Back Pain Treatments
Facet Joint Injections & Medial Branch Blocks
Back Pain Due to Facet Joint Arthropathy
Back pain is the leading cause of pain and disability in the developed world. Back pain has an enormous impact on patients, their families and the healthcare system. If you suffer from back pain you are not alone and you have many options to help manage it. 75-80% of people will experience lower back pain at some stage during their lives.
Chronic lower back pain can originate from multiple structures in the spine, including:
Back pain caused by facet joint arthritis, or facet arthropathy, is common and has multiple treatment options that do not necessarily involve surgery. The facets joints are structures at the back of the spine that help to provide the lower back with movement and flexibility. As the spine wears out with age or degeneration, the facet joints can also wear out and become arthritic. These arthritic facet joints can cause pain, just like arthritis in other joints of the body such as the hip and knee. Facet arthropathy can occur in the neck too, where it causes neck pain.
Facet Joint Injection. The facet joints, found on both sides of the back of the spine, can become painfully irritated or inflamed by arthritis. A facet joint injection may help diagnose the source of a patient's pain. It can also relieve pain and inflammation.
Investigation of Facet Arthropathy
Following the initial clinical assessment, it is usual for some type of radiological investigation to be organised. These scans are to look in detail for what might be the cause of your back pain. Investigations which may demonstrate facet joint arthropathy and other cause of back pain include:
- Lumbar spinal x-ray
- Bone scan including SPECT CT
- CT Scan
- MRI Scan
Treatment of Facet Joint Arthropathy and Back Pain
Unless patients have significant neurological deficits, such as lower limb weakness, or bowel or bladder dysfunction, the initial treatments for back pain due to facet joint arthropathy are conservative non-operative therapies. Non operative treatments represent the mainstay of conservative therapies for low back pain and include :
- Analgesia (pain medications)
- Non-steroidal anti-inflammatory medications (NSAIDs)
- Steroid pain injection therapies
- Radiofrequency Ablation (RFA)
- Behaviour modification - e.g. avoiding heavy lifting
- Weight loss - this is important as extra weight places more stress on the spine contributing to back pain.
- Strengthening exercises - to strengthen core and paraspinal muscles to provide extra stability to the spine thereby reducing pain.
When facet arthropathy is confirmed on radiological studies, a trial of steroid injection therapy is often a simple way to obtain pain relief. These injections are either a facet joint injection or a medial branch block injection.
A facet joint injection is an injection of local anaesthetic and steroid, into and around an arthritic facet joint, to reduce inflammation and pain arising from the joint.
A medial branch block is an injection of local anaesthetic and steroid around the nerves which supply an arthritic facet joint, in order to numb the joint, thereby reducing back pain.
These injections are performed for two reasons:
- Diagnostic - to confirm that the injected joint is the source of the pain. A second procedure, called a radiofrequency ablation, can then be performed to give long-lasting pain relief.
- Treatment - to help reduce pain and inflammation due to facet joint pain, which can last from a few days, to a few months.
Multiple joints may need to be injected to give adequate pain relief and determine which joints are the symptomatic ones.
Medial Branch Block. This diagnostic procedure is performed to identify a painful facet joint. The facet joints are the joints between the vertebrae in the spine. They allow the spine to bend, flex and twist.
FAQs about Facet Joint Injections and Medial Branch Blocks
Why does Dr Oehme recommend a facet joint injection or medial branch block?
Following failure of medications and other non-operative measures to control back pain due to facet arthritis, a facet joint injection or medial branch block is a safe and simple treatment that may help relieve the symptoms of back pain due to facet joint arthritis.
The injection of local anaesthetic and steroid reduces the inflammation in both the facet joint, and the nerve to the facet joint, to help reduce pain. In most patients with facet arthropathy, it is worthwhile trying a facet injection or medial branch block prior to consideration for surgery or other invasive treatments.
If the injection helps control the pain, surgery may be avoided or delayed. In addition, if the injection is helpful, a more permanent radiofrequency ablation of the nerve to the facet joint can be performed to give long lasting pain relief.
What happens during the injection?
Most facet joint injections and medial branch blocks are performed by a radiologist under CT guidance. These are routinely performed at most radiology facilities. These injections are also commonly performed by pain specialists.
The patient lays face down on the CT scanner or x-ray table. The procedure is performed as a sterile procedure to reduce the chance of infection. A small amount of local anaesthetic is injected into the skin so that the needle passes through without causing any pain. A radiologist or pain physician who specialises in the procedure performs the injection.
A needle is advanced under CT or x-ray guidance, either into the arthritic facet joint (facet joint injection) or around the nerve to the arthritic facet joint (medial branch block). Once the position of the needle is confirmed with CT or x-ray, a small mixture of local anaesthetic and steroid is injected. The local anaesthetic numbs the nerve or joint whilst the steroid reduces inflammation. The needle is removed following the injection and the patient is able to mobilise.
Dr Oehme will advise if a steroid injection is appropriate for you at your consultation. His rooms will also book the procedure at an experienced radiology facility. For more information about facet joint injections watch the video above.
In addition to treating facet arthritis in the lumbar spine, facet joint injection can be used to treat facet joint arthritis in the neck too. This is a common and effective treatment for neck pain.
What are the risks of having a facet joint injection?
Most steroid injections are performed very safely and most patients have minimal side effects. The most common complication is to have some discomfort around where the needle passes. This usually resolves over the course of a day or so.
Often the nerve pain or back pain will disappear almost immediately after the injection, if it has been successful. Sometimes, however, it does take a couple of days for the inflammation and pain to subside. In a small percentage of patients the injection may have no clinical benefit. Although this is frustrating for patients, it is helpful information for the surgeon as it may indicate the back pain is due to another cause or another spinal level.
Other rare complications including infection, bleeding, bleeding causing haematoma requiring surgery, back pain, or rarely, neurological injury.
What factors might prevent me from having this procedure?
Factors which may preclude you from having a facet joint injection include:
1. If you are taking blood thinning medications such as aspirin, Plavix or Warfarin.
2. If you have an allergy to contrast material.
3. Abnormal spinal anatomy
4. Morbid obesity
What happens after the procedure?
Patients are usually asked that someone else will drive them home from the injection. You are able to walk almost immediately after the procedure. It is also advisable that you should not perform any strenuous exercise for a period of one to two days after the injection.
How long do facet joint injections and medial branch blocks last?
The response of patients to steroid injections is variable. A small percentage of patients will have no benefit from the procedure. Most patients will have benefit that lasts somewhere between two weeks to two months. Some patients will get longer lasting relief from the procedure.
If pain returns, one option is to have another injection. The second option is to have permanent radiofrequency ablation of the nerves to the facet joints. In severe cases of facet joint pain spinal fusion may be indicated. If you have any doubt, Dr Oehme will advise you if having an injection is an appropriate treatment.
Who performs facet joint injections?
Dr Oehme will recommend facet joint injections in many patients prior to consideration for surgery to see if it settles back pain. Dr Oehme does not perform the procedures himself, but will refer you to either a specialist radiologist who performs the procedure under CT guidance, or to a pain physician who performs the injection under sedation with x-ray guidance.
Dr Oehme will advise if an injection is appropriate for your spinal condition. For more information or to arrange a time to discuss surgery with Dr Oehme contact Keyhole Neurosurgery on 1800 DO SPINE (1800 367 746).