The facet joints in your back and neck can be the source of pain. The facet joints join two adjacent vertebral bodies together behind the spinal cord, completing the bony canal that protects the spinal cord and creating the joints that limit how far back we can twist and turn. The joint can the source of low back pain, either because of injury from trauma or degeneration or arthritis, as we get older. Facet joint pain is usually limited to the back and buttocks or neck and shoulders, without any pain into the hands or feet.
There is no clear way on physical exam or imaging to diagnose whether pain is coming from the facet joints. Pain with pushing over the joints and pain with bending back suggest that the pain is coming from the facets. The best way to diagnose whether pain is coming from the facet joints is with diagnostic facet injections.
Diagnostic facet injections are done by injecting small amounts of local anesthetic around the nerve which supplies the facet joint. This nerve is called the medial branch of the dorsal ramus, except for L5, which is supplied by the dorsal ramus and C2-3, which is supplied by the third occipital nerve. Facet injections done by blocking the nerves are usually called medial branch blocks. Diagnostic facet injections are also sometimes done by injecting into the facet joint itself, which is called an intra-articular injection.
When you have a facet injection, your doctor will want to know how much pain you have prior to the procedure. Your pain should be at least 3/10 or it will be hard to know if you have any relief from the injection. For that reason, you should not take any pain pills for several hours before the procedure, so that you will be best able to judge pain relief. Also, only a small amount of sedation, with no opioids, will be provided during this procedure, to make sure that any relief you have is from the injection and not from the sedation. Rarely, you can have general anesthesia for the procedure.
All facet procedures require fluoroscopy or, rarely, CT scan, guidance.
After the procedure, your doctor will want to know how much pain relief you have from the procedure before you leave the facility. You will be asked to keep track of how long the relief you get from the procedure lasts. It is best to write down the length of time the pain relief lasts, because few remember later on. If your pain relief is appropriate for the duration of the local anesthetic, you will have a second injection. We are going to the second injection because too many people without facet disease still get relief from just one injection for the appropriate length of time. The second injection will have a local anesthetic with a different duration. If pain relief last for the appropriate length of time for both procedures, you are a candidate for a radiofrequency ablation of the joints.
Therapeutic facet injections are provided to people who get at least 50% relief from a diagnostic injection for at least 6-8 weeks. These can be either medial branch or intra-articular.
Intra-articular facet injections are also done to treat facet joint cysts. Facet joint cysts are swellings of the joint, like a ganglion cyst in your wrist. If they are inside the spinal canal, they can cause compression of the nerve roots and pain, just like a disc protrusion.
Radiofrequency ablation (RFA) of the medial branches is an effective way to treat facet pain. RFA involves placing a radiofrequency needle close to the facet joint and heating up the nerve, so that the nerve no longer carries pain information from the joint. If you get at least 50% relief for at least 6-12 months, you can keep on having facet RFA procedures for as long as you need. I have been some patients on whom I have repeat the procedure annually for 10 years, although that length of treatment is the exception.
Call the Helm Center today for a consultation to see if facet joint injections may be the best procedure for you to find relief.