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). They 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).

Facet joints have been recognised as a possible source of chronic LBP since the early 1900's (Peh,2009, Manchikanti et al, 2004.

 

Facet Joint Injection

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

The diagram below demonstrates an intra-articlar facet joint injection

A facet joint injection

Lumbar facet joint injections serve two main purposes;
1. To diagnose lumbar facet joints as a source of pain
2. As a therapeutic technique to help relieve the pain

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 therapeutic facet joint injection.

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.

Therapeutic facet joint injection

A local anaesthetic is initially given to decrease the nocioceptive 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).

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.

Procedures

Diagram 3.1 summarising facet injection types and substances

Lumbar Facet Joint Injection Procedure

•The Patient is given the opportunity to ask any questions to relevant doctors
• Sedation is not normally required for the procedure, but some patients can request sedation.
• Consent forms are signed by the patient.
• The patient will be asked to lie in supine whilst a plastic needle cannula will be inserted into the back of the hand.
• The patient will then be asked to lie in prone. The back is cleaned with antiseptic solution and local anaesthetic will be injected into the skin. The patient may experience ‘stinging’ during this stage.
• X- Ray machine will be used during the procedure to help guide and identity the facet joint site.
• 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 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.
• 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.

(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]).

Implications for Treatment

Facet injections are general offered as a last resort after failure to improve following a period of conservative treatments, such as physiotherapy, drug therapy, bedrest, chiropractic manipulations and exercise .
These injections might be used in conditions were facet joints may become suspectible to becoming painful such as;

1. Lumbar Facet Syndrome
2. Spondylolisthesis
3. Spondylolysis
4. Ankylosing Spondylitis
5. Spinal Stenosis
6. Trauma (e.g. road traffic accidents or sports/work with repetitive forceful hyperextentions)

(Peh,2009; Harvey and Tanner, 1991;)

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

Side effects from the procedure include;

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

Side effects from the steroids include;

1. Fluid retention
2. Weight gain
3. High blood pressure
4. Increase in blood sugar (mainly diabetics) (BUPA, 2009)

Complications

1. Unexpected allergic reaction to anaesthetic or steriod medication (BUPA,2009)
2. Spondylodiscitis, (very rare) occured in a 78 year old male at L2-L4, this emphasised the importance of 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. Allergies to the 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)