Lumbar Facet Joint Injections

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Original Editors - Georg Baker, Michelle harvey, Tommy Pearson, Joe Wakefield

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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 available 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

Diagnostic facet joint injection

The following two-step response pattern are the current gold standard which is used to diagnose facet joint syndrome, which may indicate a need for 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)

Effectiveness of Facet Joint Injections

How effective facet joint injections are in treating LBP is still widely debated. For the purposes of this physiopedia page only a hand-full of studies regarding two topics will be reviewed. The aim of this section is to produce concise conclusions on what researchers believe is the current effectiveness of facet joint injections.

Corticosteroid Facet Joint Injections Vs Placebo Injections

The evidence was in agreement; corticosteroid facet joint injections do not provide short term pain relief (n=210). However the two papers found on this topic showed conflicting evidence with regard to whether this type of injection provided pain relief within the first three months of administration. Only one paper (2) looked into its long term effect concluding that a corticosteroid provided better pain relief than a placebo, this was also proved to be statistically significant.

Corticosteroid Facet Joint Injections Vs Alternative Treatments

Only four studies could be found regarding this topic. The literature produces contrasting conclusions, some found no statistical difference between an injection having corticosteroid combined with local anaesthetic compared with just local anaesthetic ⁽⁴⁾. Another study investigated whether facet joint injections combined with a home exercise program was more effective at reducing pain than a home exercise program alone. No significant differences were found between the groups immediately post intervention and no follow up assessments where implemented to assess the long term outcomes.

A study awarded by a Cochrane review ⁽⁶⁾ for being of high quality and reliability compared a corticosteroid/anaesthetic injection with a nerve block using similar medication ^(7). The facet joint injections were shown to be a more effective way of providing pain relief however this was only proved to be significant after one month but then were not significant after three.

On conclusion, the evidence looking into what the most effective solution that should be used when injecting into the facet joints is small. Further research is required into this area before reliable conclusions can be made and before systematic reviews can perform a meta-analysis producing even more reliable conclusions.

Implications for Practice & Research

Based on the current state of research there in insufficient evidence to support or refute the use of injection therapy. Even though it would be foolish to rule out injection therapy as an effective treatment for LBP all together, more research is needed 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.

NICE guidelines for LBP released in May 2009 recommended future research to be implemented investigating the effectiveness of facet joint injections (1). Therefore, it is recommended that professionals in the future dive deeper into this large pool of literature and create new physiopedia pages solely dedicated to this topic.

Conclusions 

Facet joint injections are becoming increasingly more popular in current practice (5) 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.

This physiopedia page aimed to give physiotherapy professionals an insight into the basic information surrounding facet joint injections. Alongside this aim was to highlight areas of literature which have not been reviewed, therefore encouraging professionals in the future to create physiopedia pages regarding this large topic.

References for last two sections:

1 - NICE clinical guidelines, CG88, Low Back Pain, 2009

2 – 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.
3 – Lilius. G, Harilainen. A, Laasonen. E, Myllynen. P, 1990, Chronic unilateral low back pain. Predictors for the outcome of facet joint injections, Department of Physical Medicine and Rehabilitation, Helsinki University Central Hospital, Finland, Spine, Volume 15, Edition 8, Pages 780-782.
4 – Manchikanti. L, Boswell. M, Singh. V, Pampati. V, Damron. K, Beyer. C, 2004, Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic and lumbar regions, Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, Kentucky, USA, BMC Musculoskeletal Disorders, Volume 5, Edition 15, Pages 227-231.
5 – 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
6 – 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
7 – Marks. R, Houston. T, Thulbourne. T, 1992, Facet joint injection and facet nerve block: a randomised comparison of 86 patients with chronic low back pain, Department of Orthopaedic Surgery, Dundee Royal Infirmary, Dundee DD1 9ND, Scotland, UK, Pain, Volume 49, Edition 3, Pages 325-328