Facet Joint Syndromes
Facet Joint Ablation/Rhizotomy/Block
Facet Joint Syndromes
Why did I have a Facet Joint Nerve Block?
Facet joints (or Zygopophyseal joints) link the bones of the spine together in the back of the spine. Two facet joints are present at each spinal segment. They are named for the spinal bones that they connect. There are two joints per level, a right and left joint.
The facet joints restrict the motion of the spine so that the spinal cord is not damaged, but yet still allows twisting, flexion and extension motions.
Why do facet joints cause pain?
Facet joints are possible sources of back pain when injured or when they develop arthritis. These changes cause the release of pain generating substances which sensitize nerve endings located in the joint. Despite their damage and pain generation they are usually still quite functional as joints. It is the pain itself which limits the function of the spine. The facet joint is innervated by a small nerve that branches out from a spinal nerve called the medial branch of the dorsal primary ramus.
What are some of the signs and symptoms of facet joint pain?
Facet joint pain from the lower back usually consists of pain or tenderness in the lower back slightly over to one or both sides, pain with lower back extension, pain with twisting, and commonly, radiation of pain to the buttocks or back of the thighs.
Facet joint pain is often described as low back pain with standing, walking or both. Occasionally it radiates to the buttocks or outer thighs.
Facet joint pain from the neck results in neck pain, headaches, shoulder pain, or scapular pain.
Can an MRI, Cat-Scan or x-ray determine whether or not a facet joint is causing pain?
No. While imaging may show damage such as arthritis in the spine, all damage does not hurt. And conversely, pain does not show up on an MRI or an X-ray. These imaging tests may lead us towards suspecting the joint may cause pain, but there are many other potential pain generators in the spine. The only reliable test for diagnosing facet joint pain is with a series of controlled and thus diagnostic facet joint nerve blocks.
What is a facet joint block?
A facet joint block is a diagnostic test, and NOT a therapeutic procedure. You may have pain relief, but it will not last. The physiatrist (spine and pain rehabilitation doctor) will use fluoroscopy (real time video x-ray) to guide a thin needle to the individual facet nerves where a small amount of local anesthetic (usually half a milliliter) is placed on the nerve which sends pain from the joint. Real-time radiographic imaging is mandatory in accurately and safely placing the needle.
Why do we do two?
Initially only one block was performed. However, with only one block, it was found that a significant percentage of people who then went on to have treatment still had pain afterwards—indicating that the diagnosis of facet joint pain was incorrect. We had missed the correct diagnosis- and it was felt that a placebo effect could explain the discrepancy. A more rigorous method followed: this time with two blocks, and a pain diary to be kept by the patient. Since different local anesthetics have different durations of effect, the journal documents if the length of pain relief correlates to the length of the anesthetic action. Only the physician knows which anesthetic is used. If the diary matches the anesthetic for two trials, we find we havediagnostic accuracy greater than 90 percent.
Might it hurt MORE after the injection?
POSSIBLY, AFTER THE BLOCK, IT IS IMPORTANT TO RECOGNIZE THAT THERE MAY BE SLIGHTLY INCREASED PAIN DUE TO THE USE OF THE SMALL NEEDLE. IT IS VERY IMPORTANT TO TRY AND SEPARATE THIS NEW, PROCEDURAL PAIN FROM THE OLD PAIN WE ARE TRYING TO TREAT. YOU MAY HAVE TEMPORARY NEW PAIN, BUT CONCERN YOURSELF WITH WHETHER OR NOT THE OLD PAIN IS GONE.
Are facet joint blocks safe?
Yes. When performed by experienced physicians the risk is very, very small. As noted above, patients may experience some small amount of injection site tenderness. This will go away after a day or so. Risks such as headache, infection, or bleeding are extremely rare when done expertly AND with fluoroscopic video x-ray guidance.
Do the injections hurt?
Formally trained spine and pain physicians take great care in doing procedures with the least pain possible, and so with agile hands the pain is minimal. A minority of patients, however, may have some momentary discomfort. 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 an hour to several hours, depending on the anesthetic used.
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 the joint is the 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.
How long does it take? What’s involved?
The injection itself takes a few seconds to a minute for all levels blocked.
You will be asked to lie face down on a table in the fluoroscopy suite. Your back will be cleansed with an antiseptic (either iodine or Hibaclense) solution and the area will be numbed, and the injection performed.
If you have sedation your driving reflexes may be impaired. You will need someone to drive you home after the procedure. Please make the necessary arrangements.
What’s the purpose of all these blocks?
If we can establish that the facet joint is the source of pain for you, then we can de-activate the nerve and stop the pain signal coming from the joint. This treatment is called a facet joint nerve ablation.
What’s involved with the ablation?
The ablation, from the patient’s perspective is very similar to the diagnostic block. All the same protocols are used, however after the numbing the nerve, the tip of the needle is heated up and the nerve is inactivated. This takes a little longer to do, the procedure taking a little longer than half an hour. We define a “good result” as having at least 50% pain relief. Most patients get better than 50%. Many get 100% relief, but everyone is different. It is rare to encounter one disease in the spine without the co-existence of any others. Pain from the other problems may continue to plague you. We aim, hope for, and commonly have excellent results.
Great, now that I have pain relief, how long will it last?
The nerve has not been permanently killed and so it has a chance of growing back and “re-innervating” the joint. It may take 6-18 months or commonly longer, and it may never happen. We just don’t know. If is does happen the treatment is another ablation. We find with subsequent ablations the nerve may have less chance of growing back.
Don’t I need this nerve? Shouldn’t I be feeling the pain to know that I should stop doing something that is hurting me?
Pain serves a very useful function for most people. It tells us when we are damaging our body, and it encourages us to stop doing the damage. In situations of chronic pain, however, there is no purpose to pain. It only causes the body harm. It delays or diminished healing, causes depression, loss of sleep, diminishes function and can shorten one’s life. When someone suffers from chronic pain, stopping the pain will benefit in many ways. You may be able to resume activities you were unable to do before. Your mood may change. You may be able to rest better. Life may take on new and renewed purpose. It is a privilege to treat you. Thank you.
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