A cervical facet joint injection can be used to diagnose or treat various manifestations of zygapophysial syndrome. In the case of suspected cervical facet syndrome, the injection will be inserted into the painful region of the neck in an effort to ascertain the involvement of the joint in the symptomatic expression. Cervical facet syndrome describes a condition wherein the zygapophysial joint itself, or the small nerves innervating the joint, are the source of neck pain. Facet syndrome can be divided into 2 categories, depending on the cause: mechanical pain and neurological pain. Facet syndrome remains one of the hotly debated topics within the neck pain treatment sector. This is due to many reasons, including the use of this very procedure as a diagnostic evaluation tool.
This commentary examines the utilization of facet syndrome injections in the neck and details many of the common problems associated with all manner of zygapophysial injections.
Indications for Cervical Facet Joint Injections
Facet syndrome neck pain is typically suspected in cases that fall into one of several possible categories:
Facet syndrome might be implicated as the possible source of pain if spinal imaging shows joint deterioration, but does not visualize a more likely scapegoat in the affected region. This is common in the “process of elimination” diagnostic evaluation protocol suffered by many patients.
Facet syndrome might be suspected if mild to moderate pain is localized on the central spine in a relatively small area, typically over 1 to 3 vertebral levels and does not radiate.
Facet joint syndrome might be theorized to exist if the patient has pain upon movement in particular ranges of motion, once again, typically in the central spine, in a limited region.
All of these types of pain might exist with multiple diagnoses, which is why facet syndrome is rarely the primary suspicion or diagnosis made. In fact, most “verified cases” of facet syndrome are pronounced after 2 to 3 revisions of other working diagnostic opinions.
If facet syndrome does indeed become the primary working diagnostic theory, then a facet injection is a common medical treatment response. Other possible therapy recommendations include physical therapy, with or without the injection, pharmaceutical therapy or surgery, depending on the severity and particulars of the problem.
Cervical Facet Joint Injection Varieties
Facet injections fall into 2 distinct categories, although, many times the distinction disappears when 2 goals are combined during preliminary treatment:
The first designated application of a facet injection is used to test the diagnostic suspicion of zygapophysial joint syndrome. Basically the injection will be given and the response evaluated to determine if the pain is being generated by the joint or not. Sometimes this can be a 2 part process, with the initial injection being delivered into the joint itself, while the second might be delivered around the medial branch nerve.
The second type of facet joint injection is used to treat “verified” cases of zygapophysial pain, regardless of which type of symptom is sourced. The utilization of a treatment series of injections will depend wholly on the results of a diagnostic series that can confirm or deny involvement of the facet joint as the actual causation of discomfort.
As mentioned in the first sentence of this section, both the diagnostic and treatment processes are often combined together, especially when the caregiver already feels that they have identified the root cause of pain. In these instances, multiple injections will often be placed into the same or neighboring facet joints with the intent to confirm involvement of the joint or local nerves and simultaneously inject lasting analgesic substances into the region for treatment. It is in these circumstances that many of the problems commonly associated with facet block injections occur.
Cervical Facet Joint Injection Technique
Regardless of which type of injection is given, diagnostic or therapeutic, the procedure will be virtually identical, with the only difference involving the actual substances utilized.
The recipient will remain awake and the injection is performed as simple outpatient procedure.
The injection will involve a long needle that is carefully guided into the affected region. The ideal and medically correct method of administration involves the inherent use of fluoroscopy, which is a live x-ray technology that allows visualization of the needle within the body for improved accuracy.
Once inserted into the correct anatomical placement, the substances will be injected, the needle withdrawn and the patient evaluated for the results over time.
In a diagnostic injection, small amounts of a powerful short to medium duration anesthetic are typically utilized. This process helps the diagnostician to ascertain whether the affected area is the actual source of pain or not.
In therapeutic injections, the substances used will be long-lasting anesthetics and a corticosteroid to provide enduring analgesia and anti-inflammatory treatment to the joint. These injections are typically called facet nerve blocks, facet joint blocks or medial branch blocks, depending on the specifics of the diagnosed condition. As mentioned above, sometimes no diagnostic injection is used, but instead, the doctor will skip immediately to treatment protocol, placing a long-lasting anesthetic and steroids anatomically, without any definitive evidence to verify the facet joint as the true cause of symptoms. This is improper medical treatment and borders on malpractice, but we see it each and every week within the back and neck pain sector.
Cervical Facet Joint Injection Concerns
There are many downfalls to the use of injections for treating suspected facet syndrome. Listed below are the risks of proper treatment, as well as the many possible consequences of improper treatment. When the diagnostic and treatment protocols are respected and all procedural steps are followed as directed, the following complications can still occur:
Patients might suffer nerve damage or spinal cord damage due to direct contact with the needle or from a secondary issue enacted by the injection, such as infection. Infections can occur in the skin, in the deeper tissues or in the spinal anatomy. The deeper they occur, the worse the consequences can potentially become.
Continued bleeding is a minor risk, but can be significant for those with certain preexisting health issues that should have disqualified them from receiving the injection.
Spinal fluid leaks are possible and might require secondary medical interventions to resolve.
Other possible problems with facet injections might involve any or all of the following scenarios:
Anesthetic can spread, spoiling the results of the diagnostic phase of injection treatment. Migrating anesthetic can numb nerves in a large area and cover up pain from virtually any regional source.
When a single set of injections are performed towards both diagnostic and therapeutic ends, this risk increases drastically, since the amount of anesthetic is increased and the effects are longer lasting. This single “time saving” process costs many thousands of patients added suffering each year, by incorrectly labeling them as suffering from cervical facet joint syndrome.
Neglecting to utilize live x-ray is foolhardy and drastically increases the risk of poor diagnostic and treatment results. Patients are advised to insist on the use of fluoroscopy or to seek evaluation and treatment with a new care provider.
As with any treatment, patients must learn why facet injections are used and should fully understand all the risk factors, including the common incidence of misdiagnosis due to faulty procedure, too much anesthetic or a simple lack of enlightened medical know-how.