Image Guided Facet Joint Corticosteroid Injection

Authors: Prof Mark Khangure*
                            Dr Jason Wenderoth *

What are the generally accepted indications for an image guided facet joint corticosteroid injection?

Image guided facet joint corticosteroid injections can be used for diagnostic or therapeutic purposes.

Diagnostic indications:

• Pain with features of facet joint syndrome and thought to be of facet joint origin.
• Contemplation of radiofrequency neurotomy.

Therapeutic indications:

• Known facet joint syndrome with chronic pain localised to the joint. Usually after failure of conservative measures.
• Previous pain syndrome relieved by facet joint injection.

What are the prerequisites for having an image guided facet joint corticosteroid injection done?

• History and clinical examination suggesting facet joint origin of back or neck pain, with pain persisting beyond 3 months.

History:

• low back pain;
• deep, aching quality;
• localised unilateral or bilateral;
• referral to flank, buttock, upper thigh, iliac crests, groin;
• ensure there are no red flags such as: fever, chills, sweats, weight loss that would suggest neoplastic of infective causes of the symptoms;
• previous injections: Where? Response?

Examination:

• point tenderness;
• exacerbation with extension and rotational manoeuvres.
• Recent quality imaging CT or magnetic resonance imaging showing facet joint pathology of the relevant area and excluding other serious pathology.
• Information about anticoagulants and bleeding diathesis. It may be necessary to stop or adjust the dosage. The reason for anticoagulants may determine what can be stopped.
• Knowledge of patient allergies and history of diabetes.

What are the absolute contraindications for an image guided facet joint corticosteroid injection?

• Spinal infection.
• Severe bleeding diathesis for whatever cause, including anticoagulants.

What are the relative contraindications for an image guided facet joint corticosteroid injection?

• Skin infection.
• Coagulopathy.
• Pregnancy.

Where it is not possible to withhold anticogulant agents, the added risk of significant bleeding, including intraspinal/epidural haemorrhage, should be discussed with the patient in order to allow for fully informed consent.

What are the adverse effects of an image guided facet joint corticosteroid injection?

This is a very safe procedure and lower risk than both image guided epidural corticosteroid steroid injection and image guided nerve root corticosteroid injection.

Allergy to the local anaesthetic may produce itching and hives or, rarely, a more severe allergic reaction, as with an allergy to any medication.

Reaction to the corticosteroid is common, and produces redness and flushing of the face and body, usually starting a few hours or the day after the procedure and lasting a few days, the so called ‘cortisone flare’.

Allergy to corticosteroid ranging from a mild rash to anaphylaxis is very rare, occurring in fewer than 1 in 250,000 patients.

A numb arm(s) or leg(s) may result if the anaesthetic mixed with the steroid leaks into the adjacent epidural space. This lasts an hour or so in most people and is also uncommon.

Bleeding into the joint and joint infection are the more serious complications. These complications are extremely rare, as the procedures are always carried out under sterile conditions. If any of the following symptoms are experienced within the first 2 weeks after the patient’s injection, they should seek urgent medical advice:

• Fevers or night sweats.
• Worsening pain beyond 5–7 days after the procedure.
• Persistent or new weakness or numbness in arm(s) and/or (if injection was in the neck).
• Persistent or new weakness or numbness in leg(s) (if the injection was in the lower back).
• Loss of control of bladder or bowel function.

Bleeding into the joint is very uncommon, and usually requires no active treatment and can be managed with pain medication and follow up with the patient’s local doctor. Joint infection is also extremely rare, but is potentially very serious. It usually requires treatment with antibiotics. In very severe cases, an operation may be required to remove the infected tissue, as well as a stay in hospital for intravenous antibiotics.

Is there any specific post-procedural care required following an image guided facet joint corticosteroid injection?

• Avoidance of strenuous activity for a couple of days.
• Driving should be avoided on the day of the procedure (it is advisable to have someone drive the patient to and from the practice).
• Patients are advised to continue any regular pain relief medications they are taking, particularly for the first 24 hours post-procedure, because the injection may in fact exacerbate symptoms during this period. After that, they are advised to wean off any medications they are on, tapering to zero on day 4–5 post-injection to assess the effect of the injection. If they are not on any medication at the time of the procedure, they are advised them to take 1g paracetamol every 6 hours for 24 hours post-procedure, then as needed according to the directions on the packaging thereafter.
• In general, anticoagulant drugs may be started the day following the procedure, but it is advised to check this with the radiologist on the day of the procedure.

Are there alternative imaging tests, interventions or surgical procedures to an image guided facet joint corticosteroid injection?

Radiofrequency ablation of the medial branch, usually after failure of facet joint blocks to provide long-term relief.

Further information about image guided facet joint corticosteroid injection

Utility of bone scan in assessing for symptomatic facet joints – there is some inconclusive evidence that symptomatic facet joints may show increased tracer activity on bone scan; however, the reliability of this data is questionable, and the sensitivity and specificity have not been determined.

*The author has no conflict of interest with this topic.

Page last modified on 31/7/2017.