Beckers Spine—August 4, 2014
Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.
This week, she reaches out to Dr. James F. Wyss, an Assistant Attending Physiatrist in the Department of Physiatry at the Hospital for Special Surgery in New York City, to discuss the use of injections into the joints for diagnosing and treating low-back pain.
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Dr. Wyss Responds:
Dear Terry:
Joint injections are powerful diagnostic and therapeutic tools utilized in musculoskeletal medicine. As a sports physiatrist who diagnoses and treats muscle and joint pains on a daily basis, I frequently utilize joint injections to confirm the diagnosis and/or to facilitate treatment.
Most patients share your anxiety about this procedure. Information about the way a joint injection is performed generally diminishes this anxiety. After the skin is numbed with a local anesthetic, a needle is guided through the skin and tissues and then into the joint so that medications can be injected inside of the joint (the space between the bones). When it is done skillfully, there can be minimal pain.
The majority of injections are anatomically guided, meaning physicians use their understanding of the anatomy to place the needle in the correct location. Other injections into deep or small structures may be image guided. Under these circumstances, ultrasound or fluoroscopy (a low-dose, portable x-ray) can be utilized to visualize the needle entering the correct location. The most common medications injected are anesthetics, such as lidocaine, and steroids. The anesthetic is utilized to improve patient comfort and to relieve pain shortly after the injection. If the injection relieves the patient’s pain quickly, then it is deemed to be a diagnostic injection. The steroid relieves inflammation or swelling and is believed to be responsible for the long-term pain relief.
Considering the two roles that these injections can serve helps us to understand when they are indicated—and it is important that patients understand when these injections are appropriate. If the diagnosis has been unclear, then a local joint injection may help to relieve pain and confirm the source of the pain. If the diagnosis has already been confirmed, then the injection can be used to treat pain and improve function when more conservative treatments have been unsuccessful or the pain is too severe for the patient to participate in or wait for conservative treatments to work. Conservative treatments include activity modification, avoidance of painful positions or activities, topical and oral medications, physical- or exercise-based therapies, and possibly complementary treatments such as manual or massage therapy and acupuncture.
If you are considering a joint injection, then you should ask yourself if you have thoroughly tried to treat your pain in a more conservative way. If the answer is yes, then you may be ready for a joint injection, and you should understand the risks of the procedure. Any time a needle pierces the skin, there are risks of bleeding or infection; injury to tissues, blood vessels, or nerves; and an allergic or adverse reaction to the medications that are injected. The risks of a major complication are considered to be less than 1 in 20,000. In other words, these are very safe injections that usually provide relief and very rarely cause problems.
Facet joints are located on the backside of the spine and connect one vertebra to another. There is a facet joint located on both the left and right side of the vertebra. Facet joints are a common cause of neck and back pain. An inflamed or arthritic lumbar facet joint typically causes low-back pain (LBP) and may cause buttock, thigh, or even leg pain.
When LBP from facet-joint arthritis can’t be relieved by more conservative treatment, then a lumbar facet injection is an option. To safely perform a lumbar facet injection, fluoroscopy is used so the needle can be visualized and guided into the facet joint. Once the needle is in the proper location, contrast dye is injected and the dye will outline the joint; this is also known as an arthrogram.
Once the proper location is found with fluoroscopy guidance, medications can be injected in an attempt to relieve pain and swelling. Facet joint injections can relieve pain shortly after the injection to help confirm the diagnosis or source of pain, and then the steroid takes a few days to begin working and can provide relief for two to three months, on average. With the correct exercise, good posture, and activity modification to avoid reproduction of the pain, then relief from these injections can last much longer. My limit is two to three injections—at the most—in one year; it is advisable to use the fewest injections necessary to control the pain, and to use all the other tools after each injection to keep the pain from coming back.
Many causes of LBP can recur during a lifetime, and facet joint pain is no exception. If your pain does return, treatment can resume, including repeating lumbar facet joint injections. If relief from these injections is temporary, then a longer-acting option for relief of facet joint pain is radiofrequency ablation. This is another treatment option performed through the skin, with the use of a needle to “burn” the small nerves that transmit pain from the facet joints to the spinal cord and brain. On average, a treatment like this can relieve LBP for longer than nine months.
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