Facet Joint Injection Potential Risks and Complications

Facet joint injections are simple and safe procedures that are well-tolerated by most patients.¹Vekaria R, Bhatt R, Ellard DR, Henschke N, Underwood M, Sandhu H. Intra-articular facet joint injections for low back pain: a systematic review. European Spine Journal. 2016;25(4):1266-1281. doi: 10.1007/s00586-016-4455-y

As with any injection procedure, there are potential risks associated with the procedure, but the side effects typically involve minor and transient discomfort, and serious complications are rare.²Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures. Eur Radiol. 2020;30(3):1507-1516. doi:10.1007/s00330-019-06483-3

Potential Side Effects of Facet Joint Injections

Localized effects at the site of injection are common in facet joint injections, including³Le 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/^,4Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul). 2020;15(1):8-18. doi:10.17085/apm.2020.15.1.8:

• Pain and tenderness
• Swelling
• Numbness
• Minor bleeding and bruising
• Worsening back or neck pain

In most cases, these effects resolve within approximately 48 hours.³Le 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/

Managing the side effects of facet joint injections

It is possible for patients to experience an increase in pain or discomfort for a few days following the procedure as the anesthetic wears off and the corticosteroid’s anti-inflammatory action begins to take effect.³Le 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/

Additionally, some patients experience an increase in pain at the injection site due in response to the formulation of corticosteroids used in the injection that causes irritation at the joint. This phenomenon is known as a “steroid flare” and usually resolves within a few days.⁵Alsop RJ, Khondker A, Hub JS, Rheinstädter MC. The Lipid Bilayer Provides a Site for Cortisone Crystallization at High Cortisone Concentrations. Sci Rep. 2016;6:22425. Published 2016 Mar 3. doi:10.1038/srep22425

Recommendations for managing pain during this interval include:

• Careful application of ice or a cold pack to the general area of the injection
• Use of prescription pain medication or over-the-counter treatments

Pain medication is sometimes limited for a few hours immediately after the procedure to allow accurate diagnostic or therapeutic results assessment. 

Potential Risks and Complications of Facet Joint Injections

Serious adverse events from facet joint injections are rare, but there are risks related to injection technique and the medications administered, including²Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures. Eur Radiol. 2020;30(3):1507-1516. doi:10.1007/s00330-019-06483-3^,3Le 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/:

• Infection
• Allergic reaction to drugs or contrast dye
• Nerve damage 
• Spinal cord injury or paralysis
• Excessive bleeding and bruising
• Vasovagal reaction (eg, dizziness, nausea, and flushing)

These events are possible with injections in all spinal regions, but cervical procedures are associated with additional complications, including vertebral artery damage and phrenic nerve palsy.³Le 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/

Potential risks of corticosteroids used in facet joint injections

Serious adverse reactions to corticosteroids (eg, triamcinolone and dexamethasone) are possible due to the slow systemic absorption of the drugs from the intra-articular space, including⁶Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PMR. 2019;11(4):409-419. doi:10.1002/pmrj.12042:

• Increased blood pressure (hypertension)
• High blood sugar (hyperglycemia)
• Immunosuppression 
• Decreased bone mineral density
• Osteonecrosis 
• Cataracts (with long-term use)
• Reproductive hormone imbalance
• Psychiatric changes (eg, mood swings, irritability, and insomnia)
• Metabolic changes (eg, increased appetite, weight gain, and fluid retention)

The risk of these adverse effects is increased with higher doses of corticosteroids and multiple injections, and it is recommended to monitor patients with underlying risk factors (eg, diabetes, heart failure, and psychiatric conditions) closely.²Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures. Eur Radiol. 2020;30(3):1507-1516. doi:10.1007/s00330-019-06483-3^,6Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PMR. 2019;11(4):409-419. doi:10.1002/pmrj.12042 

Long-term risks of facet joint injections

In some cases, nerve injury, prolonged use of corticosteroids, and unmanaged infections cause structural changes and lasting effects, but the incidence is rare.²Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures. Eur Radiol. 2020;30(3):1507-1516. doi:10.1007/s00330-019-06483-3

It is advisable to discuss the risks, benefits, and alternative treatments with your doctor before having a facet joint injection.

See Treatment Options for Facet Joint Disorders