Faset eklem ve sinir blokajı

 
FACET EKLEM BLOKAJI VE SİNİR BLOĞU YÖNTEMİ
(FACET JOİNT İNJECTİONS OR FACET NERVE BLOCK)
Bu yöntemler 1982 yılından beri tüm dünyada ve ülkemizde kronik ağrı tedavisinde kullanılan bir yöntemdir .(low back pain or leg pain). Bu yöntem ve sonuçları hakkında yayınlanan pek çok makale vardır.
Faset eklemine gelen median dal, eklem ile aynı seviyedeki root (sinir) dan ayrılır iken, lateral dal ise seviyeni üzerinden ayrılmaktadır. Faset ekleminin ağrı ile ilişkisinin olup olmadığını ayırt etmeye yarayan serum fizyolojik ile yapılan enjeksiyonda bu dal uyarılmaktadır.
Faset eklem blokajında lateral dal (2’ inci dal) bloke edilir iken, nerve blok yönteminde ise median dal (1’inci dal) bloke edilmektedir.
Belinde basmakla ağrısı olan ve bu ağrısı arkaya doğru eğilmekle artan olgularda lateral dal bloke edilmektedir. Boyun fıtığı,sırt fıtığı, bel fıtığı, bel kayması ve sinirin geçtiği kanalın ( foraminal stenozis) dar olduğu olgularda ise median dal sinir blok yöntemi ile bloke edilmektedir.Bu yöntemler ameliyata alternatif olarak son şans olarak önerilmektedir. Eğer hastaların ağrıları bu yöntemle geçmiyor ise, olgulara operasyon önerilmektedir
Faset eklem bloku veya enjeksiyonu yöntemi; kronik bel ağrısı olan veya  faset kaynaklı ağrısı olan olgularda uygulanmaktadır. Belini kırıkçı ve çıkıkçılara çektiren kişilerde, sırt üstü düşenlerde, bel kayması olup zorlamayı takiben faset eklem yüzündeki gerilmeye bağlı ağrısı olan olgularda çoğunlukla lateral dal zedelenmektedir.
Sinir bloku yöntemini, ağrıyan diş için uygulanan ve sinirinin öldürüldüğü kanal tedavisi yöntemine benzetebiliriz. Sinirin bloke edilmesi ile ağrıyan seviyeden gelen lifler durdurulmaktadır. Fıtık orada durduğu halde, ağrı yok edilmiştir. Bir süre sonrada fıtık suyunu kaybederek küçülmektedir. Yöntemin hastaya kazandırdığı primer kazanç hastanın fıtığın küçülme zamanı gerçekleşinceye kadar ağrıyı hissetmemesidir. İşlemden sonraki dönemdeki hastalara 3 günlük mutlak bir yatak istirahati önerilmektedir.sonrasındaki 1 haftalık sürede ise oturması kısıtlanmaktadır. Bu dönemin arkasından hastaların tekrar ağrı değerlendirilmeleri yapılmaktadır. Bu yöntem sonrasında ağrıları geçen hastalara önerilerde bulunulmaktadır.
            Yöntemlerin uygulanımın da hasta seçim kuralları nedir.
1.Hastaların muayeneleri ayrıntılı olarak yapılır. Hangi dalın bloke edileceğine karar vermek için, hastanın boyun,bel,sırt  MRI olması önemlidir.
2.Hastalarda sorunlu yerlerin ayrıntılı değerlendirilmesi MRI ile birlikte yapılır.
·        Eğer ağrı bacak arkasından topuğa doğru ip gibi aynı hatta iniyor,4-5 inci parmaklara ve tabana vuran ağrı veya uyuşukluğu var ise L5-S1 seviyesinde sorun vardır.
·        Eğer ağrı bacak yanından ve diz kenarından baş parmağa doğru vuruyor ise L4-L5 seviyesinde sorun vardır.        
·        Eğer ağrı kasığa doğru vuruyorsa L3-L4 seviyesinde sorun vardır.
·        L2-L3 ve üzerindeki seviyelerde ağrılar daha çok belden öne hatta böbreklere doğru vurmaktadır.
3.Ağrılarını net ayırt edemeyen hastalara, MRI bulgularına göre plan yapılmaktadır.Fakat hastaya yapılan işlemin neresi için yapıldığı ayrıntılı olarak anlatılmaktadır.
4.Hastanın belinde 3-5 vs kadar sorunlu seviye olsa da ağrılı olan seviye bloke edilmektedir. Yapılan 1 blokaj ile tüm ağrılardan kurtulmak söz konusu değildir.5-6 seviyesinde sorunu olup, 1 veya 2 seviyesine blokaj yapılarak 1 yıl takibinde ağrısı olmayan pek çok hastamız mevcuttur. Hastalar ile karşılıklı olarak durum değerlendirilmesi yapılmaktadır.
5.  Boyun fıtıklı hastalarda boyun MRI ile kol ağrısının seviyesine göre değerlendirme yapılmaktadır.
6.Yapılan işlem dijital skopi vaya floroskopi altında lokal anestezi altında spinal iğne kullanılarak yapılmaktadır.İşlemden sonra hastalar 15 dk yatırılıp evlerine gönderilmektedir.
7. Kalp rahatsızlığı, şeker hastalığı, böbrek yetmezliği, katarakt, kan hastalık, alerjik rahatsızlık,tansiyon yüksekliği olgularda ayrıntılı olarak sorgulanmaktadır.
·        Yöntem patlak fıtığı olup,kolunda veya bacağında %50 den fazla cansızlığı olan hastalarda uygun değildir.
·        Yöntemde depomedrol flakon( ilacın içeriğindeki yağdan faydalanmaktadır, yağ lifler arasında ilerleyerek iletiyi bozmaktadır). Marcain flakon ise lokal anestezik olarak kullanılmaktadır.
·        Başarı oranlarımız %90-95 arasında değişmekte olup ,olguların %5-10 unda operasyon uygulanmaktadır.
·       Yöntemle ilgili internet çıktıları ve makaleler ektedir.
 
 CERVICAL THOIRACIC AND LUMBAR FACET JOINT INJECTIONS 
 
Facet joints are small joints at each segment of the spine that provide stability and help guide motion. The facet joints can become painful due to arthritis of the spine, a back injury or mechanical stress to the back. A cervical (neck), thoracic (upper back) or lumbar (lower back) facet joint injection involves injecting a steroid medication, which can anesthetize the facet joints and block the pain. The pain relief from a facet joint injection is intended to help a patient better tolerate a physical therapy routine to rehabilitate his or her injury or back condition.
Facet joint injections usually have two goals: to help diagnose the cause and location of pain and also to provide pain relief:
·         Diagnostic goals: By placing numbing medicine into the joint, the amount of immediate pain relief experienced by the patient will help confirm or deny the joint as a source of pain. If complete pain relief is achieved while some of the facet joints are numb it means those joints are likely to be the source of pain.
·         Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release cortisone into the facet joints to reduce inflammation, which can often provide long term pain relief. The procedure may also be called a facet block, as its purpose is to block the pain.
Anatomy of the cervical, thoracic and lumbar facet joints
The facet joints are paired joints in the back and neck, one pair at each vertebral level (one joint on each side of the vertebrae). These joints have opposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule that is filled with synovial fluid, which reduces the friction between bones that rub together.
Cervical facet joints are located on the back or side of the neck. Thoracic facet joints are in the upper back and lumbar facet joints are in the lower back. Depending on which joints are affected, pain can be located in different areas of the body:
·         Cervical facet joints. Pain caused by cervical facet joints is usually felt in the head, neck, shoulder, and/or arm.
·         Thoracic facet joints. Pain caused by thoracic facet joints is typically felt in the upper back, chest and/or arm (rarely).
·         Lumbar facet joints. Pain cause by lumbar facet joints is typically felt in the lower back, hip, buttock, and/or leg.
Cervical, thoracic and lumbar facet joint injection procedure
As with many spinal injections, facet joint injections are best performed using fluoroscopy (live x-ray) for guidance to properly target and place the needle (and to help avoid nerve injury or other injury).
The injection procedure includes the following steps:
·         An IV line will be started so that adequate relaxation medicine can be given, if needed.
·         The patient lies face down on an x-ray table and the skin over the area to be treated is well cleaned.
·         The physician numbs a small area of skin with an anesthetic (a numbing medicine). This may sting for a few seconds.
·         The physician uses x-ray guidance (fluoroscopy) to direct a very small needle into the joint. Several drops of contrast dye are then injected to confirm that the medicine only goes into the joint.
·         A small mixture of anesthetic (such as lidocaine)and anti-inflammatory medication (cortisone) is then slowly injected into the joint.
The injection itself only takes a few minutes, but the entire procedure usually takes between thirty and sixty minutes.After the procedure, the patient typically remains resting on the table for twenty to thirty minutes, and then is asked to move the area of usual discomfort to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joints that were injected are the main source of the patient’s pain. On occasion, the patient may feel numb or experience a slightly weak or odd feeling in the upper back for a few hours after the injection. On the day of the injection, patients are advised to avoid driving and avoid doing any strenuous activities.
The patient should record the levels of pain relief during the next week in a pain diary. Tracking the level of pain is helpful to clearly inform the treating physician of the injection results and in planning future tests and/or treatment, as needed.
Cervical, thoracic and lumbar facet joint injection results and follow-up
On the day of the injection, patients are advised to avoid doing any strenuous activities, unless instructed by their physician. The patient should not drive the day of the injection unless approved by the treating physician. If sedation was used, the patient should not drive for 24 hours after the procedure. Patients may notice a slight increase in pain lasting for several days as the numbing medicine wears off and before the cortisone starts to take effect. If the area is uncomfortable in the first two to three days after the injection, carefully applying ice or a cold pack to the general area of the injection site will typically provide pain relief.
If the facet joints that were treated are the source of the pain, the patient may begin to notice pain relief starting two to five days after the injection. If no improvement occurs within ten days after the injection, then the patient is unlikely to gain any pain relief from the injection and further diagnostic tests may be needed to accurately diagnose the patient’s pain.
Patients may continue to take their regular pain medicine after the procedure, with the exception of limiting pain medicine within the first four to six hours after the injection so that the diagnostic information obtained is accurate. Patients may be referred for physical therapy or manual therapy after the injection while the numbing medicine is effective and/or over the next several weeks while the cortisone is working.
On the day after the procedure, patients may return to their regular activities. When the pain is improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to increase activities gradually over one to two weeks to avoid recurrence of pain.
If the facet block procedure is effective in alleviating the patient's back pain, it is often considered reasonable for the procedure to be done up to three times per year. However, if the first facet joint injection does not relieve the patient’s pain then the injection should not be repeated.
Potential risks and complications
As with all invasive medical procedures, there are potential risks and complications associated with facet joint injections. However, in general the risk is low, and complications are rare. Potential risks and or complications that may occur from a facet joint injection include:
·         Allergic reaction. Usually an allergy to x-ray contrast or steroid; rarely to local anesthetic.
·         Bleeding. A rare complication, bleeding is more common for patients with underlying bleeding disorders.
·         Infection. Minor infections occur in less than 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
·         Worsening of pain symptoms
·         Discomfort at the point of the injection
·         Nerve or spinal cord damage or paralysis. While very rare, damage can occur from direct trauma from the needle, or secondarily from infection, bleeding resulting in compression, or injection into an artery causing blockage.
In addition to risks from the injection, some patients will experience side effects from the steroid medication, such as:
·         Transient flushing with a feeling of warmth (‘hot flashes’) for several days
·         Fluid retention, weight gain, or increased appetite
·         Elevated blood pressure
·         Mood swings, irritability, anxiety, insomnia
·         High blood sugar—diabetic patients should inform their primary care physicians about the injection prior to their appointment
·         Transient decrease in immunity
·         Cataracts—a rare result of excessive and/or prolonged steroid usage
·         Severe arthritis of the hips or shoulders (avascular necrosis)—a rare result of excessive and/or prolonged steroid usage
Patients who are on a blood thinning medication (such as Coumadin®), or have an active infection, may not be able to have this procedure, and these situations should be discussed with the treating physician. Patients should also let their doctor know of any allergies they have to medications that may be used for the procedure.
By: Ray Baker, MD
November 12, 2004
See related Health Hub:
 
 
FACET  JOINT  INJECTIONS
Facet joints link the bones of the spine together in the posterior or back part of the spine.  Two facet joints are present at each spinal segment.  They are named for the spinal bones that they connect.  For example, in the neck or cervical spine the facet joints between cervical #5 and cervical #6 are called C56.  Likewise, in the lower back the facet joints between lumbar #5 and the sacrum are called L5 S1.  Because there are two joints per level, there is a right and left joint.
What is the function of the facet joints?
The facet joints are important in restricting the motion of the cervical and lumbar spine. They allowed twisting, flexion and extension motions.
Why do facet joints cause pain?
Facet joints are possible sources of neck pain and lower back pain.  The facet joint is innervated by a small nerve that branches out from a spinal nerve.
Facet joints have been demonstrated to cause pain in studies in which healthy volunteers were subjected to injections of normal saline into the joint.

Trauma, arthritic changes can cause the release of pain generating substances which sensitize nerve endings located in the joint.
What are some of the signs and symptoms of facet joint pain?
For patients with facet joint pain from the lower back, complaints usually consist of pain or tenderness in the lower back slightly over to one or both sides, pain with lower back extension, pain with twisting, radiation of pain to the buttocks or back of the thighs.
For patients with facet joint pain from the neck, complaints are typically based on segment or  level involved.  Depending on the level involved, patients may have neck pain, headaches, shoulder pain, or scapular pain.
Does an x-ray or other test determined whether or not a facet joint is causing pain?
X-rays do not determine whether a facet joint is causing pain. However, x-rays may point out abnormalities such as osteoarthritis that may be significant in causing pain. A series of diagnostic blocks with local anesthetic are the only way to reliably determine whether in fact the facet joints are a source of pain.
What is a facet joint block?
A facet joint block involves the injection of a substance into or next to the facet joint. Typically, in a diagnostic block, local anesthetic is used.  In most cases a corticosteroid is also injected. Radiographic control is mandatory in accurately and safely placing the needle. The purpose of facet joint blocks is twofold.  Initially, it is a diagnostic block.  If the patient receives 50% or greater pain relief for at least 2 hours, there is an increased likelihood that the facet joint is important in the patients pain syndrome.  The block is then repeated to confirm the diagnosis. The second purpose of the facet block is to reduce pain.  Corticosteroids can help reduce the pain secondary to inflammatory substances that sensitize nerve endings.
Are facet joint blocks safe?
Yes.  The risks of facet joint blocks are very low with the use of x-ray control.  Patients may experience some small amount of injection site tenderness.  This will use the result in several days.  Risks such as headache, infection, or bleeding are extremely rare.
Do the injections hurt?
Patients undergoing facet joint injections all receive local anesthetic to anesthetize the skin and deeper tissues.  The patients may elect to receive intravenous sedation consisting of a sedative and/or a narcotic medication.
How long does it take for the injections to work?
Typically, the local anesthetic will work within 10 minutes and last up to two hours.  The corticosteroid usually takes longer for pain reduction.  It usually takes anywhere from 1 – 5 days for pain relief to occur if the pain is coming from the joint.
When can I resume normal activities following the block?
Most patients can resume normal activity the next day.  In some cases, patients may require an additional day.
What if I don’t get any relief from the facet joint injections?
If you don’t get relief from the facet joint injections, it is unlikely that this is a source of your pain.  You should then consider with your physician the other possible sources of your pain.  This may include other diagnostic blocks or imaging studies.
This procedure takes 15-30 minutes per level. You will be asked to lie in a prone position (face down) on a table in the fluoroscopy suite. Your back will be cleansed with an antiseptic (usually iodine) solution and the area will be numbed. The radiologist will use fluoroscopy (x-ray) to guide the placement of a thin needle to the area of a group of nerves that cause pain of facet syndrome. After correct needle placement is confirmed by x-rays, a small amount of local anesthetic and steroid will be injected.
Due to the effects of certain medications, your driving reflexes may be impaired. You will need someone to drive you home after the procedure. Please make the necessary arrangements.
PLEASE NOTIFY A TECHNOLOGIST IF THERE IS A CHANCE THAT YOU MAY BE PREGNANT !
FREQUENTLY ASKED QUESTIONS
Q. Why is a facet block performed?
A.
A facet block may be done if you have facet syndrome. Facet syndrome may manifest itself by focal tenderness over the facet joint, or by chronic back pain that may or may not radiate elsewhere. Often, patients with facet syndrome or facet arthritis may have normal radiographs (x-rays, CT scan, and MRI). Your doctor may need to diagnose facet syndrome by performing this block.
Q. Are there any special preparations / restrictions?
A.
Ideally, blood thinners should be stopped 48-72 hours prior to the procedure and any pain medications should be stopped 8 hours prior to the test. You should not have anything to eat or drink 6 hours prior to the procedure unless otherwise instructed by your physician. You will not be able to drive home after your procedure.
Q. How will I feel after the procedure?
A.
You may experience numbness and/or relief from your symptoms for up to 6 hours after the injection. Your usual symptoms may then return and may possibly be worse than usual for a day or two.
Q. When will the pain relief medication take effect?
A.
It may take 3-7 days before you will be able to feel any effects from the medication. If there is no change in your symptoms after 2 weeks, your doctor may want to investigate other possible sources of your pain.
Q. Are there any side effects?
A.
Possible side effects of the steroid medications include headaches, mild fluid retention, increased blood sugar levels, hiccups, flushing, palpitations, difficulty sleeping. These side effects occur in only about 5% of patients and commonly disappear within 1-3 days after the injection.
 
 
 
 
 Facet Joint Block
 International Spine Intervention Society - Patient Information
 
 
 
What is it?
A block that is performed to confirm that a facet join is the source of pain and decrease pain and inflammation in a facet joint or joints.
How is it done?
The patient is given a local skin anesthetic - a needle is then inserted into the facet joint or facet capsule and an anesthetic and steroid are injected by the physician. This is done under fluoroscopy.
Expected Results
Decrease in or relief of back pain.
How long does it take?
Thirty minutes.
Blocks are done in conjunction with physical therapy.

Glossary
Facet Joints-Joints located on the back of the spine on each side where one vertebrae slightly overlaps the adjacent vertebrae. They guide and restrict movement of the spine.
Fluoroscopy- X-ray imaging of a part of the body that is displayed on a screen or monitor in the block suite - this facilitates and assures proper placement of the needle and medication.
 
 
Article written 00/00/0000
Published online 00/00/0000
Last updated 08/03/2006
 
Judicious use of selective injections can provide both therapeutic and diagnostic benefits. Each shot is tailored to the specific anatomical area in question and should never be combined in the same sitting. Each shot should be performed to confirm or rule out a potential site of pain generation. In such an organized fashion a spine specialist may be able to clarify what was previously a diagnostic dilemma.
 
This information is not intended to replace the medical advice of your doctor or healthcare provider.
Always consult your doctor about specific medical conditions. Use of the SpineUniverse.com site is
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Spine Joint Injection
Sacroiliac Joint Injection
Click on the image to view animation

Sacroiliac (SI) joint blocks are injections that are primarily used for diagnosing and treating the low back pain associated with sacroiliac joint dysfunction. The SI joint lies next to the spine and connects the sacrum, the triangular bone at the base of the spine, with the pelvis.

With this treatment, a physician uses fluoroscopic guidance and inserts a needle into the sacroiliac joint to inject lidocaine (a numbing agent) and a steroid. Injecting the local anesthetic confirms the specific joint as the source of the pain, while the steroid fuels the pain relief.

An SI joint block may be repeated up to three times per year. For the treatment to be successful, the injection should be followed by physical therapy to provide mobilization and range of motion exercises.
Facet Joint Injections
Click on the image to view animation

Facet joints, located on either side of the vertebrae, give the spine its flexibility. Like other joints, the facet joints can be a source of pain when they become irritated or inflamed.
A facet joint injection serves as both a diagnostic tool and a type of treatment. Using a fluroscope as a guide, a doctor will place a needle in the center of the facet joint or in the nerves leading up to it. Then, a local anesthetic such as lidocaine or Novocain is injected through the needle. If your pain subsides, then the doctor knows that the facet joint is the root of the problem.
Because facet joint blocks only show how your symptoms react to the injection without giving any specific information about the nerves or discs, it is often used in conjunction with non-invasive tests first, such as an MRI or CT scan. If the facet joint block itself is unsuccessful in treating the pain, it will allow your doctor to clarify the diagnosis and outline an appropriate treatment plan.
Radiofrequency Neurotomy
Click on the image to view animation

A radiofrequency neurotomy uses low-level electrical stimulation to locate the nerve source of your chronic back pain and subsequently severs that nerve, effectively preventing it from transmitting pain signals from the facet joints to the brain.
Radiofrequency neurotomies are used to treat lower-back pain when the spinal facet joint has been diagnosed as the cause of lower back pain and a facet joint injection has proved to only temporarily effective.
Many patients who undergo a radiofrequency neurotomy experience increased pain immediately following procedure, but about half of all patients who undergo this procedure will experience lasting pain relief.
It is important to schedule a follow-up visit to determine the success of the procedure. If the procedure is successful, you should expect results within 2-5 days. The improvement will be gradual. It may take up to one month for the full benefit of the procedure to occur. If this is the case, our doctors may give you a prescription for supplemental pain medication before the total pain relief is fully realized.

 
 
Copyright © 2004 Spine Institute of New York. All Rights Reserved. The content of this website should be used as an informative tool for Spine Institute of New York patients. It should not be considered professional advice nor serve as a substitute for medical consultation. Spine Institute of New York and its web developers are not responsible for any injuries or other damage resulting from erroneous or incomplete statements contained in this site.
Spine Institute of New York is also not responsible for the content or information on other sites to which this one is linked.
 
 
 
Treatment for FJD
Facet Block Being Performed
The first—and most important—issue in treating FJD is to properly diagnose that it's really what's causing the pain. One of the best ways of accurately diagnosing FJD is to perform a Facet Joint "nerve block" using a temporary pain-relieving agent combined with an anti-inflammatory chemical (such as a steroid).
This helps both properly pinpoint the joints generating pain and it provides evidence that a slightly more involved blocking procedure (such as radio frequency denervation) can effect much longer-term relief. Most insurance plans require what is sometimes called this "investigatory" blocking procedure.
Doctor Robb will happily explain the overall procedure he wishes to perform during your office consultation, of course.
Figure 3
But we'll cover a few details here, too.
For an actual fluoroscopic image taken during a joint blocking procdure, see Figure 3, above.
Click here to continue reading about Facet Joint Disease...
 
 

 

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In This Article
 
 
 
 
Discussion
 

 

Indications for and Benefits of Lumbar Facet Joint Block
Discussion
In this study the group of patients that benefited from facet joint block contained mainly individuals with acute postoperative uncontrollable local and pseudoradicular pain. In these patients, because CT scanning excluded the possibilities of recurrent disc prolapse and insufficient decompression of the spinal canal after operation for spinal canal stenosis, only the operated level and side received selective injection. In 43 (66%) of 65 patients the facet joint block was successful in relieving pain directly and in maintaining this relief by follow up. Because most cases of acute back and leg pain improve within few weeks,[1,42] it is uncertain whether the facet joint block induced long-lasting diminution of the pain or whether was related to the natural history of the disease. In these cases, the facet joint block served as a therapeutic procedure. The cause of pseudoradicular pain after microdiscectomy and osseous decompression in spinal stenosis is most likely the result of reduction of the medial facet joint with opening and release of contents of the joint. The contents of the joint cause irritation of the adjacent nerve root and therefore pain.[26,36] Symptoms in these patients responded to facet joint injection.
In other patients, the indication was not clear-cut. All injections were chosen by exclusion. It is a fact that the facet joint is rarely alone responsible for low-back pain. Provided other causes are excluded, there is an indication to perform a diagnostic facet joint injection,[21,31,36] even in cases of radicular pain in the absence of nerve root compression. Typically, there is no relation in most of the cases between the extent of the scar tissue demonstrated on CT scans and the degree of pain experienced by the patient.[32] In some cases of persistent postoperative pain, especially back pain, extensive back muscle injury may be a cause.[18] This is especially the case following extensive and multisegmental laminectomy, as would be performed in multisegmental lumbar spinal canal stenosis. In these cases the lumbago predominates the symptomatology. These patients are not candidates for facet joint injections.
Despite the diversity of symptoms, it was possible in 121 patients (52.6%) to identify and treat by injection one level and side selectively. Unfortunately CT scans of the lumbar spine do not reveal early degenerative changes in the facet joint, and they were unable to demonstrate facet joint inflammation. Using sophisticated methods like single- photon emission CT scanning to identify the affected joint[6] is expensive, time consuming, and in our opinion unnecessary.
On the other hand, if the clinical picture and the radiological features do not help to indicate the one level or side to be treated, it is necessary to inject the two or three lower levels bilaterally. The effect of multisegmental injections is questionable. Additionally, it was an unpleasant experience for 22.6% of the patients in this series.
There was no need for the infiltration of the skin with a local anesthetic. One predictor of an optimum position of the cannula is the fact that we cannot inject more than 1 ml into the joint. A periarticular injection is also helpful in some of the cases in which facet joint syndrome is suspected; however, the effect is short with a mean duration of 1 week (in 14 patients [6%] in this series) in contrast to an exact intraarticular injection that may yield 1 to 3 months of relief or longer. Despite great care in inserting the spinal needle, the first author (A.B.) punctured the dura in two of the first 10 cases, which can be explained as a learning curve.
Postoperative pseudoradicular pain may be minimized by making an intraoperative intraarticular injection of corticosteroid into the opened joint. Similar results can be obtained if one also coagulates the joint, although there is no long-term difference in the response between percutaneous facet joint coagulation and facet joint injection with corticosteroids.[16,17]
All except two injections were performed using fluoroscopy. With this simple method it was possible to visualize the joint in 227 patients (99%) in the oblique position so that the spinal needle could be introduced. Only in three cases was an additional CT scan required to determine the exact localization of the cannula in the joint, because of obesity, scoliosis, and interbody cages, respectively. Performing the injection under fluoroscopy has many advantages including less exposure to radiation, the short duration of the procedure, and lower costs. A percutaneous blind injection of the facet joint is not recommended[34] and was practically not possible in this series, because the position of the cannula had to be corrected at least once in all the 715 joints injected.
In 28 patients the facet joint injections were performed as an additional attempt at pain therapy, because other alternatives were insufficient. In these patients, the response to the injection was questionable (Table 5).
In no case was a simultaneous facet joint and periradicular injection performed. The periradicular injection may perhaps be helpful in cases of suspected postoperative periradicular fibrosis and venous congestion in the lumbar root canal nerve root, which is thought to be one of the causes of low-back pain with radicular irritation.[4,13]
Because the facet joint behaves similarly to a myofacial trigger point, the effect of a local anesthetic usually lasts longer than its pharmacological effect. In this series, however, there were 28 patients (12.2%) who reported alleviation of the symptoms, which we could not correlate with the effect of the facet joint injection; the indication was unclear. All of them reported marked diminution of symptoms many days after the first injection (local anesthetic) perhaps due to placebo effect. Although the lumbar facet joint as a source of low-back pain becomes more confusing the more clinical studies that are reported,[5,9,10,14,17,19,25,33,36,38,39] the facet joint may be responsible for at least some degree of low-back pain with pseudoradicular and radicular radiation.[2,3,7,8,11,12,15,17,21,24,26-28,30,37,43] Experimentally, a marked reduction of the nerve activity occurs in facet tissue injected with local anesthetic and corticosteroid agents.[2] Therefore, percutaneous facet joint injection aims to denervate the facet joint, from which the pain seems to originate.


 

 
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 Thoracic Facet Joint Injection
Paul Dreyfuss, M.D.
Clinical Associate Professor
University of Texas Health Science Center
San Antonio, TX, USA
 
What are thoracic facet joints and why are facet joint injections helpful?
Thoracic facet joints are small joints about the size of the thumb nails located in pairs on the back of the spine. They provide stability and guide motion in the mid back. If the joints become painful they may cause pain in the mid back, ribs, chest or abdomen.
A facet joint injection serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. Additionally, the temporary relief of the numbing medicine may better allow a chiropractor or physical therapist to treat that joint. Also, time release cortisone (steroid) will help to reduce any inflammation that may exist within the joint(s).
What happens during the procedure?
An IV will be started so that relaxation medication can be given. The patient is placed on the X-ray table, face down so the physician can best visualize these joints in the mid back using x-ray guidance. The skin in the area of the mid back is scrubbed using 2 types of sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a very small needle, using x-ray guidance into the joint. A small amount of contrast (dye) is injected to insure proper needle position inside the joint space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected. One or several joints may be injected depending on location of the patients usual pain.
What will happen after the procedure?
Immediately after the procedure, the patient will move around and try to imitate something that would normally bring about their usual pain. Patients are then asked to report the percentage of pain relief and record the relief experienced during the next week on a post injection evaluation sheet ("pain diary"). This will be given to the patient when they are discharged home.
The chest and mid back may feel weak or numb for a few hours. This is fairly uncommon, but does occasionally happen. The patient may be referred to a chiropractor or physical therapist immediately after the injection(s) while the numbing medicine is still working for manipulation or massage.
General Pre/Post Instructions
Patients can eat a light meal within a few hours before the procedure. If a patient is an insulin dependent diabetic, they must not change their normal eating pattern prior to the procedure. Patients may take their routine medications. (i.e. high blood pressure and diabetic medications). Patients should not take pain medications or anti-inflammatory medications the day of their procedure. Patients have to be hurting prior to this procedure. They may not take medications that may give pain relief or lessen their usual pain. These medicines can be restarted after the procedure if they are needed.
 
 
Article written 02/20/2000
Published online 02/20/2000
Last updated 09/06/2005
 
 
 
Thoracic facet joints can precipitate mid-back pain with possible referred symptoms into the chest and/or abdomen. The only test that proves that the facet joint is the source of pain is a diagnostic facet joint block, as CT scan, X-Ray, and MRI are usually unremarkable. In contrast to a treatment or therapeutic block (injection) in which a steroid is used, a diagnostic injection only uses a local anesthetic. It is essential that the specific offending joint be identified so that a targeted therapeutic injection can be offered. While many patients will be successfully relieved of their symptoms, not everyone is cured. In those cases a procedure known as radiofrequency denervation should be considered.
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