Chapter 23: Facet Joint Interventions: Intra-Articular Injections, Medial Branch Blocks, and Radiofrequency Ablations

INTRODUCTION

• The prevalence of persistent low back pain secondary to involvement of lumbosacral facet joints has been described in controlled studies as varying from 15% to 45% based on types of populations and setting studies. Lumbar facet joint interventions are used to diagnose as well as treat facet joint–related pain.

• Prevalence of thoracic facet joint pain has been shown to be 34% to 48% in patients with chronic thoracic back pain.

• Prevalence of cervical facet joint pain has been shown to be 36% to 67% in patients with chronic neck pain.

INTRA-ARTICULAR FACET JOINT INJECTIONS AND MEDIAL BRANCH BLOCKS

Indications

Common indications for diagnostic facet joint interventions include the following:

• Lumbar spine

  • Traumatic or arthritic nonradicular low back pain.

  • Patients can experience pain radiating in to the buttock but rarely radiating beyond the level of the knee.

  • Pain on palpation is worse with extension of the lumbar spine and rotation or twisting of spine.

• Thoracic spine

  • Traumatic or arthritic nonradicular upper back or posterior chest wall pain.

  • Typically the patient experiences pain on palpation and extension and rotation or twisting of thoracic spine.

• Cervical spine

  • Traumatic or arthritic neck pain, suboccipital headache, persistent and disabling axial neck and/or upper thoracic pain or suspected cervicogenic headache

  • Typically pain and/or headache with neck movements in flexion, extension, and rotations

• Duration of pain of at least 3 months

• Average pain level of >5 on a scale of 0 to 10

• Intermittent or continuous pain causing functional disability

• Failure to respond to more conservative management including physical therapy modalities with exercises and nonsteroidal anti-inflammatory agents

• Lack of evidence either for discogenic or sacroiliac joint pain

• Lack of disk herniation or evidence of radiculitis

CONTRAINDICATIONS

Common contraindications for facet joint interventions include the following:

• Suspected or proven discogenic, sacroiliac joint or myofascial pain in case of lumbar facet interventions

• Allergies to drugs being considered for the procedure

• Inability of patient to understand consent, nature of the procedure, needle placement, or sedation

• Localized or generalized infection

• Anticoagulation therapy

• Nonaspirin combination antiplatelet therapy

• Pregnancy

• Bleeding diathesis

• Needle phobia

• Psychogenic pain

RELEVANT ANATOMY

Lumbar Spine

• Facet joints (Figure 23-1)

  • Lumbar facet joints are formed by the articulation of the inferior articular process of the superior lumbar vertebra with the superior articular process of the inferior vertebra.

  • The lumbar joints exhibit features of typical synovial joints.

  • The articular facets are covered by articular cartilage, and the synovial membrane bridges the margins of the articular cartilage of the two facets in each joint.

  • Surrounding the synovial membrane is a joint capsule that attaches to the articular process, a short distance beyond the margins of the articular cartilage.

• Ligaments

  • Ligaments connect spinous process, lamina, and bodies of the adjacent vertebrae.

  • Anterior ...