Facet Joint Injection



Facet Joint Injection


Donald V. La Barge, III, MD










Axial NECT shows the needle tip image at the superolateral margin of the right L4/5 facet joint. Note that the needle is nearly within the plane of image and that the needle tip casts a dark artifact image.






Axial NECT shows the needle tip image well seated within the right L4/5 facet joint. Imaging above and below to determine precise needle tip position is important with CT-guided interventions.


TERMINOLOGY


Abbreviations



  • Facet joint injection (FJI)


Synonyms



  • Facet joint injection = facet joint block


  • Facet = zygapophyseal joint


Definitions



  • Injection of corticosteroid ± anesthetic into lumbar facet joint


PRE-PROCEDURE


Indications



  • Facet joint osteoarthritis


  • Synovial cyst causing neurologic symptoms


Contraindications



  • Local or systemic infection


  • Coagulopathy


  • Allergy to injectate


Getting Started



  • Things to check



    • Imaging of facet joint for pathology and anatomic relationships


    • Informed consent


    • Laboratory: Coagulation parameters


  • Medications



    • Corticosteroid


    • Long-acting anesthetic (e.g., bupivacaine)


    • Short-acting anesthetic (e.g., lidocaine)


    • Myelography-safe iodinated contrast


  • Equipment list



    • Radiopaque marker


    • Sterile prep and drape materials


    • 18-gauge drawing needles


    • 5 mL syringe for local anesthetic with 1.5 inch 25-gauge needle


    • 5-10 mL syringe for contrast with extension tubing


    • 3 mL syringe for injectate


    • 22-gauge spinal needle


    • Hydrogen peroxide


    • Sterile bandage


PROCEDURE


Patient Position/Location



  • Best procedure approach



    • Prone



      • Angle C-arm or PA fluoroscopy tube slightly toward side of joint to be injected


      • May need slight cranial angulation as well to optimize joint visualization


      • Generally, lower 1/3 of joint is most amenable to needle entry/injection in arthritic joint



        • Inferior recess may be only accessible site for injection in severely arthritic joint


Equipment Preparation



  • Draw ˜ 5 mL local anesthetic


  • Draw 5-10 mL myelography-safe iodinated contrast



    • Attach extension tubing and preload with contrast to remove air


  • Draw injectate



    • e.g., 80 mg methylprednisolone/0.5% bupivacaine, total volume 2 mL


Procedure Steps



  • Ensure correct spine level for injection


  • Angle equipment to maximize visualization of facet joint


  • Target lower 1/3 of joint space



    • Often, arthritic joints will have redundancy inferiorly, creating a more accessible joint space


  • Mark skin


  • Perform sterile prep and drape


  • Apply local anesthetic



    • Confirming trajectory of anesthetic needle may aid placement of spinal needle


  • Place spinal needle into subcutaneous tissue, and confirm trajectory with imaging


  • Advance until bone is reached or feel needle advance into joint space



  • If reach bone, “walk” needle into joint


  • Attach preloaded contrast tubing and syringe


  • Slowly inject only enough contrast to confirm needle tip in joint space



    • Document needle placement with imaging


  • Remix and attach injectate syringe


  • Slowly inject



    • May require high pressure injection via 1-3 mL syringe


  • Note patient’s symptoms during and immediately following injection


  • Remove needle, and attain hemostasis


  • Cleanse skin with hydrogen peroxide


  • Dry skin, and apply bandage


  • Synovial cyst therapeutic rupture



    • Same steps as FJI


    • Alternate approach is interlaminar puncture of cyst



      • CT guidance suggested for translaminar approach


    • Patient will often feel “pop” with cyst rupture



      • May require significant injection pressure


      • Can be quite painful for patient


    • Interventionalist will see sudden spread of contrast into epidural space with cyst rupture


Findings and Reporting



  • Document level of injection


  • Pain scale and pain characteristics



    • Before procedure


    • During injection


    • After procedure


  • Other symptoms/complications


Alternative Procedures/Therapies



  • Radiologic



    • Medial branch block


    • Epidural steroid injection


    • Percutaneous facet joint fusion


  • Surgical



    • Fusion


  • Other



    • Rhizotomy


    • Radiofrequency ablation


POST-PROCEDURE


Expected Outcome



  • Improved pain symptoms


Things to Do



  • Help patient from procedure table


  • Establish follow-up


  • Remind patient to keep pain diary until next clinic appointment


Things to Avoid



  • Strenuous activity for remainder of day


  • Bathing for 48 hours


OUTCOMES


Problems



  • Failure to alleviate pain



    • Technical failure



      • Wrong level injected


      • Injection extraarticular


    • Clinical failure



      • Facet joint not source of pain



        • May require multilevel injections


      • Multifactorial pain


Complications



  • Most feared complication(s)



    • Thecal sac puncture



      • Cord injury


      • Meningitis


      • Cerebrospinal fluid leak


  • Other complications



    • Bleeding


    • Infection


    • Nerve injury



SELECTED REFERENCES

1. Datta S et al: Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician. 12(2):437-60, 2009

2. Martha JF et al: Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients. Spine J. 9(11):899-904, 2009






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