Lumbar Facet Joint Injections

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Introduction[edit | edit source]

LBP affects roughly 80% of the UK population and is the 2nd most common cause of long term-sickness from work ([1]). 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 ([2]). This figure is likely to have risen in recent years due to a larger number of LBP cases becoming chronic ([3]).

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) ([4]).

Spinal Injections Chart.jpg

figure 1.1

The effectiveness of facet joint injections is largely unknown but despite this the procedure is still commonly performed by clinicians ([5]). 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[edit | edit source]

Lumbar Facet Joint[edit | edit source]

Facet (zyagapophysial) joints are formed of the superior and inferior articulating processes of adjacent vertebra (Strayer, 2005[6]). These are classed as plane synovial joints (Palastanga, Field and Soames, 2006[7].) Within the Lumbar spine they are orientated in a vertical projection (Palastanga, Field and Soames, 2006[7]). 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[8], Palastanga, Field and Soames,2006[7]). Free and encapsulated nerve endings supplied by the medial branches of the dorsi rami innervate the facet joints (Sehgal et al, 2007[9]; Manchikanti et al,2004[10]).

First reported in the early 1900s by Goldthwait, facet joints have been recognised as a possible source of chronic LBP (Peh,2009[8], Manchikanti et al, 2004[10].

Facet Joint Injection
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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[8]; Manchikanti et al,2004[10];Sehgal et al, 2007[9] ).

Procedures
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Risks
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In general this procedure carries low risk complications (Peh, 2009[11]; Cheng and Adbi, 2007[12]) and these risks are based on single case studies, injection procedure reviews and hospital procedure information.

Side effects
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From the procedure  included;

  1. Localised tenderness, bleeding and pain at the injection site (BUPA, 2009[13]; Seghal et al, 2007[14] )
  2. Fainting (Seghal et al, 2007[14])
  3. Paraesthesia (duration few minutes-hours) (Peh,2009[11])

From the steroids included;

  1. Fluid retention, weight gain, high blood pressure, increase in blood sugar (mainly diabetics) (BUPA, 2009[13])

Complications
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  1. Unexpected allergic reaction to anaesthetic or steriod medication (BUPA,2009[13])
  2. Spondylodiscitis, (very rare) occur in a 78 male at L2-L4 , emphasis was placed on proper sterlisation before procedures (Falagas et al, 2006, Seghal et al, 2007[14]).
  3. Septic arthritis (Cheng and Adbi, 2007[12]; Peh, 2009[11])
  4. Chemical meningism associated with an inadvertent dural puncture
  5. Excessive Bleeding (BUPA, 2009[13])
  6. Transient paraplegia and tetraplegia found in two separate case studies following cervical facet injections without image guidance (Peh,2009[11]; Sehghal et al, 2007[14])

Contraindications
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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[11]; MedCentral Health Central, 2012[15])


Implications for Treatment[edit | edit source]

Conclusions & Suggestions for Future Research[edit | edit source]


References[edit | edit source]

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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
  4. ↑ NHS Hospital Episode Statistics, 2011. main Procedures and Interventions: Outpatient Statistics[excel]Available at: <http://www.hesonline.nhs.uk> [Accessed 20 November 2012]
  5. ↑ 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
  6. ↑ Strayer,A., 2005. Lumbar Spine: Common Pathology and Interventions. The Journal of Neuroscience Nursing. 37(4) pp 181-193.
  7. ↑ 7.0 7.1 7.2 Palastanga,N.,Field,D.,Soames,R.,2006. Anatomy and Human Movement: Structure and Function. Butterworth Heinemann Elsevier:London
  8. ↑ 8.0 8.1 8.2 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]
  9. ↑ 9.0 9.1 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].
  10. ↑ 10.0 10.1 10.2 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].
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Cite error: Invalid <ref> tag; no text was provided for refs named Peh, 2009
  12. ↑ 12.0 12.1 Cheng,J., Adbi,S.A., 2007. Complications of Joint, Tendon and Muscle Injections. National Institutes of Health. [online] Available at:&lt; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2084363/pdf/nihms27149.pdf&gt; [Accessed 28 December 2012]
  13. ↑ 13.0 13.1 13.2 13.3 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]
  14. ↑ 14.0 14.1 14.2 14.3 Cite error: Invalid <ref> tag; no text was provided for refs named Seghal et al, 2007
  15. ↑ MedCentral Health System, 2012. Facet Injections. [online] Available at< http://www.medcentral.org/Main/FacetInjections.aspx> [Accessed 30 December 2012].
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