The facet joints are located on both sides of the spine,
along the entire length of the spine. They are present from the cervical (neck)
to the lumbosacral (low back) spine. Each facet joint is connected to the other
by a smooth, pearly substance called hyaline cartilage. Arthritis and similar
conditions can cause degenerative changes in the cartilage that can produce
pain and limit mobility. Two nerves supply each facet joint. These are the
"Medial branch nerves" and can become irritated following injury. The
facet joints, along with the intervertebral discs, are the means by which each
vertebral body in the spinal column, articulates with the next vertebral body
above and below. Just like any other joint in the body, it is susceptible to
trauma, as well as wear-and-tear (arthritis / arthralgias).
Facet injections are used for patients with low back pain
and leg pain stemming from inflammation or irritation of the facet joints.
These patients normally do not respond to other conservative means, such as
oral anti-inflammatory medication, rest, lumbar corsets or physical therapy.
Facet injections may provide relief of pain and inflammation as well as provide
more diagnostic information for your physician. Facet blocks can be used as a
diagnostic test to determine if the patient will benefit from a facet
radiofrequency rhizotomy. The pain relief can last from days to years, or in
some cases, permanently. The physician uses a relatively short-acting
anesthetic to temporarily numb nerves to relieve pain. A long-acting steroid
medication is frequently added to the anesthetic to reduce swelling and
inflammation, and to provide more lasting pain relief. The procedure takes just
a few minutes; fluoroscopy (x-ray) is used so that the exact location of pain
can be pinpointed.
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Do not eat solid food for at least 6 hours
before your procedure.
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Take your medications as usual, unless your
nurse tells you otherwise. When taking your medications, take just enough water
to help swallow them, and no more than that. Avoid taking any blood thinners,
such as Aspirin or Aspirin-containing medications, such as Excedrin. If you are
not sure, ask our staff for guidance.
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Someone must come with you to drive you home.
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Arrange for someone to be available to assist
you at home, if needed.
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If you are a diabetic, call prior to your
appointment to discuss possible alterations in your insulin dose for that day.
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If you are on aspirin or Coumadin therapy, you
will need to stop it, prior to the procedure. Make sure to notify your nurse
and physician, prior to the day of your procedure.
At the time of your injection, you will be asked to put on a patient gown (opened towards the back), and sign a consent form. Your blood pressure, pulse rate and respiration will also be checked. You will be asked what medications you are presently taking and if you have any allergies to medication. Depending on your pain location and the facet joints to be treated, you will be positioned on your stomach with a pillow under your abdomen [for back], or with a small pillow under your chest and your forehead resting on a small pad [for neck area]. Your blood pressure and heart rate will be constantly monitored. Prior to the procedure, your back will be cleansed with antiseptic solution and the physician will numb the area around the injection. A burning sensation lasting 2-3 seconds is to be expected. You may receive a small dose of Valium, or a similar agent, to help you relax. After that, your doctor will position a special needle into the facet joint. During placement of the needle, you can expect to momentarily feel your usual pain, which lets the doctor know the needle is positioned correctly. He/she will then inject the medication slowly. You can expect to feel pressure, but usually not much discomfort, during the injection. Facet injections are performed using a C-arm fluoroscope (X-Ray machine) to direct needles through the skin and muscles of the back to the path of the sensory nerves that are located in the facet joints. At that point a mixture of anesthetic and a steroid (Depomedrol or triamcinolone) is injected into or around the joints. The Facet Block is temporary, since the medication is eventually absorbed into the body. After your injection, you will return to the recovery room for a 30-45 minute observation period. It is important that you have someone to drive you home afterward. In the follow-up visit the physician will inquire about the level of pain relief obtained from the procedure.
Facet blocks are used to diagnose and occasionally treat a
number of painful conditions, including twisting work or sports injuries, low
back pain without disk disease, facet arthritis, and pain after back surgery
without new disk disease. The steroid injected reduces the inflammation and/or
swelling of tissue in the joint space. This may in turn reduce pain, and other
symptoms caused by inflammation / irritation of the joint and surrounding
structures.
The actual procedure may take only 15 to 20 minutes.
Nevertheless, you need to allow sufficient time for the legal paperwork, the pre-procedure
nursing assessment, the procedure preparation, as well as the recovery period.
On the average, you should plan to spend 2 to 3 hours in the facility.
The injection consists of a mixture of local anesthetic
(like lidocaine or bupivacaine) and a steroid medication (triamcinolone =
Aristocort, or methylprednisolone = Depo-medrol). The choice of local
anesthetic and steroids is dependent on the location of the block and the
desired duration of effects. Occasionally the physician will select a
short-acting or a long-acting local anesthetic, without informing the patient
of the choice. This helps the physician in the evaluation of the effectiveness
of the procedure. When the patient returns for evaluation, if the described duration
of benefits is concordant with the expected duration of the local anesthetic
used, this will provide significant validity to the test.
The procedure involves inserting a needle through skin and
deeper tissues (like a "tetanus shot"). So, there is some discomfort
involved. However, we numb the skin and deeper tissues with a local anesthetic
using a very thin needle prior to placing the needle near the facet joint.
Intravenous sedation is also available.
No. This procedure is done under local anesthesia and
sedation. An IV will be started to give you a medication to help you relax.
However, physicians frequently try to limit the amount of medication you
receive so that you may go home as soon as possible. Let your doctor know how
you feel; extra time must be allowed for patients who receive IV medications,
sometimes referred to as "conscious sedation." For "conscious
sedation", unless contraindicated for a specific patient, many doctors use
Versed and Fentanyl. Versed is a fast-acting anti-anxiety medication that helps
patients relax, yet remain awake. This medication is similar to Valium.
Patients frequently report partial amnesia (memory loss) regarding the
procedure, but do not feel drugged or high afterward. Fentanyl, on the other
hand, is a strong narcotic or pain medication. This medicine will help you with
the discomfort of the procedure. All patients receiving sedation are monitored
closely, because these drugs can cause serious drops in blood pressure, heart
rate, and breathing rate, in some individuals. Putting a patient to sleep, or
even over sedating the patient, may be unsafe, since you lose the ability to
monitor correct needle placement, risking the possibility of permanent nerve
damage.
Immediately after the injection, you may feel that your pain
may be gone or significantly reduced. This is due to the local anesthetic
injected. This will last 4 to 6 hours. Leg numbness and weakness is rather
uncommon after the procedure (when done for the lower back pain). Arm numbness
and weakness could be seen after the procedure (when done for neck pain). This
should be self limiting and should wear off in 4 to 6 hours. Your pain will
return and may actually feel worse than usual for 5 to 10 days. This is due to
the mechanical process of needle insertion as well as initial irritation form
the steroid itself. You should start noticing pain relief after that. On the
average, it takes 5 to 10 days for the steroids to bring the swelling down to a
point where the patient will be able to tell a difference.
You should have a ride home. Do not plan on doing anything
else for the rest of the day. You should not drive, since you may be under the
influence of sedatives (drunk, for all practical purposes). You should avoid
making any important decisions, since you may regret them later, as the
sedation wears off. We advise the patients to take it easy for a day or so after
the procedure. You may feel great, but we advise you against doing things that
you were not been able to do while in pain. Remember that this feeling of
wellbeing may be secondary to the sedation and the effects of the local
anesthetics (numbing medicine), both of which will wear off. Remember to apply
ice to the affected area, 15 minutes on and 15 minutes off. Remember to wrap
the ice with a towel, to prevent burning the skin. Perform the activities as
tolerated by you. Use common sense.
Unless there are complications, you should be able to return
to work the next day or so. The most common thing you may feel is soreness in
and around the injection sites.
The immediate effect is usually from the local anesthetic
injected. The local anesthetics take 15 to 20 minutes for their peak effect.
This wears off in 4 to 6 hours. The steroid starts working immediately after it
is injected, but it takes about 5 to 10 days for the patients to see any
benefits. This period of time is dependent on the amount of swelling present in
the area. The more swelling, the longer it takes for the benefits to be seen.
The beneficial effect of the steroids can last anywhere from a couple of days
to several months, or even years. The duration of benefits is directly related
to the underlying condition. The information on the duration of these
medications and their effects is used by your pain physician in interpreting
the results of the procedure, and ultimately determining the mechanism of your
pain.
This depends on your pain specialist and the techniques
available to him/her, to treat your problem. There are several society
guidelines available. Depending on which your physician follows, there may be
several answers to this question. In our practice, we take one step at a time
and we do not pretend to predict the future, as we are physicians and not
fortune tellers. However, to give you an idea, these are some of the
possibilities that you may encounter in our practice:
· Above all, our injections are diagnostic, meaning that we are very interested in whether or not you experience relief of the pain during the initial 4 to 6 hours after the injection. During this time, you should be under the effects of the numbing medicine (local anesthetics). If you do, then this will confirm that this is where the pain was coming from. After this initial relief, whether or not you get long term benefit is only going to tell us if you had swelling associated with it, or not. If you get long term benefit, there was swelling, if not, we are then dealing with mechanical compression, mostly independent of swelling. Therefore, it is of outmost importance for you to keep track of this period and to accurately provide us with this information. Whether or not you get relief from the injection, it will always provide us with good information that we can later use to get closer to the root of the problem.
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If the first injection does not relieve your
symptoms in about a week to two weeks, you may be recommended to have one more
injection. This is occasionally done, just to make sure that the lack of
response was not secondary to a technical difficulty during the procedure (i.e.
distorted anatomy secondary to prior surgeries).
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If you get incomplete relief of the pain during
the initial 4 to 6 hours after the injection, you will need to be reevaluated
to assess the origin of this persistent pain. In other words, whatever pain
went away during the duration of the numbing medicine, will be considered as
originating from the blocked facet joints. Whatever pain did not go away
during the effects of the numbing medicine, will be considered as coming from
somewhere else, the location of which will need to be determined at a later
time.
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If your pain completely goes away and does not
seem to be returning, then there is no need for further treatments.
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If you get excellent results (more than 50%
relief of the pain), but they just do not last, we may recommend moving on to a
radiofrequency.
We generally do not perform or recommend more than three
injections in a six-month period. Each case is evaluated individually. If three
injections have not helped you, it is very unlikely that you will get any
further benefit from more injections. At this point you should consider other
alternatives, such as radiofrequency. Also, giving more injections may increase
the likelihood of side effects from the steroids.
It is very difficult to predict if the injection will indeed
help you or not. Generally speaking, the patients who have recent onset of pain
may respond much better than the ones with long standing pain. Remember that
above all, this is a diagnostic procedure meant to help us find the cause of
your pain. Even a procedure that does not provide you with relief of the pain,
it will provide your physician with invaluable information about the mechanism
of your pain, ultimately putting us one step closer to the solution of the
problem.
Generally speaking, this procedure is safe. However, with
any procedure there are risks, side effects, and possible complications. The
most common side effect is pain ñ which is temporary. The other risks involve,
infection, bleeding, worsening of symptoms, spinal block, Epidural block etc.
The other risks are related to the side effects of steroids: These include
weight gain, increase in blood sugar (mainly in diabetics), water retention,
suppression of body's own natural production of cortisone etc. Fortunately, the
serious side effects and complications are uncommon.
If you are allergic to any of the medications to be injected,
if you are on a blood thinning medication (e.g. Coumadin), or if you have an
active infection going on, you should not have the injection. If you can safely
come off of your blood thinners, then you can have the procedure.
You will be given specific instructions to take home. Most
patients having a facet injection are pain-free on discharge. For some
patients, the pain relief can be long-term; however, it is unusual for one
block to completely relieve pain for a long period of time. Keep a pain diary
between appointments so that your doctor can work with you more effectively.
Your physician will need specific information about your response to treatment
so that he can determine whether additional facet injections will help you.
Help yourself by following instructions about medications, exercise, relaxation
techniques, and sleep aids.
As with everything in medicine, results can vary; you may have complete pain relief, partial relief, or no change in your pain level after the facet block. As in all invasive procedures, there is a small chance of infection or bleeding. Numbness and /or loss of feeling in the back or extremities can last for several hours. Your physician will discuss the risks and benefits of facet blocks with you prior to treatment.
Be aware that this procedure cannot be effectively done without x-ray guidance and proper training. Currently the U.S. Department of Justice (U.S. DOJ)is carefully investigating practitioners claiming to be performing "Facet Blocks", after completing a weekend course. Many of these are not true facet blocks, and therefore, the Office of the Inspector General (OIG) is currently investigating those practices for fraud. We highly recommend that you have these procedures done only by a Board-Certified Pain Specialist with Fellowship Training in these procedures. We occasionally get questions about Orthopedic surgeons, Neurosurgeons, and Neurologists performing these procedures. We all have our own areas of expertise, however, I would personally prefer that my brain be operated by a Neurosurgeon, my bones be fixed by an Orthopedic surgeon, my nerve conduction test be done by a Neurologist, and all of my nerve blocks be done by a Pain specialist. Just as I would not want my Pain specialist to operate on my brain, I would not want my Neurosurgeon to do my Pain blocks, but that is just me. Technically, it is not illegal for these physicians to perform them.