Pelvic and Spinal instability | Facet Joint Injections
In this article, David Woznica, MD discusses the options to lower back pain including facet joint injections.
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Doctors have released new research in which they investigated the relation between the structures of the low back, sacrum, and pelvis and how degenerating facet joints influenced lower spine instability.
Osteoarthritis of the facet joints is one of the most common degenerative changes in the spine. It is considered to be formed secondary to repetitive stress or trauma and spinal deformity with secondary overload. The cause(s) of facet joints osteoarthritis, however, have not been clearly identified.
The researchers looked at CT images of women who were between the ages of 30-35 years old. They looked at their pelvic alignment (pelvic incidence), and curvature at various parts of the spine.
What they found was the curvature of the spine had a much higher angle at the L1-L5 and sacrum region. While at the L5 itself and the sacral slate the angle was much lower. 1
Clearly it can be suggested that instability and weakness in the facet joints cause significant movement and pain in the lower spine.
What is a facet joint injection?
There is often a great amount of confusion when it comes to facet joint injections as a non-surgical treatment option for back pain. Some think facet joint injection to be solely the use of steroids. In fact some patients are routinely given the choice of facet joint injections or Radiofrequency neurotomy. This is where heat generated by radio waves are targeted to damage specific nerves and interfere with their ability to send pain signals to the brain.
A facet joint injection can be performed for one of two purposes. One purpose is diagnostic in that it confirms or denies that the facet joint is the cause of back pain or neck pain. The second purpose is therapeutic in treating the facet joints. Diagnostically, a small amount of anesthetic is injected into the facet joint near the area of pain. If pain relief results then the facet joint is deemed the culprit of pain. Once the facet joint is pinpointed as the problem area, further injections of anesthetics and anti-inflammatory agents are injected to try to achieve more permanent pain relief.
A facet joint injection usually involves a patient lying on an X-ray table so that the physician can guide the needle placement using a fluoroscopic X-ray. A contrast dye is first injected so that the physician can confirm that the medication will go to the proper spot. Once proper placement is determined, the physician will inject the medication, usually an anesthetic and corticosteroid, into the facet joint.
In a comparison of these two “popular treatments” doctors found that Intra-articular steroid or radiofrequency denervation (Heat generated by radio waves is targeted at specific nerves to disrupt their ability to transmit pain signals) appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results in terms of pain relief and function improvement, but improvements were similar in both groups.2 In other words, good for the short-term.
However in new research,doctors tested whether paraspinal block reduces pain scores compared to placebo in women with chronic pelvic pain refractory to drug therapy. Drugs did not work.
- Paraspinal anesthetic block had a small effect on visual analog scale pain score immediately after the injections, but no sustained benefit after one week. 3 Here symptom suppression has failed.
Facet joint pain and the capsular ligament
The facet joint or apophyseal joint helps to connect one vertebrae to another vertebrae. This joint connects the superior articular process of one vertebrae with the inferior articular process of the other. Capsular ligaments are part of the joint capsule that surrounds the facet joint. The capsular ligaments join together with surrounding ligaments to provide stability to the joint. The capsular ligament is a very important structure and is key in the treatment of spinal pain and spinal instability, as these tiny ligaments hold the facet joint in place. They also have nerve fibers which are associated with pain.
Facet Joints and Capsular Ligaments Nerve Fibers
Nerve fibers and nerve endings are located in the ligamentous and joint capsular structures of the spine. The joint capsules themselves are innervated by various types of sensory nerve endings. Since this is the case, it would make sense that these nerve endings are associated with pain.
The capsular ligaments of the facet joint can support about twice the body weight in a young adult, with their strength decreasing with age. According to one study which applied extra load on the capsular ligaments of rats, the loading altered joint stability and caused ligament damage. This damage produced changes in the alignment of the ligaments capable of causing persistent pain.
The facet joint and capsule have been demonstrated in various studies as the site of pain following injury to the spine. Abnormal movement in the facet joint during such forceful conditions as that which occurs in whiplash, plays a role in production of pain. It is not unusual in these cases, for the capsular ligaments to exceed their physiologic range during these events, causing stretching and damage to these ligaments.
Facet Joint and Capsular Ligament Damage Causes Pain
Studies have also shown that the capsular ligaments can be altered in the absence of gross ligament injury. This altering is described as ligament laxity. The instability of the facet joint and the laxity of the capsular ligaments puts stress on the nerve endings, thus causing the pain associated with the condition.
Prolotherapy and PRP Facet joint injections
At Caring Medical, we have successfully treated the facet joints and the capsular ligaments with Prolotherapy. Generally, an injury to the spine will cause damage to the facet joints and capsular ligaments at various levels of the spine. For this reason Comprehensive Prolotherapy would be required in order to treat all injured areas. Prolotherapy to the facet joints and capsular ligaments will help the body to stimulate repair of the damaged ligaments. When the capsular ligaments are strengthened, the joint will become stable, and the pain will go away.
In one research study, doctors showed a 63% improvement in patients receiving Prolotherapy following diagnostic block injection for sacroiliac joint pain had improved at six months, compared to 33% who had intra-articular corticosteroid. Further, sacroiliac prolotherapy showed good long-term outcomes at one year. 4
In the medical journal Pain Physician, doctors in China wrote of “A New Technique for the Treatment of Lumbar Facet Joint Syndrome Using Intra-articular Injection with Autologous Platelet Rich Plasma.”
In this research they looked at 19 patients with lumbar facet joint syndrome (8 men, 11 women between the ages of 38 and 62) who received lumbar facet joint injections with autologous PRP under x-ray fluoroscopic guidance.
Patients were followed up immediately, at one week, one month, 2 months, and 3 months following treatment, and progress was measured with a series of standardized scoring systems.
- At one week after treatment, low back pain reduced significantly
- The outcomes were assessed as “good” or “excellent” for 9 patients (47.37%) immediately after treatment,
- 14 patients (73.68%) at one week,
- 15 patients (78.95%) at one month, 1
- 5 patients (78.95%) at 2 months,
- and 15 patients (78.95%) at 3 months.
In the short-term period of 3 months, the new technique of lumbar facet joint injection with autologous PRP is effective and safe for patients with lumbar facet joint syndrome.5
For a comprehensive review of Prolotherapy for low back pain please see our article for various back pain problems.
1. Sahin MS, Ergün A, Aslan A. The relationship between OSTEOARTHRITIS OF THE LUMBAR FACET JOINTS Aand lumbosacralpelvic morphology. Spine (Phila Pa 1976). 2015 Jul 30. [Pubmed]
2. Lakemeier S, Lind M, Schultz W, Fuchs-Winkelmann S, Timmesfeld N, Foelsch C, Peterlein CD. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg. 2013 Jul;117(1):228-35. [Pubmed]
3. da Rosa KF, Amantéa VA, dos Santos AC, Savaris RF. Efficacy of paraspinal anesthetic block in patients with chronic pelvic pain refractory to drug therapy: a randomized clinical trial. Rev Bras Ginecol Obstet. 2015 Mar;37(3):105-9. [Pubmed]
4. Chakraverty R, Dias R. Audit of conservative management of chronic low back pain in a secondary care setting–part I: facet joint and sacroiliac joint interventions. Acupunct Med. 2004 Dec;22(4):207-13.
5. Wu J, Du Z, Lv Y, Zhang J, Xiong W, Wang R, Liu R, Zhang G, Liu Q. A new technique for the treatment of lumbar facet joint syndrome using intra-articular injection with autologous platelet rich plasma. Pain physician. 2016 Nov 1;19(8):617-25. [Pubmed] [Google Scholar]