Facet joint and epidural injections: doctor answers patient questions

The doctor is in!

Peter Ullrich, MD

The following explanations, insights and advice about spinal injections - including facet injections and epidural injections - are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.com.

Patients frequently e-mail us questions about spinal injections, and while we don’t provide individual responses, periodically, Dr. Ullrich will take time to respond to the more frequently asked questions and we publish the responses in this section of the site.

Please understand that the following responses to questions about spine injections like epidural and facet joint injections represent the opinion of one physician, and are intended for informational purposes only and not as a substitute for professional medical help or advice.

Spinal injection questions and physician responses

Question: I have herniated disc at L5-S1, spondylolisthesis grade 0-1 at L5-S1 and spondylolysis. I had an epidural injection (actually a caudal injection). Three days after, I started feeling better, although still far from normal. But I can drive sometimes for 30 minutes, sit 20-30 minutes, and walk 10 minutes. I am more functional than before. My second injection was supposed to be two weeks later. However, when I called to make my appointment; it was scheduled for 6 weeks later, and no appointment was made for the third injection. I've read that it is recommended to have each ESI (epidural steroid injection) 2 weeks apart to get maximum results.

My question is: how important is how far apart are the injections done? Is it OK if I get the next injection six weeks after the first injection? I don't want the effect to wear off and I may get better. Is this a procedure that is better to have in a good hospital or can anybody do the injections (meaning I can go anywhere just to get them 2 weeks apart)?

Doctor’s response: It probably does not matter all that much whether or not the epidural steroid injections are two weeks apart. The two weeks is more of a guideline that the injections should not be done any sooner than two weeks. Some people even do not have the second or third injection if they are doing very well, and that is probably why your third injection has not been scheduled yet. There really is nothing magical about having them done two weeks apart, this is just the soonest they can be linked together.

To answer your other question, a lot of different specialists do epidural injections, and it is not all that difficult of a procedure. They should be done under fluoroscopy, but it probably does not matter if they are done in a big hospital or a small one. Many office practices now even have a flouroscopy machine so they can be done right in a doctor’s office. Finally, the epidural injections are primarily meant to provide enough pain relief so that you can progress with physical rehabilitation, and it’s the physical rehab that really helps you heal and feel better over the long term.

Question: My 90 year old mother suffers from spinal stenosis. A recent Wall Street Journal article mentions that in patients with back pain due to arthritis, doctors are using radio-frequency heat to deaden nerves. Do you know where this procedure is being performed? I would take her anywhere this is being done, as she is not a candidate for surgery.

Doctor’s response: If she has spinal stenosis and her pain is mainly from the stenosis, then the radiofrequency rhizotomy would not be useful for her. If her pain is from osteoarthritis of the facet joints, she may be a candidate. It is critical to first determine which condition is the actual cause of the pain or the treatment won’t be effective.

For a radiofrequency rhizotomy, usually three separate injections into the facet joint would first be performed to see if injection with Lidocaine would be useful. If it gives her consistent, temporary relief of her pain, then the radiofrequency rhizotomy may be an option. Unfortunately, it only helps 30-40% of patients and the pain relief is often temporary (6-12 months). It is actually an old treatment, and any spine clinic or center would probably be able to do it for her.

Question: I am a 32 year old female and have chronic low back and leg pain that goes down to my foot on the left. An MRI showed degenerative disc disease L3 thru S1, a diffuse bulge at L4/5 (worse to the left) and facet osteoarthropathy mildly impinging the L5 nerve roots. It also showed an annular tear at L5/S1 and posterior protrusions at L3/4 and L4/5. I am due to have an epidural block for the leg pain and facet injections. I am also in physical therapy. Do you think it is possible to rehabilitate my back to the level of being able to lift in excess of 50 lbs? If I pick up my 25 lb child too much, my back pain gets worse.

Doctor’s response: In all likelihood, a lot of the findings that are on your MRI scan were there before you were having much back pain. The findings on your MRI are not specific or diagnostic of any specific pathology. Probably the more important question is whether or not your nerve root is pinched by the disc bulge. If it is, the epidural may help calm down the inflammation. At that point, exercises would be helpful. If the injection does not help, you may want to see a spine surgeon to see if you would be a candidate for a microdecompression.

Rehabilitation is probably your best place to start. Assuming that it helps relieve your back pain, I do not know why you wouldn't be able to lift 50lbs, as there are not any significant structural defects in your back based on the MRI scan findings.

Question: What are the options for treating facet joint that has slipped slightly forward at L-4 and L-5 (as results of MRI showed)? I have tried Vioxx and stretching and strengthening exercises for 3 months. The pain continues, especially after golf or tennis or sitting, occasionally in buttocks and down left leg, regularly have slight tingling in left foot, no known instance causing injury--seems to have developed from overuse--primarily golf. I am male, age 55.

Doctor’s response: This is most likely a degenerative spondylolisthesis. Besides medication and physical therapy, other choices to treat the spondylolisthesis would include epidural steroid injections or a one level spine fusion. Epidural injections are easier to go through, but the surgery is more reliable. Basically, if the joint has slipped, then the facet joint is degenerated and is no longer competent to stabilize the spine properly. A fusion surgery should stabilize the unstable painful joint. Where there is no motion, there shouldn't be any more pain. Besides medications you may want to consider physical therapy and/or chiropractics. If this does not improve the pain, and it is limiting your normal level of functioning, you may want to consider epidural injections. If these do not work, a spinal fusion may be a reasonable option. Usually, surgery is only considered for patients with significant functional limitations.

Question: I have two herniated disks in the cervical spine and one herniated disk in the lumbar spine. I am considering getting an epidural for the cervical area, which is the one that bothers me the most. I read the potential risks and side effects for lumbar epidural from your website and would like to know if the risks for the cervical are similar - or are there additional risks involved with the cervical? Also, my family has a history of strokes due to a gene mutation that predisposes to strokes by creating blood clots. I have been tested by a hematologist and do not carry the gene. However, my blood test showed a low antithrombin reading. If bleeding is a risk from an epidural, could clotting be another risk?

Doctor’s response: For the most part, the risks of a cervical epidural injection are about the same. I have heard of one rare complication where an epidural caused a cerebrospinal fluid leak which lead to paralysis of one of the muscles in the eye. However, this is exceedingly rare.

A cervical epidural injection would not carry any risk of clotting. Local clotting after an injection would be good, and the only clotting to worry about is in the deep venous system of the legs, and this should not be a risk with a local injection.

Question: In August 2001, I was diagnosed with a synovial cyst. Prior to the diagnosis, I was a fitness walker but was unable to continue until this past spring. No doctor has been able to tell me what caused this cyst and the chance of recurring problems from it. Can you?

Doctor’s response: A synovial cyst is caused by osteoarthritis and degeneration of the facet joint. As the joints become more arthritic they produce more fluid. A synovial cyst is where a ball valve develops that lets the synovial fluid out but not back into the joint. This creates a cyst that usually fills into the spinal canal and causes compression (stenosis) of the nerve roots. Usually, there is both the compression problem and instability at that joint. The treatment and natural history is most akin to a degenerative spondylolisthesis and spinal stenosis.

The treatment choices for a synovial cyst from osteoarthritis and degeneration of the facet joint are a facet injection, an epidural injection or a surgical decompression of the nerve root. The surgery, however is usually also done with a fusion since there usually is instability. The cyst does tend to cause recurring problems until it is surgically excised. However, surgery is only suggested if the cyst limits your activity greatly.

If you are having problems finding answers and treatment, I would suggest seeing a spine specialist (for either conservative or surgical treatment).

What next?
If you have questions about epidural steroid injections, facet joint injections or other spinal injections, please use this site to find peer-reviewed health information about spinal conditions, diagnosis and treatment options. The quickest way to locate information on the site is to use the “keyword search” box located in the upper left hand corner of each page. Also, if you want to talk online with others who may be in a similar situation or exchange information with other patients, please go to the Spine Forum Message Boards.

Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health.com’s Medical Advisory Board.