relief might have been due to the solution not being injected into the facet joint but surrounding tissues.
 
The studies shown suggest these injections may be no better than placebos, that some patients might benefit from short or long relief while other might not and that these injections might be used in conjunction with other treatments. 
 
== Implications for Practice &amp; Research  ==
 
On conclusion, the evidence on the effectiveness of facet joint injections is inconclusive due to wide variation between studies that limits the number of comparable studies.&nbsp; NICE guidelines (2009) <ref name="NICE 2009">NICE clinical guidelines, CG88, Low Back Pain, 2009</ref> for LBP and the Cochrane review recommend further comparable research is required into this area before reliable conclusions can be made. Furthermore, research into which demographic groups respond more favourably to injection therapy would be useful to improve the efficiency of this treatment.


== Conclusions  ==
== Conclusions  ==


Facet joint injections are becoming increasingly more popular in current practice <ref name="Mayer, 2004">Mayer. T, Gatchel. R, Keeley. J, McGeary. D, Dersh. J, Anagnostis. C, 2004, A randomised clinical trial of treatment for lumbar segmental rigidity, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center at Dallas, TX, USA, Spine, Volume 29, Edition 20, Pages 2199-2205</ref> and therefore it is important every professional treating LBP is aware of the; procedure, risks, implications and their effectiveness. The increasing popularity of this treatment may be due to it being passive compared to the alternatives (exercise programs and postural care) which require the patient to make active changes to their lifestyle. The small amount of literature on whether a facet joint injection is as effective as its alternatives have contrasting conclusions. However it is clear that the literature base is simply not large enough yet to effectively inform practice.  
Facet joint injections are becoming increasingly more popular in current practice <ref name="Mayer, 2004">Mayer. T, Gatchel. R, Keeley. J, McGeary. D, Dersh. J, Anagnostis. C, 2004, A randomised clinical trial of treatment for lumbar segmental rigidity, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center at Dallas, TX, USA, Spine, Volume 29, Edition 20, Pages 2199-2205</ref>
* The increasing popularity of this treatment may be due to it being passive compared to the alternatives (exercise programs and postural care) which require the patient to make active changes to their lifestyle.
* The small amount of literature on whether a facet joint injection is as effective as its alternatives have contrasting conclusions.
* It is clear that the literature base is simply not large enough yet to effectively inform practice.  


== References ==
== References ==
<references />  
<references />
 
[[Category:Nottingham University Spinal Rehabilitation Project]]
[[Category:Lumbar Spine]]  
[[Category:Lumbar Spine]]  
[[Category:Lumbar Spine - Interventions]]
[[Category:Lumbar Spine - Interventions]]
[[Category:Nottingham_University_Project]]
[[Category:Extended_Scope]]  
[[Category:Extended_Scope]]  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Interventions]]
[[Category:Interventions]]

Latest revision as of 10:28, 13 April 2022

Original Editors - Georg Baker, Michelle Harvey, Tommy Pearson, Joe Wakefield as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - Tommy Pearson, Joe Wakefield, Michelle harvey, Lucinda hampton, Kim Jackson, Laura Ritchie, Admin, Rachael Lowe and George Baker

Introduction[edit | edit source]

Facet joint injection.png

Facet (zygapophyseal) joint injections are performed primarily for the diagnosis and differentiation of facet syndrome and radicular pain syndrome, and are one of the spinal interventional procedures.

  • They can be performed under fluoroscopic, or CT image guidance (cervical, thoracic or most commonly lumbosacral facet joints can be injected)
  • One or multiple joints can be injected during one procedure[1].
  • Spinal injections are one of the many varieties of treatments considered when an individual presents with chronic LBP [2].

The effectiveness of facet joint injections is largely unknown but despite this, the procedure is still commonly performed by clinicians [3].

  • Although early studies reported reasonable long term relief of symptoms (20-54%), more recent studies have suggested that steroid injection "is of little value". However, short term relief is common (59-94%) and therefore it remains a useful procedure, especially to confirm the diagnosis[1].

Lumbar Facet Joints[edit | edit source]

Lumbar vertebra.png

Lumbar Facet (zygapophysial) joints are formed of the superior and inferior articulating processes of adjacent vertebra [4].

  • Classed as plane synovial joints [5].
  • Orientated in a vertical projection [5].
  • Articular surfaces are covered by hyaline cartilage, surrounded by a thin fibrous joint capsule that contains a synovial membrane that secretes synovial fluid into the joint space [6] [5].
  • Free and encapsulated nerve endings supplied by the medial branches of the dorsi rami, innervate the facet joints [7][8].

Facet Joint Injection[edit | edit source]

  • Facet joints have been recognised as a possible source of chronic LBP since the early 1900's [6][8].
  • Facet joint injections have two main purposes; one to relieve pain both short and long term and the other to be used conjunctively with the physical examination as a diagnostic tool to determine whether the facet joint is the source of pain [6][8][7].

[9]

  1. Diagnostic Facet Joint Injection

The following two-step response pattern is the current gold standard which is used to diagnose facet joint syndrome, which may indicate a need for a therapeutic facet joint injection[10]

1. Saline is injected causing distension of the problematic facet joint - this should reproduce/increase the patients’ pain.
2. Injection of local anaesthetic into the facet joint - this should reduce/relieve the patients’ pain[11].

Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain.

  • These patients may benefit from specific interventions to eliminate facet joint pain such as Therapeutic Facet Joint Injection or neurolysis (by radiofrequency or cryoablation)[12]
  • Neurolysis is the application of a chemical or physical destructive agent to a nerve to create a long-lasting or permanent interruption of neural transmission.[13]

2. Therapeutic Facet Joint Injection

A local anaesthetic is initially given to decrease the nociceptive signals in and around the facet joint. This is followed by the therapeutic injection which typically contains a mixture of a long-acting steroid (e.g. Triamcinolone) and local anaesthesia (e.g. Bupivacaine).

  • Early studies reported reasonable long term relief of symptoms (20-54%)
  • More recent studies have suggested that steroid injection "is of little value".
  • Short term relief is common (59-94%) [1].

Procedures[edit | edit source]

Facet joint injections: Minimally-invasive - outpatient procedure can be performed in just a couple hours. The procedure itself usually takes less than 15 minutes.

  • To start, patients usually only receive a local anesthetic, but in some cases they may opt for general sedation.
  • To begin the procedure, patients will lie face down on the examining table. The area to be injected will be cleaned and numbed with a topical numbing agent before a local anesthetic is administered.
  • The doctor inserts a needle using fluoroscopy to ensure proper placement.
  • Once the needle is in place, guided also by a fluoroscopic dye, an anesthetic and a steroid will be injected into the facet joint.
  • The steroid reduces inflammation and irritation and the anesthetic numbs the pain.
  • The combination medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation.[14]
  • The needle will then be removed and a dressing applied to the injection area.
  • Post-procedure care
    • pain score assessed immediately and 15-20 minutes post-procedure
    • observe for 20 minutes for any immediate complications
    • advise to complete pain diary for the next two weeks[1]
  • In normal circumstances, the patient is able to return home via escort two hours post-procedure. Under no circumstances is the patient allowed to drive home 2 hours post-treatment.[15]

Implications for Treatment[edit | edit source]

Facet injections are generally offered following failure to improve from a period of conservative treatments eg physiotherapy, drug therapy, bed rest, and exercise.

The following are examples of when injections may be used

  1. Lumbar Facet Syndrome: both diagnostic (i.e. relief of pain after injection of local anaesthetic) and therapeutic chronic low back pain.
  2. Spondylolisthesis
  3. Spondylolysis
  4. Ankylosing Spondylitis
  5. Spinal Stenosis
  6. Trauma (e.g. road traffic accidents or sports/work with repetitive forceful hyperextensions)[6][17]
  7. Low back pain (+/- sciatica) with normal imaging findings
  8. Post-laminectomy syndrome[1]

Complications[edit | edit source]

Rare:

Contraindications[edit | edit source]

There were no definite contraindications; however this procedure was generally avoided in patients with;

  1. Systematic infections
  2. Skin infections over the injection site
  3. Bleeding disorders (Coagulopathy) or patients taking blood thinning medication
  4. Allergies to the medication or contrast agents used during the procedure
  5. Progressive neurological disorders that may be masked by the procedure
  6. Pregnancy (due to exposure to radioactive material, eg x-ray)
  7. Uncontrolled diabetes and heart disease[6][18]

Effectiveness of Facet Joint Injections[edit | edit source]

On conclusion, the evidence on the effectiveness of facet joint injections is inconclusive due to wide variation between studies that limits the number of comparable studies. 

A recent Cochrane review [16] evaluated lumbar facet injections random controlled trials used in sub-acute (< 6 weeks) and chronic (> 3 months)

  • They stated due to a lack of inconsistency between studies in terms of area, drugs, dosage and outcome measures statistical pooling was not possible and as such performed a best-evidence synthesis.

NICE guidelines (2009) for LBP recommends

  • Further comparable research is required into this area before reliable conclusions can be made (including research into which demographic groups respond more favourably).[19]

Conclusions[edit | edit source]

Facet joint injections are becoming increasingly more popular in current practice [20]

  • The increasing popularity of this treatment may be due to it being passive compared to the alternatives (exercise programs and postural care) which require the patient to make active changes to their lifestyle.
  • The small amount of literature on whether a facet joint injection is as effective as its alternatives have contrasting conclusions.
  • It is clear that the literature base is simply not large enough yet to effectively inform practice.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Radiopedia Facet joint injections Available from:https://radiopaedia.org/articles/facet-joint-injection (last accessed 10.9.2020)
  2. ↑ NHS Hospital Episode Statistics, 2011. main Procedures and Interventions: Outpatient Statistics[excel]Available at: http://www.hesonline.nhs.uk [Accessed 20 November 2012]
  3. ↑ Eckel. T, 2004, Facet Joint Injections, Department of radiology, Lewis-Gale medical centre, 1900 Electric road, Salem, Virginia, USA, Journal of spinal pain, Volume 21, Edition 1, Pages 123-129
  4. ↑ Strayer,A., 2005. Lumbar Spine: Common Pathology and Interventions. The Journal of Neuroscience Nursing. 37(4) pp 181-193.
  5. ↑ 5.0 5.1 5.2 Palastanga,N.,Field,D.,Soames,R.,2006. Anatomy and Human Movement: Structure and Function. Butterworth Heinemann Elsevier:London
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Peh,W.C.G., 2009. Image-guided Facet Joint Injection. [online] Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107686/pdf/biij-07-e4.pdf[Accessed 27 December 2012]
  7. ↑ 7.0 7.1 Sehgal,N., Dunbar,E.E., Shah,R.V., Colson,J., 2007. Systematic Review of Diagnostic Utility of Facet (Zygopophysial) Joint Injections In Chronic Spinal Pain: An Update. Journal of Pain Physician [online] Available at:http://www.painphysicianjournal.com/2007/january/2007%3B10%3B213-228.pdf[Accessed 29 Nov 2012].
  8. ↑ 8.0 8.1 8.2 Manchikanti, L., Boswell,M.V., Singh,V., Pampati,V., Damron,K.S., Beyer,C.D., 2004. Prevalence of Facet Joint Pain in Chronic Spinal Pain of Cervical, Thoracic, and Lumbar Regions, [online] Available at:http://www.biomedcentral.com/content/pdf/1471-2474-5-15.pdf[Accessed 27 December 2012].
  9. ↑ Facet injections Facet Injections - Pain Management Available from: https://www.youtube.com/watch?v=FJq68eIx4KM Last accessed 14.11.2019)
  10. ↑ Sehgal, N., Shah, R., McKenzie-Brown, A. and Everett, C. (2005) Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician 8(2): pp.211–224.
  11. ↑ Murtagh, F. (1988) Computed tomography and fluoroscopy guided anesthesia and steroid injection in facet syndrome. Spine 13(6): pp.686–689.
  12. ↑ 12.0 12.1 Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A, Heck O, Boubagra K, Grand S, Krainik A. Facet joint syndrome: from diagnosis to interventional management. Insights into imaging. 2018 Oct 1;9(5):773-89.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206372/ (last accessed 14.11.2019)
  13. ↑ Hanania MM, Argoff CE. PERMANENT NEURAL BLOCKADE AND CHEMICAL ABLATION. Pain Management Secrets E-Book. 2009 Jul 31:296. Available from: https://www.sciencedirect.com/science/article/pii/B9780323040198000391 (last accessed 14.11.2019)
  14. ↑ Pain Dr Facet jt injections Available from:https://paindoctor.com/treatments/facet-joint-injections/ (last accessed 10.9.2020)
  15. ↑ NHS Evidence 2012. Lumbar facet joint injection. [online] Available at: http://www.royalberkshire.nhs.uk/pdf/Lumbar_facet_joint_injection_dec10.pdf [Accessed 04 January 2013].
  16. ↑ 16.0 16.1 Staal. B, Bie. R, De Vet. H, Hildebrandt. J, Nelemans. P, 2008, Injection therapy for subacute and chronic low back pain, Department of Epidemiology and Caphri Research Institute, Maastricht University, Maastricht, Netherlands, The Cochrane database of systematic reviews, Volume 16, Edition 3
  17. ↑ Harvey,J., Tanner, S., 1991. Low Back Pain in Young Athletes. Journal of Sports Medicine. 12(6) pp.394-406.
  18. ↑ MedCentral Health System, 2012. Facet Injections. [online] Available athttp://www.medcentral.org/Main/FacetInjections.aspx[Accessed 30 December 2012].
  19. ↑ NICE clinical guidelines, CG88, Low Back Pain, 2009
  20. ↑ Mayer. T, Gatchel. R, Keeley. J, McGeary. D, Dersh. J, Anagnostis. C, 2004, A randomised clinical trial of treatment for lumbar segmental rigidity, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center at Dallas, TX, USA, Spine, Volume 29, Edition 20, Pages 2199-2205
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