Lumbar Facet Joint Injections

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Introduction

LBP affects roughly 80% of the UK population and is the 2nd most common cause of long term-sickness from work (). 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 (). This figure is likely to have risen in recent years due to a larger number of LBP cases becoming chronic ().

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) ().

figure 1.1

The effectiveness of facet joint injections is largely unknown but despite this the procedure is still commonly performed by clinicians (). The Physiotherapy proffession are required to remain up to date with all available procedures each patient has aailable to them in treating their condition. Consequently, background knowledge regarding this treatment should be known by every clinician who regularly see’s LBP patients. Therefore this physiopedia page aims to use current literature to shine a light on the main areas surrounding this popular intervention, including:

1. The different procedures used for a facet joint injection
2. The risks facet joint injections cause
3. The variety of conditions that lead to facet joint injections being used

The effectiveness of facet joint injections coupled with some suggestions for future research/physiopedia pages will be included in the conclusion.

Background

Lumbar Facet Joint

Facet (zyagapophysial) joints are formed of the superior and inferior articulating processes of adjacent vertebra (Strayer, 2005). These are classed as plane synovial joints (Palastanga, Field and Soames, 2006.) Within the Lumbar spine they are orientated in a vertical projection (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 (Peh,2009, Palastanga, Field and Soames,2006). Free and encapsulated nerve endings supplied by the medial branches of the dorsi rami innervate the facet joints (Sehgal et al, 2007; Manchikanti et al,2004).

First reported in the early 1900s by Goldthwait, facet joints have been recognised as a possible source of chronic LBP (Peh,2009, Manchikanti et al, 2004.

Facet Joint Injection

Facet joint injections have two main purposes; one to relieve facet pain both short and long term and the other to be used conjunctively with physical examination as a diagnostic tool  in determining the facet joint to be the source of pain (Peh, 2009; Manchikanti et al,2004;Sehgal et al, 2007 ).

Procedures

Risks

In general this procedure carries low risk complications (Peh, 2009; Cheng and Adbi, 2007) and these risks are based on single case studies, injection procedure reviews and hospital procedure information.

Side effects

From the procedure  included;

1. Localised tenderness, bleeding and pain at the injection site (BUPA, 2009; Sehgal et al, 2007 )
   
2. Fainting (Sehgal et al, 2007)
   
3. Paraesthesia (duration few minutes-hours) (Peh,2009)
   

From the steroids included;

1. Fluid retention, weight gain, high blood pressure, increase in blood sugar (mainly diabetics) (BUPA, 2009)
   

Complications

1. Unexpected allergic reaction to anaesthetic or steriod medication (BUPA,2009)
   
2. Spondylodiscitis, (very rare) occur in a 78 male at L2-L4 , emphasis was placed on proper sterlisation before procedures (Falagas et al, 2006, Sehgal et al, 2007).
   
3. Septic arthritis (Cheng and Adbi, 2007; Peh, 2009)
   
4. Chemical meningism associated with an inadvertent dural puncture
   
5. Excessive Bleeding (BUPA, 2009)
   
6. Transient paraplegia and tetraplegia found in two separate case studies following cervical facet injections without image guidance (Peh,2009; Sehgal et al, 2007)
   

Contraindications

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. Allergics to medication or contrast agents used during the procedure
   
5. Progressive neurological disorders that maybe masked by the procedure
   
6. Pregnancy (due to exposure to radioactive material, eg x-ray)
   
7. Uncontrolled diabetes and heart disease
   

(Peh, 2009; MedCentral Health Central, 2012)