Facet infiltration

Facet infiltration at a glance

• Goal: Pain reduction in facet joint arthrosis/facet syndrome; if necessary, diagnostic test block
• Location: small vertebral joints of the cervical spine, thoracic spine or lumbar spine
• Procedure: precise needle placement under imaging (ultrasound, CT or fluoroscopy) and injection of local anesthetic ± low-dose cortisone
• Duration: a few minutes; subsequent short monitoring
• Onset of action: often rapid (minutes to hours) due to local anesthetic; possible longer-term effect (days to weeks) through anti-inflammatory effects
• Importance: Building block of step therapy – complements active measures, not replaces them
• Risks: mostly low; et al. temporary numbness, bruising, rarely infection or allergic reaction

Anatomy: What are facet joints?

Facet joints (Latin: Articulationes zygapophysiales) are paired, small joints between the vertebral arches. They stabilize the spine and control movements such as bending, stretching and turning. Like all joints, they can wear out (spondylarthrosis), become inflamed and cause pain, which is often movement-related and can radiate to the buttocks, hips or shoulders. Unlike nerve root irritation, facet syndrome usually does not cause electrifying pain in the toes or fingers and rarely causes significant loss of sensitivity or strength.

When does facet infiltration make sense?

Facet infiltration can be considered if symptoms persist despite conservative therapy according to guidelines or if a clear diagnosis is needed. Typical situations:

• Mechanical back pain with aggravation when hollow back (extension), prolonged standing or back bending
• Radiation near the buttocks/hip without typical nerve root signs (pseudoradicular)
• Locally tender vertebral arch joints (facet tenderness) with positive provocation tests
• Imaging evidence of spondyloarthrosis (e.g. MRI/CT), correlating with clinical evidence
• Cervicogenic headache or neck pain with movement pain from the cervical spine facets
• Diagnostic block to differentiate from other causes of pain (intervertebral disc, ISG, muscles)

Contraindications are examined individually (see below). Every infiltration is preceded by a careful clinical examination and the exclusion of warning signs.

Conservative therapy first: step concept

As conservative orthopedics, we primarily rely on active, non-invasive measures. Facet infiltration is a component of step therapy - especially when pain hinders training or persists despite consistent measures.

• Education, ergonomic advice, activity adjustment
• Targeted physiotherapy, stabilization and strength training (torso, hips), mobility
• Pain-adapted medication (e.g. short-term NSAIDs, after medical consideration)
• Physical therapy (heat/cold), manual techniques
• Multimodal concepts for chronic pain (including behavioral medicine approaches)

Only when these building blocks do not have sufficient effect or diagnostic clarity is lacking is facet infiltration considered.

Diagnostics: This is how the source of the pain is isolated

The diagnosis of facet syndrome is based on a combination of history, physical examination and, if necessary, imaging. Important indications are movement-dependent pain, local pressure pain over the facets and specific provocation tests.

• History: course, pain triggers, nighttime pain, previous operations
• Examination: posture, range of motion, pain provocation during extension/rotation, neurological status
• Imaging: MRI/CT to assess spondyloarthrosis and rule out other causes
• Diagnostic infiltration: short-acting local anesthetic; Pain reduction speaks for facet origin

Differential diagnoses include, among others: Intervertebral disc pathologies, nerve root irritations, sacroiliac joint problems, myofascial trigger points and hip joint problems. Warning signs (e.g. fever, unwanted weight loss, pronounced neurological deficits, pain at rest at night, tumor history) require immediate clarification.

Preparation in our practice in Hamburg

Before the procedure, we discuss your symptoms, previous illnesses and current medication. Please bring any existing findings (MRI/CT) with you. Certain blood-thinning medications may need to be paused or changed in consultation with the prescribing doctor - do not make any changes on your own.

• No sobriety required; Light meal recommended
• Report any allergies (e.g. to local anesthetics, contrast media) in advance
• Diabetes: take into account possible short-term increases in blood sugar when taking steroids
• After the infiltration, do not actively participate in traffic for the rest of the day if numbness could occur - organize pick-up

Process: Step by step for facet infiltration

The actual injection usually only takes a few minutes. Sedation is usually not necessary.

Effect, duration and evidence

As a result of the local anesthetic, many patients quickly feel an improvement - this also serves as a diagnostic classification. The possible longer-term effect of an additional cortisone component develops in the following days. The duration of action is individual and depends on the severity of the osteoarthritis, accompanying factors and activity level.

• Short-term pain relief is common; medium to long-term effects are possible, but cannot be predicted with certainty
• Best benefit if the infiltration is specifically embedded in an active therapy program (e.g. training progression)
• Repetitions are planned individually and cautiously; Before each new injection, a risk-benefit assessment is carried out

Studies show a benefit for diagnostic facet blocks and selected therapeutic infiltrations, particularly for short-term relief. This cannot be expected to cure osteoarthritis.

Risks and possible side effects

Facet infiltration is considered low-risk if it is performed under sterile conditions and image-guided. However, side effects are possible:

• Local reactions: tenderness, hematoma, temporary numbness or feeling of warmth
• Infection at the injection site (very rare); strict hygiene reduces the risk
• Accidental vascular or soft tissue injection, temporary dizziness/nausea
• Allergic reactions to medications/contrast media
• Cortisone-related effects: short-term increase in blood sugar, facial flushing, sleep disturbance - usually temporary
• Extremely rare: nerve irritation

We discuss risks individually and answer your questions in detail before the procedure.

Contraindications: When should you not infiltrate?

• Acute local infections or systemic infection
• Uncontrolled blood clotting disorders
• Severe allergy to substances used with no alternative
• Unclear neurological deficits without prior clarification
• Pregnancy: relative contraindication, individual benefit-risk assessment

Follow-up care and behavior after infiltration

• Take it easy physically on the day of treatment; Return carefully to everyday activities the following day
• Cold/heat as needed, light stretching and mobilization exercises according to the therapy plan
• Continue active strengthening as soon as the symptoms allow
• Redness, fever, increasing pain or persistent numbness: please consult a doctor

Alternatives and complementary procedures

The choice of procedure depends on the leading source of pain. Depending on the findings, the following options may be considered:

• Continuation and intensification of active therapy (physiotherapy, training, multimodal pain therapy)
• Periradicular therapy (PRT) or nerve root injections for radicular pain
• SIJ infiltration for sacroiliac joint problems
• Joint infiltrations on the shoulder/knee/hip/OSG for peripheral joint pain
• Trigger point treatment for myofascial pain
• Radiofrequency therapies on the medial branches may be considered in selected cases; Strict indication, benefit-risk assessment required

Regenerative procedures are only discussed after careful indication and information about the evidence and alternatives.

Special situations: cervical spine, thoracic spine, lumbar spine

• Cervical spine facets: can cause neck and occipital pain; high precision and safety precautions required
• BWS facets: rarer, often combined with muscular causes; Careful differential diagnosis is important
• Lumbar facets: common in spondyloarthrosis; Pain typical when standing/walking for long periods of time

Frequently asked questions about facet infiltration

Short answers to common concerns. We will discuss your personal situation at the appointment.