Facet joint blocks BWS

What are facet joint blocks of the thoracic spine?

The facet joints (also vertebral joints or zygapophysial joints) connect two vertebrae with each other. They provide guidance and stability and can cause pain if worn, irritated or overloaded. A facet joint block is an image-guided injection of small amounts of a local anesthetic, often combined with a low-dose glucocorticoid, directly into the affected joint or its pain-conducting nerve branch (medial branch).

In the thoracic spine, the facet joint cause is less common than in the cervical or lumbar spine, but occurs particularly in cases of segmental overload, poor posture (e.g. kyphosis), Scheuermann's disease, after accidents or in degenerative changes. The blockage can help to relieve the pain and at the same time provides an important indication as to whether the facet joint is actually the source of the discomfort.

Anatomy and pain development in the thoracic spine

The thoracic spine consists of 12 vertebrae (Th1–Th12). Laterally, ribs connect the spine to the ribcage. The facet joints lie in pairs between the vertebral arches. They are surrounded by a joint capsule, contain cartilage and are sensitively supplied via the medial branches of the dorsal ramus - it is precisely these nerves that transmit facet pain.

• Possible triggers for facet pain: degenerative cartilage wear (arthrosis), capsule irritation, microinstability, incorrect posture, muscular imbalance, post-traumatic changes.
• Typical pain characteristics: dull, pressing, local paravertebral pain, often dependent on stress or position (uncomfortable extension/rotation), occasionally radiating in a belt-like manner without radicular signs.
• Differentiation: In contrast to intercostal neuralgia, facet pain usually involves mechanical triggers; Neurological deficits are atypical.

It is important to distinguish it from other causes such as intervertebral disc problems, myofascial trigger points, intercostal neuralgia, osteoporotic vertebral fractures or visceral causes (e.g. heart, lungs, upper abdomen).

Typical complaints and indications

A facet joint block can be considered if the clinical impression and examination indicate facet joint-related pain - especially if conservative measures have not yet helped sufficiently.

• Localized thoracic spine pain, increased when leaning back, bending to the side or rotating
• Morning stiffness, starting painful after rest
• Pressure pain over the paravertebral facet joints
• Stress-related complaints (sitting/standing for long periods of time, vibrations)
• Exclusion or low probability of radicular symptoms (numbness, pronounced reduction in strength)

Indications are diagnostic clarification (“Is the facet joint the source of pain?”) or therapeutic relief if facet involvement is confirmed. The basis for the decision is always the overall view of the anamnesis, examination and, if appropriate, imaging.

Diagnostics: How do we confirm the cause?

At the beginning there is a structured anamnesis with a record of the course of the pain, triggers, accompanying symptoms and previous illnesses. This is followed by a careful physical examination with functional and provocation tests as well as an assessment of posture and breathing mechanics.

• Clinical tests: Pain on extension/rotation, local tenderness over the affected segment, myofascial trigger points of the paravertebral muscles
• Imaging: X-ray (axes, spondylophytes), if necessary MRI if intervertebral disc damage, edema, fracture or tumor is suspected; CT for detailed bony assessment if necessary
• Red flag screening: weight loss, fever, pain at night when resting, trauma, neurological deficits - may require further investigation

If facet pain is suspected, a diagnostic block with pure local anesthetic can be performed. If it leads to a clear, plausible improvement over time, this supports the diagnosis. For more advanced procedures (e.g. radiofrequency denervation), reproducible, significant pain relief is usually required after one or two test blocks. In the thoracic spine the evidence is somewhat more limited than in the cervical/lumbar spine; The indication is therefore made particularly carefully.

Conservative therapy first

The block is not a substitute for active, conservative treatment. We usually combine them with a structured program to address the cause in the long term.

• Physiotherapy: segment-related mobilization, posture training, stabilization and targeted strength endurance training
• Self-exercises: mobilization of the thoracic spine, stretching of the chest and shoulder girdle muscles, breathing exercises
• Pain-adapted activity and ergonomics: workplace, sitting and lifting techniques, break management
• Heat/cold depending on tolerance; if necessary TENS
• Medication: short-term NSAIDs/analgesics as tolerated, no long-term therapy without indication
• Treatment of myofascial trigger points if involved

Only if these measures are not effective enough or the diagnosis remains uncertain will a facet joint block be considered.

Process of the facet joint block in the thoracic spine

The procedure is usually carried out on an outpatient basis. Immobilization is not necessary; light activity is permitted. There should be no active participation in traffic on the day of treatment.

In the case of multi-segmental complaints, in individual cases several joints can be treated one after the other. The number of injections is determined individually and cautiously.

Effectiveness and evidence

The best effect is expected when the facet joints are actually the primary source of the pain. Diagnostic blocks with pure local anesthetic provide important information in this regard. Therapeutically, injections can reduce pain in the short term and make active therapy easier.

• Short-term pain relief is relatively common; the duration varies from hours to weeks, rarely months.
• There are fewer studies in the thoracic spine than in the cervical spine; the results are more heterogeneous. Careful patient selection is crucial.
• Repeated steroid injections should be limited and well-justified to minimize possible side effects.
• If there is significant but only temporary improvement after diagnostic blocks, radiofrequency denervation of the medial branches can be considered - after strict indication testing and explanation.

Important: A blockade does not replace training, posture work and lifestyle measures. However, it can create a window of opportunity for effective practice and load building.

Risks, side effects and contraindications

Facet joint blocks are considered gentle when carried out professionally, image-guided. However, side effects are possible. We discuss these transparently in advance.

• Temporary complaints: puncture pain, feeling of pressure, muscular irritation, short-term numbness or feeling of warmth
• General reactions: dizziness, nausea, fluctuations in blood pressure
• Rare complications: infection, bleeding/hematoma, allergic reaction, very rarely nerve irritation
• BWS specifics: Due to the proximity to the thorax, anatomical precision is particularly important; The risk of serious complications such as pneumothorax is very low if the technique is correct, but is in principle present
• Steroid-related effects (if used): temporary increase in blood sugar, skin redness/flushing, sleep disturbances; Note cumulative dose

• Contraindications: local infection, systemic infection/fever, uncontrolled coagulation disorder, relevant allergy to local anesthetics, unexplained neurological deficits, pregnancy as a relative contraindication to steroids
• Special features of anticoagulation: Adjustment only after consultation with the prescribing doctor; Benefit-risk assessment

Do not actively drive a car on the same day after the injection. If you have alarming signs such as increasing shortness of breath, fever, severe pain, rapidly growing hematoma or neurological abnormalities, please see a doctor immediately.

Aftercare: What is important afterwards?

• Rest on the day of treatment, gradually increasing activity from the following day onwards
• Cooling is possible for local complaints, pay attention to skin protection
• Pain diary: intensity, duration, activity - helps to evaluate benefits and next steps
• Continue physiotherapy/self-exercises as soon as possible as long as it is possible to adapt to the pain
• Ability to work and play sports individually; Contact if you are unsure

The effect of the local anesthetic sets in quickly and wears off after hours. A possible steroid-related reduction in inflammation often only becomes apparent after a few days. The follow-up appointment is used to assess the effect and plan further therapy.

Alternatives and additions

Depending on the findings, various conservative and interventional options are possible. The aim is always to keep invasive measures as low as possible and to strengthen self-efficacy.

• Conservative: Physiotherapy, medical training, posture training, weight and stress management, pain medication in low effective doses and limited duration
• Myofascial procedures: trigger point treatment, dry needling (with appropriate qualifications), fascia techniques
• Blocks close to the nerve: Medial branch block as an alternative/supplement to intra-articular infiltration
• Radiofrequency denervation: Can be considered if facet cause is established and response to test blocks is good; Evidence in the thoracic spine is more limited than in the cervical/lumbar spine
• Other infiltrations depending on the differential diagnosis: intercostal nerve infiltration for intercostal neuralgia, rarely epidural procedures for radicular pain
• Regenerative procedures (e.g. PRP) have not yet been sufficiently proven in the thoracic spine for facet joints; Use only in individual cases and after informed consent

We will decide together which approach is suitable based on your goals, the findings and previous therapy attempts.

Who is the blockade not suitable for?

Not everyone with thoracic spine pain benefits from a facet joint block. In the case of primary myofascial complaints, a clear radicular pattern, inflammatory rheumatological causes or unclear red flags, other paths are in the foreground.

• Acute infections, fever, local skin inflammation
• Uncontrolled coagulation disorders or unbalanced anticoagulation
• Severe, unexplained neurological deficits (immediate clarification)
• Pregnancy (particularly weigh up against the addition of steroids)
• Lack of willingness to undergo concurrent active therapy

Your treatment in Hamburg: safe, targeted, integrated

In our orthopedic practice in Hamburg, we use facet joint blocks of the thoracic spine in a targeted and conservative manner - always embedded in a conservative overall concept. The procedure is image-controlled and under sterile conditions. What is important to us is careful indication, transparent information and close integration with physiotherapy and self-exercises.

Our location: Dorotheenstraße 48, 22301 Hamburg. To make appointments, you can easily use Doctolib or contact us by email.

Delimitation: If it is not the facet joint

It is not uncommon for causes to overlap. A clear differential diagnosis helps to choose the right therapy.

• Myofascial thoracic spine pain syndrome: rather pressure-sensitive muscle strands, trigger points, often associated with stress and posture
• Intercostal neuralgia: neuropathic, belt-like pain along a rib, aggravated by coughing or deep breathing
• Herniated disc of the thoracic spine: less common, can cause radicular symptoms and neurological deficits
• Structural changes such as Scheuermann's disease: affect axes and load; Therapy aims at posture and muscle balance
• Red flags: infectious, tumorous or osteoporotic causes must be ruled out depending on the medical history