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Facet joint injections are commonly performed to diagnose and manage facet joint pain (also referred to as lumbar spondylosis or zygapophyseal joint pain). Pain from facet joint etiology can be challenging to diagnose due to a lack of specific physical exam findings and imaging criteria. This activity will review the anatomy, indications, technique, and complications associated with facet joint injections and highlight the role of the interprofessional team in managing facet joint pain. Objectives: Review the relevant anatomy and physiology associated with facet joint injection. Identify which patients would benefit from a facet joint injection. Describe the technique of performing a facet joint injection. Summarize complications associated with facet joint injection. Access free multiple choice questions on this topic.

Facet joint injections are one of the most commonly performed procedures amongst all spinal interventions.[1] Facet joint pain can arise from osteoarthritis, segmental instability, trauma, meniscoid impingement, and inflammatory synovitis.[2][3] Patients with facet joint pain may present with symptoms of neck pain, back pain, and pain worsened with hyperextension, bending laterally, and rotation. Facet mediated pain is typically axial in nature, with rare radiation into the upper extremities or lower extremities in cervical and lumbar facet disease, respectively. Therefore, a key diagnostic question to ask patients with suspected facet pain is, “Does your pain extend below the knee or beyond the elbow?” with positive responses decreasing the likelihood of facet disease as the putative source of pain. However, none of the above are specific for the diagnosis of facet disease. In addition, imaging in those with facet joint pain may be completely normal or show degenerative findings. Ultimately, facet joint pain is a diagnosis of exclusion after other etiologies have been ruled out. Thus, performing facet joint injections under image guidance has become a valuable tool in diagnosing facet joint pain and may provide therapeutic benefits.[4]

Overall, facet joint interventions are considered to be moderate to low risk procedures.[11] Complications from image-guided facet joint injections are rare. These include septic arthritis, hematoma, excessive bleeding, nerve root irritation, vasovagal reactions, facet capsule rupture, psoas abscess, dural puncture, vertebral artery damage (reported in cervical injections), intrathecal injection, epidural abscess, meningitis, pneumothorax, and phrenic nerve palsy (reported in cervical injections).[5][12][13][14][2] Due to the specific complications associated with cervical facet joint injections, it is less commonly performed at this level. In a study evaluating adverse events related to facet joint injections, major complications were rare and typically related to infections in patients over the age of 60 years old with underlying risk factors.[1] Issues such as swelling and pain at the needle insertion site typically resolve spontaneously and only last a short period. Local anesthetics rarely cause severe reactions, and steroid injections may cause local reactions that resolve within 48 hours.[2]

Facet joint injections are commonly used to diagnose facet joint pain and may provide therapeutic effects. An interprofessional healthcare team approach is critical to ensure patient safety and the proper execution of the procedure. Prior to entering the interventional suite, there should be a review of the patient’s medical history, allergies, labs, and consent. The team will typically involve the physician performing the procedure, nurse, pharmacist, and imaging technician. Communication is important as each individual plays an essential role in the procedure. The nurse will assist with bringing in equipment, administering medications, and placing monitors on the patient for vital signs. The imaging technician should position the fluoroscopy or CT in an appropriate location before the procedure and be aware of which levels are to be imaged. Communication to a pharmacist should be employed if there are any questions or concerns about the medications. Positioning of the patient is the responsibility of the entire team but is typically performed by the nurse then adjusted as needed to optimize access to the desired facet joint. The patient is typically awake for the procedure, and thus communicate with the patient about the expectations during the procedure is important. After the procedure, the patient is monitored by the nurse for any immediate adverse effects. Before departure, the patient should be educated on common issues after the procedure, such as injection site tenderness and precautions that would warrant immediate medical attention. The clinician who performed the procedure should be available to answer any questions if the nurse cannot. The interprofessional approach amongst physicians, nurses, pharmacists, and ancillary staff will provide the best outcomes for the patient. [Level 5]