Lumbar Facet Joint Injections

Original Editors - Georg Baker, Michelle Harvey, Tommy Pearson, Joe Wakefield as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - Tommy Pearson, Joe Wakefield, Michelle harvey, Lucinda hampton, Kim Jackson, Laura Ritchie, Admin, Rachael Lowe and George Baker

Introduction

Facet joint injections serve as both diagnostic tests and treatment interventions for chronic low back pain. These image-guided procedures help physiotherapists and clinicians differentiate between facet syndrome and radicular pain - crucial for developing targeted treatment plans.

The Procedure

Performed under fluoroscopic or CT guidance, these injections can target cervical, thoracic, or lumbar facet joints (most commonly lumbar). Single or multiple joints can be treated in one session, making it an efficient diagnostic tool.

Clinical Evidence

While long-term effectiveness remains uncertain, facet joint injections provide valuable clinical information:

• Short-term relief: 59-94% of patients experience pain reduction
• Long-term outcomes: Mixed results (20-54% in early studies)
• Diagnostic value: Confirms facet joints as pain source

Physiotherapy Implications

For physiotherapists, positive response to facet joint injections indicates:

• Facet-mediated pain patterns
• Potential for targeted manual therapy approaches
• Opportunity for exercise prescription during pain-free periods
• Need for spinal stabilization and mobility programs

The diagnostic clarity from these injections helps physiotherapists tailor treatment strategies more effectively for chronic low back pain patients

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Lumbar Facet Joints

Lumbar Facet (zygapophysial) joints are formed of the superior and inferior articulating processes of adjacent vertebra .

• Classed as plane synovial joints .
• Orientated in a vertical projection .
• 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 .
• Free and encapsulated nerve endings supplied by the medial branches of the dorsi rami, innervate the facet joints .

Facet Joint Injection

• Facet joints have been recognised as a possible source of chronic LBP since the early 1900's .
• Facet joint injections have two main purposes; one to relieve pain both short and long term and the other to be used conjunctively with the physical examination as a diagnostic tool to determine whether the facet joint is the source of pain .
  

1. Diagnostic Facet Joint Injection

The following two-step response pattern is the current gold standard which is used to diagnose facet joint syndrome, which may indicate a need for a therapeutic facet joint injection

1. Saline is injected causing distension of the problematic facet joint - this should reproduce/increase the patients’ pain.
2. Injection of local anaesthetic into the facet joint - this should reduce/relieve the patients’ pain.

Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain.

• These patients may benefit from specific interventions to eliminate facet joint pain such as Therapeutic Facet Joint Injection or neurolysis (by radiofrequency or cryoablation)
• Neurolysis is the application of a chemical or physical destructive agent to a nerve to create a long-lasting or permanent interruption of neural transmission.

2. Therapeutic Facet Joint Injection

A local anaesthetic is initially given to decrease the nociceptive signals in and around the facet joint. This is followed by the therapeutic injection which typically contains a mixture of a long-acting steroid (e.g. Triamcinolone) and local anaesthesia (e.g. Bupivacaine).

• Early studies reported reasonable long term relief of symptoms (20-54%)
• More recent studies have suggested that steroid injection "is of little value".
• Short term relief is common (59-94%) .

Procedures: Facet Joint Injection Procedure

Quick Overview

• Duration: 15-minute procedure, 2-hour outpatient visit
• Anesthesia: Local anesthetic (general sedation optional)
• Guidance: Fluoroscopy ensures accurate needle placement

Procedure Steps

1. Patient positioned face-down
2. Injection site cleaned and numbed
3. Fluoroscopy-guided needle insertion into facet joint
4. Combined steroid and anesthetic injection
5. Medicine spreads to reduce inflammation across spinal levels

Post-Procedure Protocol

Immediate care (20 minutes observation):

• Pain scores at 0 and 15-20 minutes
• Monitor for complications

Discharge requirements:

• Patient escort mandatory
• No driving for 2 hours post-procedure
• Complete pain diary for 2 weeks

Understanding this timeline helps physiotherapists:

• Schedule appropriate follow-up appointments
• Interpret pain diary results for treatment planning
• Recognize optimal windows for exercise prescription during pain relief periods.

(Platelet Rich Plasma) PRP for Facet Joints

Platelet-Rich Plasma (PRP) therapy involves injecting concentrated platelets from the patient's own blood into painful lumbar facet joints. This treatment aims to promote natural healing and reduce chronic lower back pain.

The Research: A study of 78 patients with chronic facet joint syndrome compared PRP injections to local anesthetic injections over one year. Patients received 3-5 CT-guided injections at weekly intervals, targeting at least two facet joint levels.

Key Findings

Pain Relief:

• PRP superior to local anesthetic from 6 weeks onwards (p<0.001)
• Significant pain reduction maintained for one year

Function Improvement:

• Oswestry Disability Index improved 50% at 6 months (p<0.001)
• Benefits sustained at one year (p<0.01)

Clinical Implications for Physiotherapists: PRP therapy for lumbar facet joints demonstrates long-term pain reduction and functional improvement. This treatment may complement physiotherapy interventions for patients with chronic facet joint syndrome who haven't responded adequately to conservative management alone.

The sustained benefits make PRP a valuable option for patients requiring prolonged pain relief to engage effectively in rehabilitation programs.

Implications for Treatment

Facet injections are generally offered following failure to improve from a period of conservative treatments eg physiotherapy, drug therapy, bed rest, and exercise.

• Studies have shown the interval of 6 weeks post-injection, when pain is ideally 80-100% elimintated  physiotherapy treatments (eg land-based lower back mobility exercise, Manual Therapy Techniques For The Lumbar Spine, McKenzie Method) may be of benefit to improve the longer-term outcomes of patients with chronic low back pain.

The following are examples of when injections may be used

1. Lumbar Facet Syndrome: both diagnostic (i.e. relief of pain after injection of local anaesthetic) and therapeutic chronic low back pain.
2. Spondylolisthesis
3. Spondylolysis
4. Ankylosing Spondylitis
5. Spinal Stenosis
6. Trauma (e.g. road traffic accidents or sports/work with repetitive forceful hyperextensions)
7. Low back pain (+/- sciatica) with normal imaging findings
8. Post-laminectomy syndrome

Complications

Rare:

• Infection, including septic arthritis and discitis-osteomyelitis
• Allergic/anaphylactic reaction
• Local reaction to steroid injection (usually >48 hours)
• Bleeding

Contraindications

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. Allergies to the medication or contrast agents used during the procedure
5. Progressive neurological disorders that may be masked by the procedure
6. Pregnancy (due to exposure to radioactive material, eg x-ray)
7. Uncontrolled diabetes and heart disease

Effectiveness of Facet Joint Injections

On conclusion, the evidence on the effectiveness of facet joint injections is inconclusive due to wide variation between studies that limits the number of comparable studies. 

A recent Cochrane review evaluated lumbar facet injections random controlled trials used in sub-acute (< 6 weeks) and chronic (> 3 months)

• They stated due to a lack of inconsistency between studies in terms of area, drugs, dosage and outcome measures statistical pooling was not possible and as such performed a best-evidence synthesis.

NICE guidelines (2009) for LBP recommends

• Further comparable research is required into this area before reliable conclusions can be made (including research into which demographic groups respond more favourably).

Conclusions

Facet joint injections are becoming increasingly more popular in current practice

• The increasing popularity of this treatment may be due to it being passive compared to the alternatives (exercise programs and postural care) which require the patient to make active changes to their lifestyle.
• The small amount of literature on whether a facet joint injection is as effective as its alternatives have contrasting conclusions.
• It is clear that the literature base is simply not large enough yet to effectively inform practice.