Cervical, Thoracic, and Lumbar Facet Joint Injections

Facet joint injections aim to reduce spinal facet joint pain through targeted delivery of anesthetic and/or steroid medication directly into the joint.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,2Said N, Amrhein TJ, Joshi AB, N NCN, Kranz PG. Facets of facet joint interventions. Skeletal Radiology. Published online October 17, 2022. doi: 10.1007/s00256-022-04184-5 They provide a minimally invasive option to manage facet joint pain compared to spinal surgery.

Facet joint injections are performed in an outpatient setting, such as an office-based surgical suite or outpatient surgical center, and in most cases, patients are able to return to their normal activities the next day. 

Pain Originating from a Facet Joint

Facet joints are a pair of small joints that connect each segment of the spine at the back. They provide stability and help guide motion within the segment. Spinal arthritis, trauma, and increased mechanical stress are the most common causes of facet joint pain (also referred to as facet joint disorder).¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

Research indicates that about 70% of neck pain and 50% of back pain involves the facet joints.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

• Cervical facets cause pain in the head, neck, shoulders, and arms, as well as headaches
• Thoracic facets affect the upper and mid back and chest
• Lumbar facets cause pain in the low back area, hips, buttocks, and legs

Facet joint pain may be localized or radiate to adjacent areas as described above.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

Goals of Facet Joint Injections

Facet joint injections serve diagnostic and therapeutic purposes, and are used to confirm the involvement of facet joints as the source of pain and provide targeted pain relief.³Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1

• Diagnostic. A diagnostic facet joint injection (also referred to as a facet block) is used to pinpoint spinal facets as a pain generator. In this injection, an anesthetic is injected into the facet joint to block nerve pain signals, and a positive response (at least 80% improvement in pain) typically confirms that the joint is the source of spinal pain.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,3Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1 
• Therapeutic. A therapeutic facet joint injection treats spinal pain originating from the facets. In this injection, a combination of anesthetic and corticosteroid medications is injected into the joint to provide extended pain relief. The anesthetic temporarily blocks pain signaling until the corticosteroid takes effect and reduces inflammation.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,3Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1

The pain relief from a facet joint injection is intended to help a patient better tolerate activities and a physical therapy routine to rehabilitate his or her injury or back condition.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/

When Facet Joint Injections are Recommended

Candidates for facet joint injections include patients who have experienced moderate to severe facet pain lasting 3 months or longer and who have not responded to non-surgical treatments, such as pain-relieving medication and physical therapy.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,3Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1

Common conditions treated by facet joint injections

Facet joint pain is associated with several arthritis and spinal conditions, including¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,4Curtis L, Shah N, Padalia D. Facet Joint Disease. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541049/^,5Zhou KL, Dong S, Ji W, et al. Effects of massage therapy for patients with thoracic facet joint disorders: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020;99(49):e23480. doi:10.1097/MD.0000000000023480:

• Facet joint osteoarthritis
• Spinal osteoarthritis
• Degenerative spondylolisthesis
• Rheumatoid arthritis
• Ankylosing spondylitis
• Scoliosis

Facet joint pain arises from inflammation, swelling, and/or the erosion of cartilage in the joints in these conditions.⁴Curtis L, Shah N, Padalia D. Facet Joint Disease. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541049/

When Facet Joint Injections May Not be Recommended

These injections should also be avoided in the following circumstances due to the significantly increased risk of complications¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,2Said N, Amrhein TJ, Joshi AB, N NCN, Kranz PG. Facets of facet joint interventions. Skeletal Radiology. Published online October 17, 2022. doi: 10.1007/s00256-022-04184-5:

• Active infection (systemic or local)
• Bleeding disorders
• Allergies to medications used or imaging contrast
• Progressive neurological conditions 
• Pregnancy 

Additionally, facet joint injections are not utilized in the treatment of non-facet pathologies, such as fractures, tumors, or infections.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,3Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1

Types of Facet Joint Injections

Facet joint injections involve precisely placing a thin needle into a facet joint with imaging guidance techniques, such as fluoroscopy (live x-ray) or ultrasound.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,2Said N, Amrhein TJ, Joshi AB, N NCN, Kranz PG. Facets of facet joint interventions. Skeletal Radiology. Published online October 17, 2022. doi: 10.1007/s00256-022-04184-5

Medications Used in Facet Joint Injections

The anesthetics commonly used in facet injections include¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/:

• Bupivacaine
• Lidocaine
• Ropivacaine

Using these medications in any intra-articular injections (such as facet, hip, and knee) is considered off-label as they potentially cause damage to the cartilage in joints. However, this effect has only been seen with infusions of the medications over several hours, and it has yet to be demonstrated in facet joint injections.⁶Bupivacaine HCl. Package insert. Xellia Pharmaceuticals USA LLC; 2023.^,7Lidocaine hydrochloride injection. Package Insert. B. Braun Medical Inc; 2022.

The commonly used corticosteroids for facet injections are¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^: 

• Triamcinolone
• Dexamethasone
• Methylprednisolone
• Betamethasone

Dexamethasone is preferred in thoracic and cervical injections due to the lower risk of drug particles causing blockages in blood vessels (embolism). These medications are FDA-approved in the US for intra-articular injection.⁸Triamcinolone acetonide injection, suspension. Package Insert. Amneal Pharmaceuticals LLC; 2023.^,9Dexamethasone sodium phosphate injection, solution. Package Insert. Fresenius Kabi USA, LLC; 2018

Additional types of therapeutic facet joint injections

Alternative compounds used in facet injections to improve joint mobility and reduce pain include¹⁰Du R, Xu G, Bai X, Li Z. Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment. J Pain Res. 2022;15:3689-3710. Published 2022 Nov 30. doi:10.2147/JPR.S389602:

• Hyaluronic acid injection. Hyaluronic acid is injected into the facet joint’s outer capsule to lubricate the articular surfaces and relieve pain by reducing friction.
• Platelet-rich plasma injection. A concentrated form of the patient's own blood, which is rich in healing platelets, is injected into the facet joints to reduce inflammation and promote the natural healing of damaged tissues. Early studies support the effectiveness of platelet-rich plasma for treating facet joint pain, but more research is needed to establish the long-term efficacy of this treatment.

Additionally, researchers are investigating the effectiveness of biological substances, such as bone marrow stem cells, and plant-derived compounds, such as sarapin, for facet joint injections.¹¹Kwak DG, Kwak SG, Lee AY, Chang MC. Outcome of intra-articular lumbar facet joint corticosteroid injection according to the severity of facet joint arthritis. Exp Ther Med. 2019;18(5):4132-4136. doi:10.3892/etm.2019.8031

Accuracy of Diagnostic Facet Joint Injections

The usefulness of a facet joint block in correctly diagnosing facet-mediated pain varies based on injection technique, spinal region, underlying pain conditions, and additional patient-specific factors.³Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1^,12Perolat R, Kastler A, Nicot B, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018;9(5):773–789. doi:10.1007/s13244-018-0638-x

Medial branch nerve blocks are the preferred over diagnostic facet joint injections because they are more accurate. However, there is still a high potential for false-positive responses, meaning a patient experiences pain relief due to an incorrect injection into a nearby symptomatic nerve root or spinal disc instead of the facet joint.³Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1^,11Kwak DG, Kwak SG, Lee AY, Chang MC. Outcome of intra-articular lumbar facet joint corticosteroid injection according to the severity of facet joint arthritis. Exp Ther Med. 2019;18(5):4132-4136. doi:10.3892/etm.2019.8031

Performing a second block 2-3 weeks later at the same level is strongly recommended to confirm that the targeted facet joint is the source of pain.¹Le DT, Alem N. Facet Joint Injection. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572125/^,3Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1

Success Rates of Therapeutic Facet Joint Injections

Facet joint injections relieve pain and improve mobility in approximately 50% to 75% of patients. However, the extent and duration of relief varies widely between patients depending on the type of injection and individual factors (eg, disease severity or accuracy of diagnosis).³Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1^,11Kwak DG, Kwak SG, Lee AY, Chang MC. Outcome of intra-articular lumbar facet joint corticosteroid injection according to the severity of facet joint arthritis. Exp Ther Med. 2019;18(5):4132-4136. doi:10.3892/etm.2019.8031 

Intra-articular injections typically provide short-term relief for around 2-4 months.³Manchikanti L. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2020;3S;23(5;3S):S1-S127. doi: 10.36076/ppj.2020/23/s1^, 11Kwak DG, Kwak SG, Lee AY, Chang MC. Outcome of intra-articular lumbar facet joint corticosteroid injection according to the severity of facet joint arthritis. Exp Ther Med. 2019;18(5):4132-4136. doi:10.3892/etm.2019.8031