Facet Joint Injections

Good candidates have back or neck pain for at least three months that stays mainly in the spine, is often worse with leaning back or twisting, and has not improved with physical therapy and medicines^[4][1]. Injections suit people who have had lasting relief from one before or are poor candidates for ablation^[2]. If ablation is the goal, a medial branch block is usually the better test.

Most people find a facet injection uncomfortable rather than painful. The skin is numbed first, and you may feel pressure or a brief, familiar ache as the needle enters the joint. The procedure usually takes 15 to 30 minutes, often without sedation. The injection sites can be sore for a day or two, which ice and over-the-counter pain relievers usually ease.

In a sense, yes: a therapeutic facet injection usually contains a corticosteroid (“cortisone”) with a numbing medicine, much like a cortisone shot in a knee. The difference is precision — the facet joints are small and deep, so the needle is guided with live X-ray or CT, which Medicare requires^[4]. A purely diagnostic injection may contain only numbing medicine.

The numbing medicine lasts a few hours, and the steroid can take up to 72 hours to start working^[7]. After that, relief varies widely. In a landmark trial, 22% of people who received facet steroid had sustained improvement through six months, compared with 10% after a placebo injection — a difference that was not statistically significant^[5].

They can be worth it for the right person. Multispecialty guidelines recommend against routine therapeutic facet injections because evidence for lasting relief is weak, but note they may be reasonable for people at higher risk from ablation or who have had prolonged relief before^[2]. For many people, a medial branch block followed by radiofrequency ablation offers a better chance of longer relief.

If radiofrequency ablation is the plan, usually a medial branch block: guidelines for both the lower back and the neck found that medial branch blocks predict ablation success better than injections inside the joint^[2][3]. A facet joint injection may be preferred when the main goal is relief or ablation is not an option. See how the two compare.

Tell us about all your medicines, especially blood thinners, and any contrast allergy. Whether a blood thinner should be paused depends on the medicine, why you take it and the level treated^[6] — never stop one on your own; we coordinate with the prescribing doctor. If you have diabetes, check your blood sugar more often for a few days, because the steroid can raise it^[7].

Most people go home shortly afterward and return to normal activities the next day. Soreness or a short flare of your usual pain can come before the steroid takes effect. Avoid strenuous exercise that day, use ice and keep a short pain log so your physician can judge the result. Do not drive after sedation or if an arm or leg feels numb.

Serious complications are rare. Short-lived effects include soreness, a pain flare, light-headedness and a brief rise in blood sugar; infection, bleeding and nerve injury are uncommon^[7]. Repeated steroid injections add up over time and have been linked to higher diabetes risk and bone thinning, one reason the number of injections is limited^[2]. Tell us if you might be pregnant, since X-ray is used.

Only if the previous one clearly helped. New York workers’ compensation guidelines allow up to two injections per joint in a 12-month period^[7]. Medicare’s policy for New York allows up to four therapeutic sessions per spinal region in a rolling 12 months, each requiring at least 50% relief for three months or more^[4]. If relief keeps fading, ablation is usually discussed.

If you get no relief even while the numbing medicine is working, the facet joints may not be the main source, and your physician will look at others, such as the SI joint or a pinched nerve. If relief is brief, medial branch blocks and radiofrequency ablation are the usual next step; endoscopic rhizotomy is an option for some people.

Facet arthritis is a long-term, wear-and-tear condition, so the goal is usually control rather than a complete fix. Flare-ups often settle with time, exercise and physical therapy. Injections by themselves are not likely to provide long-term relief, so they work best alongside an active rehabilitation program^[7]. Many people manage facet pain well for years with a combination of approaches.

It depends on your plan and the purpose of the injection. Medicare’s policy for New York covers diagnostic injections inside the joint only when medial branch blocks cannot be done, and therapeutic facet injections only when there is a documented reason ablation cannot be performed^[4]. Commercial plans often require prior authorization. Workers’ compensation follows New York’s Medical Treatment Guidelines^[7], and no-fault has its own rules.