Series of facet injections?

[Mister Mxyzptlk]

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Anyone do this as a series? I'm seeing people have them in a series of 2 or 3.

 

[Ducttape]

Dont things seem better when it is in a "series"?

the World Series... playoff series... ...movie series like LOTR...


on the other hand, soap opera series are bad, as are the Rocky Series (after #2, that is).


but to directly address your question - only "facet injection" series are the 2 MBBs required prior to RFA, if 2 are mandated by insurance coverage for PA.

 

[lobelsteve]

Series meaning double diagnostic MBB using differential block on different dates to stratify and see if RFA is appropriate as per ISIS guidelines?

Yes, I do this every day.

 

[Dr. Ice]

Anyone do this as a series? I'm seeing people have them in a series of 2 or 3.

I never really understood why people do intra-articular facet injections. It doesnt make too much sense to me. There is no end point. MBB to diagnose facet mediated pain followed by RF if successful, but I dont get IA facet. Plus, how much volume would you put into a facet joint? Lets say patients do get better after a facet injection for a short period of time but then the pain comes back..are people really banking on "facet syndrome" to justify repeating it? People in my group do it all the time, but I dont get it...

 

[pmrmd]

I never really understood why people do intra-articular facet injections. It doesnt make too much sense to me. There is no end point. MBB to diagnose facet mediated pain followed by RF if successful, but I dont get IA facet. Plus, how much volume would you put into a facet joint? Lets say patients do get better after a facet injection for a short period of time but then the pain comes back..are people really banking on "facet syndrome" to justify repeating it? People in my group do it all the time, but I dont get it...

Because there can be long-term relief, just like after an RF.

Lets say patients do get better after an RF for a short period of time but then the pain comes back...are people really banking on "facet syndrome" to justify repeating it?

 

[Ducttape]

I never really understood why people do intra-articular facet injections. It doesnt make too much sense to me. There is no end point. MBB to diagnose facet mediated pain followed by RF if successful, but I dont get IA facet. Plus, how much volume would you put into a facet joint? Lets say patients do get better after a facet injection for a short period of time but then the pain comes back..are people really banking on "facet syndrome" to justify repeating it? People in my group do it all the time, but I dont get it...

with respect to facet joint injections, i have a few people who were historically treated with them with good efficacy and then "maintained" on them.

however, each injection is assessed for efficacy, each patient is examined prior for appropriateness, and failure of one leads to change in treatment (to MBB for RFA, for example)



i assume you repeat SI injections. Or GT injections. Or epidurals. or RFA....

 

[SSdoc33]

intra-articular for:

-young patients
-s/p MVA or trauma
-occasional post-surgical patients
-patients where it has been successful in the past

otherwise, MBB to RF is preferable, IMHO.

also, i like to think that im pretty handy with a needle, but there are times when intra-articular injections can be very technically challenging. a rarely find this to be the case with an MBB

 

[Tenesma]

i perform series of facet injections - except there is usually a gap of 6-18 months between each injection... 🙂

 

[Aether2000]

I am with Tenesma....when the pain returns and becomes bad enough then facet injections intraarticular may be offered, but not in a series.
There is some evidence the sinuvertebral nerve innervates the anterior facet capsular fibers interdigitating with the ligamentum flavum. The medial branch blocks do not cover this innervation source, therefore this may explain why some patients with what appears to clearly be facetogenic (zygapophysealogenic has way too many syllables) receive unsuccessful medial branch blocks. If the placebo plus double anesthetic blocks are performed with the 100% pain relief as required by the original guidelines, then 95% or more of patients would be eliminated from having RF, and probably over 50% of those that would benefit from RF. A single intraarticular facet injection can block all innervation sources to the joint. Trick is as was pointed out by Dr Ice, how much is enough and how much is too much. Typically 3/4 cc will not cause anterior capsular rupture of the joint, especially if administered from the inferior capsular approach to the joint.

 

[onewithpain]

Noridian/MC requires 2 MBBs, with 80% relief. They allow 5 facet procedures per level per year. So if I do MBB x 2 and then RFA on an old-timer with arthritis throughout the L spine then he may come back with additional pain above where I RFA'd. If so then I will consider intra-articular injections because I will not be allowed to do another MBBx2 and RFA as that would total 6 facet procedures for the year.

 

[Jcm800]

Because there can be long-term relief, just like after an RF.

Lets say patients do get better after an RF for a short period of time but then the pain comes back...are people really banking on "facet syndrome" to justify repeating it?

preach on brother!

 

[Dr. Ice]

Just seems like RFA is more "specific." For those of you who repeat facet injections..how much volume do you inject into the joint? Have any of you proceeded to RFA after positive short term response to intra-articular injections? From what algos says, I cant really see the logic in that either...its the wild wild west I guess...

 

[Tenesma]

my volume is about 0.5ml in the joint - and i will often add another 0.5ml posterior to the joint.

 

[bedrock]

my volume is about 0.5ml in the joint - and i will often add another 0.5ml posterior to the joint.

I do the same.

young patients
-s/p MVA or trauma
-occasional post-surgical patients
-patients where it has been successful in the past
otherwise, MBB to RF is preferable, IMHO.

Agree, other than post-surgical, which I've rarely found to be useful.

I do intra-articular for young patients, MVA, sometimes for early facet OA (pt in 40s)
Often see relief for 6 months in 40 somethings, and many of the young or MVAs never need another procedure.

If any of the above have good, but brief relief, time for RF.

 

[SIIMS]

I look at the STIR images on MRI, if there is increased signal (inflammation) in the facets and or pedicle area and patient has axial back pain that I presume could be facet mediated in this case I will do IA with steroid and have had good results.

If patient with arthritic facets that on imaging look difficult to enter or are non-inflammatory on STIR mbb to RF makes more sense to me

On a whole with this approach I end up doing a lot more mbb's

 

[ampaphb]

I do facet injections all the time for facet mediated pain. I see no reason to perform a destructive procedure when injection of anti-inflammatory medication into the joint is sufficient.

If they get 3-4 months of relief, then I repeat similar injections. If they get only 1-2 weeks of relief, I proceed with MBB.

Volume is patient specific. I usually infuse 0.1cc of contrast, and then between, 0.5-0.75cc of solution containing 3mg of betamethasone mixed with local.

I try to explain to my surgical colleagues the logical fallacy of STIR - facet joint injections are both therapeutic, AND are the diagnostic gold standard. STIR, while interesting when positive, provides no diagnostic value when negative. I don't bother obtaining such studies.

 

[SIIMS]

facet intraarticular injections, especially when used with steroid are not the diagnostic "gold standard" for diagnosing facet pain

 

[SSdoc33]

facet intraarticular injections, especially when used with steroid are not the diagnostic "gold standard" for diagnosing facet pain

Read his post again