Spinal pain can take your breath away and can arise from many different sources. What is a facet joint? What is the role of facet joints? Is a facet joint injection painful? Are facet joint injections dangerous? Let’s dig in.
The facet joint is a small joint at each level of the cervical, thoracic and lumbar spine that is located between and behind adjacent vertebrae. They are a paired joint with a right and left facet joint at each level of the spine. Like other synovial joints in the body such as the knee, the facet joint has hyaline cartilage and joint capsule (1). The facet joints are on either side the midline boney projections called spinous processes.
What Do the Facet Joints Do?
The facet joints are important shock absorbers in the posterior portion of the spine. They also limit rotation, backward bending (extension) and stabilize the spine when bending (2). This a large task for a small joint and as such the joint is susceptible to excessive wear, degeneration, and injury. The facet joint can also be injured by trauma such as a rear-end motor vehicle accident. Facet injury can lead to arthritis in the joint and pain. Lumbar facets are a common source of pain, accounting for 15-45 % of low back pain (3). Facet joint pain in the lumbar spine is commonly localized in the lower back and may involve the buttock and posterior thighs.
Is a Facet Joint Injection Painful?
Pain varies from patient to patient. Facet injections should be performed under intermittent x-ray guidance where contrast can confirm the appropriate needle placement. The injection can be performed with or without IV sedation depending upon the preference of the patient and provider. When performed without sedation the skin and subcutaneous layers are injected with numbing medication. Other factors that may influence the level of pain during a facet joint injection include the size of the needle, amount of tissue between the skin and the joint, physician’s experience and severity of spinal pain prior to the injection.
Is a Facet Joint Injection Dangerous?
Facet injections are one of the treatment options for neck, thoracic and low back pain that has not responded to conservative care (4). Injections directly into the joint (intra-articular) and medial branch blocks are the most common injections performed ( 5). All injections have inherent risks and possible complications. These include bleeding, infection, failure, escalation in pain, nerve damage and reduction in heart rate (6). Medications injected include local anesthetic and steroids. Steroids are very dangerous as they are toxic to joint cartilage (7), your body’s stem cells (8), and negatively impact your stress management hormones (9).
Regenerative Treatment Options
PRP is an effective steroid alternative in the treatment of facet pain (10). PRP is rich in growth factors that can reduce inflammation and promote healing without the toxic side effects of steroids. Blood is obtained typically from the arm, processed to concentrate the growth factors and reinjected into the facet joint.
Clinical Approach for Best Outcomes
For patients to get the very best clinical results, physicians need to change their clinical approach. At the Centeno-Schultz Clinic, we acknowledge that each of the 24 levels in the cervical, thoracic and lumbar spine are more than just single parts but rather act as one machine. This machine is called the functional spinal unit (FSU) which is compromised of multiple parts which include the disc, facet joints, ligaments, bones, and muscles. Each of these is critical in providing stability to the spine. To learn more about the different parts and their role please click on the video below.
Unfortunately, most pain and regenerative medicine clinics focus exclusively on identifying your “pain generator”. In this model, the doctor identifies one structure in the spine thought to be causing the pain.
For example, a physician may identify your facet as your ” pain generator” and as such directs all treatment toward the facet joint. This model is flawed and does not acknowledge that all the different parts of the spine work together as demonstrated in the FSU model. Most importantly it does not provide the best clinical outcome.
At the Centeno-Schultz Clinic, we utilize the FSU model and as such inject multiple structures in the spine during a single treatment to provide the best outcome. The graph below illustrates how treating multiple areas affords a better outcome. In the graphs below the pain score is on the vertical axis and time is on the horizontal axis.
The top two graphs demonstrate the reduction in pain at different time points when injecting only the lumbar facet joints. The two graphs on the bottom demonstrate that by injecting the lumbar facets plus spinal ligaments and the epidural space, patients had more pain relief. Acknowledging that there are multiple important parts is critical and a core tenant at the Centeno-Schultz Clinic.
To better understand the complexity and attention to detail required for a facet injection please click on the video below.
The facet joint is a pair of cartilage lined joints at each level of the spinal that provide important stability and resist excessive rotation and extension. They are susceptible to injury and degeneration which can cause pain. Facet injections are used when conservative therapy has failed.
A Facet joint injection is performed under x-ray guidance and may be associated with discomfort depending upon a number of factors. Bleeding, infection, escalation in pain and failure are the most common risks. Injected steroids are dangerous as they are toxic to cartilage and one’s repair cells. PRP is effective in the treatment of facet injuries. Clinical outcomes improve when the spine is viewed and treated as a functional unit. Learn more about this and other back surgery alternatives.
1. Yahia LH, Garzon S. Structure on the capsular ligaments of the facet joints. Ann Anat. 1993;175(2):185–188.DOI: 10.1016/s0940-9602(11)80179-2
2.The mechanical function of the lumbar apophyseal joints. Adams MA, Hutton WC. Spine (Phila Pa 1976). 1983 Apr; 8(3):327-30.DOI: 10.1097/00007632-198304000-00017
3.Perolat R, Kastler A, Nicot B, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018;9(5):773-89. doi: 10.1007/s13244-018-0638-x
4.Filippiadis DK, Kelekis A. A review of percutaneous techniques for low back pain and neuralgia: current trends in epidural infiltrations, intervertebral disk and facet joint therapies. Br J Radiol. 2016;89(1057):20150357. DOI: 10.1259/bjr.20150357.
5.Dreyfuss PH, Dreyer SJ, Herring SA. Lumbar zygapophysial (facet) joint injections. Spine. 1995;20(18):2040-7.DOI: 10.1097/00007632-199509150-00019.
6.Velickovic M, Ballhause TM. Delayed onset of a spinal epidural hematoma after facet joint injection. SAGE Open Med Case Rep. 2016;4:2050313X16675258. DOI: 10.1177/2050313X16675258.
7.Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015;3(5):2325967115581163.doi: 10.1177/2325967115581163.
8.Shao J, Xu X, Li G, et al. Inhibitory effects of pharmacological doses of dexamethasone on mineralization of mesenchymal progenitor cells in vitro. Pharmazie. 2009;64(10):674-9.
9.Chon JY, Moon HS. Salivary cortisol concentration changes after epidural steroid injection. Pain Physician. 2012;15(6):461-6.
10.Wu J, Du Z, Lv Y, et al. A New Technique for the Treatment of Lumbar Facet Joint Syndrome Using Intra-articular Injection with Autologous Platelet Rich Plasma. Pain Physician. 2016;19(8):617-25.