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.



  • Facet joint injection (FJI)


  • Facet joint injection = facet joint block

  • Facet = zygapophyseal joint


  • Injection of corticosteroid ± anesthetic into lumbar facet joint



  • Facet joint osteoarthritis

  • Synovial cyst causing neurologic symptoms


  • 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


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


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



  • 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


  • Most feared complication(s)

    • Thecal sac puncture

      • Cord injury

      • Meningitis

      • Cerebrospinal fluid leak

  • Other complications

    • Bleeding

    • Infection

    • Nerve injury


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

Sep 22, 2016 | Posted by in EMERGENCY RADIOLOGY | Comments Off on Facet Joint Injection
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