Facet Joint Injection Procedure

Facet joint injections are minimally invasive treatments that are typically performed in an outpatient surgical center or at a doctor's office. Patients remain awake throughout the process and go home on the same day after a brief observational period. ¹ Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

Preparing for a Facet Joint Injection Procedure

Before administering a facet joint injection, the following standard steps are typically followed to confirm the procedure's suitability for the patient's condition and ensure its safety ¹ Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/ ^{, 2} Curtis L, Shah N, Padalia D. Facet Joint Disease. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541049/ :

• Medical history. A comprehensive review of the patient’s health, medications, and allergies is conducted to discern potential contraindications or safety concerns that could interfere with the injection procedure.
• Physical exam. A physical exam is critical for determining the spinal region involved and ruling out alternative causes of pain that might require a different treatment approach.
• Imaging and labs. Medical imaging, such as x-ray or magnetic resonance imaging (MRI), and blood tests help doctors assess damage or inflammation of the facet joint. 

Patients are usually referred to a pain management doctor, anesthesiologist, or spine specialist (eg, physiatrist or orthopedic surgeon) who conducts the initial assessment and also performs the injection procedure. ² Curtis L, Shah N, Padalia D. Facet Joint Disease. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541049/

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Next steps after medical clearance for facet joint injections

Patients taking blood thinners are typically advised by their doctors to stop the medication 2 to 7 days before the injection treatment to reduce the risk of bleeding. ³ Smith CC, Schneider B, McCormick ZL, et al. Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review. Pain Med. 2018;19(3):438-448. doi:10.1093/pm/pnx152 To ensure safety, it is recommended to consult with the prescribing physician before discontinuing the medication or making any changes to the dosage.

While not required, quitting smoking before a facet joint injection is encouraged as part of a broader health strategy, as smoking can impair healing and increase the risk of complications. ⁴ An D, Ayob F, Rajaleelan W, Chung F, Wong J. Preoperative smoking cessation as part of surgical prehabilitation. Can J Anaesth. 2019;66(4):476-479. doi:10.1007/s12630-018-01283-7

Facet Joint Injection Procedure: A Step-by-Step Guide

The injection process takes approximately 15 to 30 minutes, and patients are monitored for up to 1 hour following the procedure before they return home.

Sedation is typically avoided because it interferes with assessing the patient’s response regarding pain relief from the facet joint injection. However, in some cases, medication to reduce anxiety may be given on the day of the procedure. ¹ Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

If sedation or medication is used, patients are not allowed to drive home after the procedure and should schedule a friend or family member to drive them home. 

The procedure for facet joint injections typically includes the following steps ¹ Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/ :

1. Preparation and positioning. For lumbar (low back) injections, the patient lies on their stomach in a face-down position, and, in some cases, a small pillow is placed under the abdomen to reduce the curvature of the spine. For cervical (neck) injections, the patient is placed either on their stomach or on their side. An IV line is inserted if medication for anxiety is needed.
2. Numbing of the skin. The area over the facet joint is cleansed, and a local anesthetic is administered under the skin to numb the area.
3. Needle placement. A small, thin needle is directed into the targeted facet joint using imaging guidance (eg, x-ray or ultrasound) to ensure precise placement.
4. Confirmation of needle location. A small amount of contrast dye is injected to confirm that the needle is in the joint and that the medication does not enter the bloodstream.
5. Medication administration. The doctor injects the medication directly into the joint and removes the needle.

The patient is then monitored for 30 to 60 minutes following the procedure and is asked to perform some movements to assess the pain relief.

What to Expect After a Facet Joint Injection Procedure

If the facet joint is the source of pain, most patients experience relief within a few hours following an injection due to the numbing effects of the anesthetic. ⁵ Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022;47(1):3-59. doi:10.1136/rapm-2021-103031

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However, the initial improvement in pain is temporary as the effects of the anesthetic dissipate.

• Short-acting drugs (eg, lidocaine) provide pain relief for up to 2 hours. ⁵ Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022;47(1):3-59. doi:10.1136/rapm-2021-103031
• Longer-acting medications (eg, bupivacaine) provide pain relief for up to 8 hours. ⁵ Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022;47(1):3-59. doi:10.1136/rapm-2021-103031

Pain relief from the effects of the corticosteroid medication usually begins within a few days after the injection. Some patients experience a recurrence of pain after the anesthetic wears off and before the corticosteroid exerts its full effect. ⁵ Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022;47(1):3-59. doi:10.1136/rapm-2021-103031

If there is no improvement in pain during the anesthetic phase (or diagnostic phase) of the injection, the facet joint is likely not the source of pain. ¹ Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

Returning to daily activities after facet joint injections

Patients are usually able to return to normal activities on the day after the procedure. 

To reduce the risk of infection at the injection site, it is recommended to avoid activities that involve soaking in water (eg, bathtub, swimming, or hot tub) for at least 48 hours. ⁶ Dayton P, Feilmeier M, Sedberry S. Does postoperative showering or bathing of a surgical site increase the incidence of infection? A systematic review of the literature. J Foot Ankle Surg. 2013;52(5):612-614. doi:10.1053/j.jfas.2013.02.016

When the pain is improved, starting regular exercise and activities in moderation is advisable. Even if the pain relief is significant, increasing activities gradually over one to two weeks helps to minimize pain recurrence. ⁷ Vekaria R, Bhatt R, Ellard DR, Henschke N, Underwood M, Sandhu H. Intra-articular facet joint injections for low back pain: a systematic review. European Spine Journal. 2016;25(4):1266-1281. doi: 10.1007/s00586-016-4455-y

Long-Term Outcomes of Facet Joint Injections

Lasting pain relief from facet joint injections varies among patients and depends on diagnostic accuracy and injection type. 

Typically, injections containing anesthetic and corticosteroid medications offer relief for 2 to 4 months or longer. ² Curtis L, Shah N, Padalia D. Facet Joint Disease. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541049/

Combining Complementary Treatments with Facet Joint Injections

Facet joint injections are one component of treatment for facet pain, and combining injections with different therapeutic strategies is recommended in most cases to optimize the therapeutic benefit, including ² Curtis L, Shah N, Padalia D. Facet Joint Disease. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541049/ : 

• Anti-inflammatory medications, primarily non-steroidal anti-inflammatory drugs (NSAIDs) 
• Physical therapy and exercises that strengthen the muscles around the spine 

Discussing these treatment options with a doctor before starting a new medication or exercise regimen is advisable to determine which therapies provide the most benefit while minimizing the risk of side effects and adverse events.

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