INVITED REVIEW ARTICLE

Percutaneous Imaging-guided Spinal Facet Joint Injections

Hsien Khai Tan, MBBS, MMed, FRCR, Kian Ming Chew, MBBS, FRCR, and Wilfred C.G. Peh, MD, FRCP, FRCR

Summary: The spine is the most common cause of chronic back pain. It can cause signicant loss of function or disruption in activity of daily living and is extremely common in the elderly. Of the various causes of spinal pain, facet joint syndrome is often a diagnosis of exclusion, as it is difcult to differentiate the latter from pain secondary to degenerative disk disease or spinal stenosis because of overlapping clinical features and poor correlation between the clinical presentation and the imaging abnormalities. Further, localizing the source of pain is challenging as facet joint disease may not be limited to only 1 joint. Pain arising from the facet joints can be attributed to segmental instability, synovitis, synovial entrapment, trauma, meniscoid impingement, chondromalacia, and osteoarthritis. Facet joint injection is performed under uoroscopy or computed tomography guidance, which facilitates accurate needle placement while reducing potential injury to the surrounding vital structures. Indications of facet joint injection include clinical suspicion of facet joint syndrome, chronic pain not relieved by trial of nonsteroidal anti-inammatory drugs and physiotherapy, patients with conrmed facet joint syndrome, presence of adjacent segment deterioration after spinal fusion or persistent low back pain after a stable posterolateral fusion, and patients in whom oral or systemic drug therapy have to be withdrawn because of adverse effect or have exceeded the maximum tolerable dose. Given the high success rate and low complications, image-guided facet injection is deemed safer and more effective compared with conventional blind injections. Key Words: chronic back painfacet joint syndromefacet joint injectionimage-guided facet injection. (Tech Orthop 2013;28: 1217)

facet joint (or the facet joint syndrome) is often a diagnosis of exclusion. Lumbar facet injections were rst described by Goldthwait4 in 1911 and were further endorsed by Putti5 in 1927. Badgley6 in 1941 suggested that the facet joints could be the primary source of pain separate from the nerve compression and demonstrated that facet joint pathology could cause symptoms, including pain radiating to the lower extremities. This theory was proven in 1963 when Hirsch et al7 injected hypertonic saline into the facet joints, successfully reproducing low back pain along the sacroiliac and gluteal areas with radiation to the greater trochanter. Mooney and Robertson8 in 1976 and McCall et al9 in 1979 started using uoroscopic guidance for facet joint injection with steroids and local anesthetics. Facet joint disease may not be limited to 1 joint, and localizing the source of pain is a challenging process. Facet joints were proven to be the cause of pain in 15% to 45% of patients with low back pain,1015 in 54% to 67% of patients with neck pain,1618 and in 48% of patients with thoracic pain.19 For an anatomic structure to be deemed as a potential cause of pain, it must full the following criteria: (1) It must have a nerve supply. (2) It should be capable of causing pain similar to that seen clinically in normal volunteers. (3) It must be susceptible to painful diseases or injuries. (4) By using diagnostic techniques of known reliability and validity, the structure must be demonstrated as a source of pain in patients.20

he spine is the most common source of chronic back pain. Depending on its severity, spinal pain can cause signicant functional limitations and disruption of activities of daily living.1 Potential causes of spinal pain include degenerative disk disease, ligamentous disorders, facet joint arthropathy, infections, and neoplasm. Pain arising from the facet joints can be attributed to a variety of causes, including segmental instability, synovitis, synovial entrapment, trauma, meniscoid impingement, chondromalacia, and osteoarthritis. It is often difcult to differentiate pain secondary to degenerative disk disease, spinal stenosis, and facet joint syndrome clinically, mainly because of the overlapping clinical features. Furthermore, imaging abnormalities often do not correlate well with clinical symptoms.2,3 Therefore, pain arising from the

FACET JOINT ANATOMY

The facet joints are paired diarthrodial articulations located between the posterior elements of vertebrae, with the inferior articular process articulating with the superior articulate process of the vertebra below.21,22 They are also known as the zygapophyseal joints, where the articular surfaces are covered by articular cartilage with a bridging synovial membrane, tough brous capsule, and intervening layer of loose areolar tissue.23,24 The joint capsule is decient in the ventral aspect where the joint is in contact with the ligamentum avum. The superior and inferior aspects of the facet joints are redundant, forming superior and inferior recesses.25 The facet joints are anatomically designed to restrain excessive mobility of the spine and assist in distribution of axial force over a broad area. Variation in shapes and orientation of the facet joints when descending from the cervical to the lumbar spine determines the direction and degree of movements of the different segments of the spine. The facet joints have a dual nerve supply from the medial branches of the dorsal rami of the spinal nerves at the same level and from the level above, with the exceptions of the atlanto-occipital joint, atlantoaxial joint, and C2/3 joint, which are supplied by the C1, C2, and C3 nerves, respectively. The joint capsules are richly innervated by free nerve endings, proven by previous histologic studies.26
Techniques in Orthopaedics$


From the Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, Singapore, Republic of Singapore. The authors declare that they have nothing to disclose. Address correspondence and reprint requests to Wilfred C.G. Peh, MD, FRCP, FRCR, Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, 90 Yishun Central, Singapore 768828, Republic of Singapore. E-mail: wilfred.peh@alexandrahealth.com.sg. Copyright r 2013 by Lippincott Williams & Wilkins ISSN: 0148-703/13/2801-0012

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Imaging-guided Spinal Facet Joint Injections

INDICATIONS AND CONTRAINDICATIONS2733

There is no specic radiologic, clinical, or physical examination nding that is diagnostic of the facet joint syndrome. The indications of facet joint injection may therefore be described as being diagnostic or therapeutic or both.

TECHNIQUE, DRUGS, AND EQUIPMENT

The procedure is usually performed on an outpatient basis, and patients are asked to fast for 6 to 8 hours before the procedure. Informed consent should be obtained from the patient by the procedurist, with all risks and potential complications clearly explained. The procedurist should also ask about the type, location, nature, and severity of pain, as well as history of prior treatment, including the previous surgery. The patients medical and imaging records should be carefully reviewed, paying close attention to any documented drug allergy and signicant abnormalities in the prior imaging studies. Usually, no premedication is required but mild or lowdose sedation in the form of a short-acting benzodiazepine may be administered in anxious patients just before the start of the procedure. Depending on the availability of facilities and expertise, facet joint injection may be performed under uoroscopy or computed tomography (CT) guidance. Except for thoracic facet joint injection, uoroscopy guidance is the preferred choice in our institution in view of lower radiation exposure and ease of procedure. When uoroscopy guidance is used, the procedure is performed in an interventional suite equipped with C-arm uoroscopy. Instruments are prepared and thoroughly checked before the procedure. A time-out routine is performed before starting the procedure to ensure correct patient and site of injection. Baseline vital signs are obtained and physiological monitoring (pulse oximetry, blood pressure, and pulse rate) is performed during the procedure, particularly when conscious sedation is used. Resuscitation equipment should be readily available. The facet joint injection set in our institution consists of: (1) injection apparatus consisting of a 10-mL syringe with a 24-G hypodermic needle for skin inltration of local anesthetic, a 22-G spinal needle for injecting the facet joint, and a 1-mL insulin syringe for injection of mixture of steroid and local anesthetic agent into the facet joint; (2) drugs consisting of 1% Lidocaine for local skin inltration, 40 mg/mL of Triamcinolone acetate (Shincort), and 0.5% Bupivacaine (a medium-acting local anesthetic agent). A volume of 0.5 mL of Triamcinolone acetate (40 mg/mL) and 0.5 mL of Bupivacaine (0.5%) are mixed in a syringe for injection into each facet joint. It is usually not necessary to inject a contrast agent for purposes of conrming needle position.

Diagnostics
 Clinical suspicion of facet joint syndrome:
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Chronic headaches with radiation to suboccipital region, shoulders, or midback region associated with restricted neck movement. Focal tenderness over the facet joint upon direct palpation, associated with signs of paravertebral muscle spasm. Low back pain that is brought about or aggravated by movements, such as stretching, rotation, sideways bending, and hyperextension. Low back pain that is brought about or increased by maintenance of certain positions, such as sitting erect for a prolonged period of time. (Pseudo)radicular pain with the absence of neurological decit and root tension signs on raising the leg straight.

 Chronic pain, which is not relieved by trial of nonsteroidal anti-inammatory drugs and physiotherapy.  Chronic neck pain after whiplash injury.  Postlaminectomy syndrome with no evidence of arachnoiditis or recurrent disk disease.  Suspected adjacent segmental degeneration after fusion surgery.

Therapeutics
 Patients with conrmed facet joint syndrome, particularly those who show a positive response toward diagnostic facet injection.  Presence of adjacent segment deterioration after spinal fusion or persistent low back pain after a stable posterolateral fusion.  As an adjunct to conservative management.  In patients in whom oral or systemic drug therapy have to be withdrawn because of adverse effect or have exceeded the maximum tolerable dose. Contraindications to facet joint injections are relative, with no absolute contraindications. These include:  Systemic, bacterial, or local skin infection.  Underlying bleeding disorders or ongoing anticoagulation therapy.  Allergy to any of the injectates.  Patients who are already receiving maximum amount of steroids.  Progressive neurological disorder, which may be masked by the procedure.  Inability to obtain percutaneous access to the target facet joint.  Pregnancy. For patients who are on anticoagulation therapy, the risks and benets of stopping anticoagulation therapy should be explained to the patient after discussion with the referring clinician. Diabetic patients should be informed about the possibility of suboptimal sugar control after injection of steroids, particularly when multilevel injection in a single setting is planned.
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Cervical Facet Joint Injection

The cervical facet joints are oriented in an oblique coronal plane with 35 to 45 degrees of posterior slope.34,35 In our experience, the lateral position allows the most straightforward access to the cervical facet joints, although some interventionalists adopt a posterior or oblique approach. In our practice, the patient lies in a lateral position, with the side of injection facing upward. A soft pad is placed underneath the neck to prevent lateral exion of the neck. If the lower cervical levels (C5/C6 and below) are targeted, the shoulders may need to be drawn down to improve visualization and gain access to the facet joints. Under strict aseptic precautions and direct uoroscopy guidance, the target level is identied by counting downward from C2 vertebra. The patients neck is adjusted to obtain a true lateral position, particularly of the facet joints. The skin entry site is marked with an artery forceps and subsequently anesthetized with local anesthetic agent. Under intermittent uoroscopy guidance, a 22-G needle is directed vertically and
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advanced gradually into the facet joint. The inferior-posterior aspect of the joint is the preferred target (Fig. 1) to ensure that the needle tip is away from the intervertebral foramina and spinal canal. A slight feeling of giving way can be appreciated by the experienced practitioners when the needle enters the facet joint. If necessary, the C-arm can be rotated to the anteroposterior projection to determine the depth of the needle. In our opinion, this additional step is not necessary but may be useful for the less-experienced practitioner. Once the needle is thought to be intra-articular in position, the patients neck is rotated from one side to the other side by a few degree increments, while observing the position of the needle tip under uoroscopy. If the needle tip is within the joint, it will move together with the joint regardless of the direction of rotation of the neck. Alternatively, a facet arthrogram with 0.1 to 0.3 mL of contrast agent can be performed. Filling of the superior or inferior recesses of the joint capsule veries the intra-articular position. Excessive contrast agent injection should be avoided as this may restrict subsequent injection of the drug mixture due to a smaller volume within the facet joints. After conrmation of the needle position, the drug mixture can then be injected. Alternatively, the procedure may be performed using a posterior approach.36 The patient is placed in the supine oblique position at approximately 45 degrees with the side to be injected facing up. The head should be turned away from the side to be injected. The frontal tube is then angled until the facet joint is best visualized, and a 22-G needle is then advanced into the joint. True lateral and anteroposterior views are obtained subsequently to conrm the needle position.

The general principles and equipment used for thoracic facet joint injection are similar to that used in cervical facet joint injection. The main difference is the positioning of the patient, which is prone in the case of thoracic facet joint injection. The medial side of the joint has a more posterior location, and it is therefore more supercial compared with the lateral half when the joint is targeted through a posterior approach. This explains why the medial half of the joint is the preferred target point in our practice. A CT uoroscopy is recommended as this allows direct visualization during needle placement while avoiding the lungs and nerve roots. This is particularly helpful in patients with extensive degenerative changes and spinal deformities. Thoracic facet injection is performed through a posterolateral approach under strict aseptic precautions. Placement of the needle tip is just below the inferior margin of the inferior articular facet and posterior to the adjacent superior articular facet (Fig. 2). This allows access into the inferior joint recess. Access into the interfacetal portion of the joint is not possible or necessary. Alternatively, the injectate may be deposited in the extracapsular soft tissue posterior to the inferior portion of the facet joint. This is sufcient to relieve the patients pain if it is facet related.37

Lumbar Facet Joint Injection

The lumbar facet joints are curved structures that have a sagittal oblique orientation. The superior facets face anterolaterally, whereas the inferior facets face posteromedially.38 Hence, the posterior aspect of the joint lies further away from the midline compared with the anterior aspect. The procedure may be performed under uoroscopy or CT guidance, with CT being preferred in difcult cases, for example, in patients with marked degenerative joint disease. The patient lies prone in both settings with a pillow placed under the abdomen to straighten the spine. Under pulsed uoroscopy, the patient is gently rotated through an arc with the side to be injected raised off the couch, until the vertical posterior joint gap becomes visible. The initial portion of the joint to be seen in the prole will be its posterior aspect and further rotation will bring its

Thoracic Facet Joint Injection

The thoracic facet joints are nearly vertical and coronal in orientation, which helps to protect the spine form shearing forces. They are inclined nearly 60 degrees to the coronal plane and rotated so that the superior facet faces posteriorly, superiorly, and laterally. They are thus not accessible through a straight posterior approach because of the overlying lamina. Direct lateral approach is not possible in the thoracic spine.

FIGURE 1. Fluoroscopic-guided cervical facet joint injection. A, Lateral radiograph shows usage of artery forceps tip to indicate level of the right C4/5 facet joint. B, Tip of a 22G needle has been placed into the posterior aspect of the right C4/5 facet joint.

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FIGURE 2. CT-guided thoracic facet joint injection. A, Axial CT image of the lower thoracic vertebra, with the patient in a prone position. Surface marker is placed over the left T8/9 facet joint. B, A 22G needle has been inserted and its tip advanced into the left T8/9 facet joint, targeting its medial aspect.

anterior aspect into prole. Care should be taken not to overrotate the patient as the anterior portion of the joint space may come into view rather than the posterior portion, making needle placement into the joint impossible. Alternatively, the tube may be tilted to obtain an equivalent projection of the facet joint. Rotation may be as little as 30 degrees for the upper lumbar spine, whereas the lower lumbar spine may require obliquity of up to 60 degrees. This varies from patient to patient. When the posterior aspect of the facet joint is seen in prole, the corresponding skin-entry site is marked. Following standard skin preparation and local anesthetic injection, a 22-G spinal needle is directed vertically into the center of the facet joint space (Fig. 3) while under intermittent uoroscopy guidance to check the position of the needle tip. Intra-articular position of the needle tip is conrmed using the same methods described for cervical facet joint injection. Should attempts to gain an intra-articular position prove difcult; for example, in patients with large osteophytes, periarticular injection is an

acceptable alternative.38,39 During periarticular injection, the needle is rotated 360 degrees at the desired location, and 1.0 to 1.5 mL of equal portions of the local anesthetic and steroid mixture is injected around the facet joint. In our experience, we found that the outcome of a periarticular injection was comparable to that of intra-articular injection. Following the procedure, the patient is usually monitored for 15 to 30 minutes before discharge. Response to procedure is recorded in the same format as in preinjection questionnaire using a visual analog scale. The patient should be instructed to report any acute worsening of existing neck or back pain or development of any new neurological symptoms, for example, anesthesia or weakness of extremities. Complications are rare, particularly if aseptic precautions are adhered to and if the procedure is performed under imaging guidance with an accurate needle-positioning technique. Possible complications can be classied into those related to needle placement and drug administration. Complications related to needle placement include bleeding, spondylodiscitis, septic

FIGURE 3. Fluoroscopic-guided lumbar facet joint injections. Radiographs show the position of the 22G needle tip within the left (A) L4/5 and (B) L5/S1 facet joints.
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arthritis, dural puncture, spinal cord injury, intravascular injection, spinal anesthesia, neural trauma, and pneumothorax.31,32,40,41 Postinjection anesthesia and paralysis are mostly transient and usually resolve within minutes to hours. A case of transient tetraplegia after cervical facet joint injection has been previously reported by Heckmann et al,42 but the procedure was performed without image guidance. There have also been isolated cases of epidural and spinal abscesses, meningitis, and generalized infection leading to death.4346 Although severe allergic reactions in response to contrast agent and local anesthetic are uncommon, symptoms such as facial ushing and transient syncope may occur. Steroid injection may produce local reaction, most often occurring immediately after injection and may last for up to 48 hours.33 Applications of ice packs help to relieve the symptoms. Systemic side-effect of steroid is usually not an issue, given the small dose and localized steroid injection, unless there are repeated injections at multiple levels.

5. Putti V. New concepts in the pathogenesis of sciatic pain. Lancet. 1927;2:5360. 6. Badgley CE. The articular facets in relation to low back pain and sciatic radiation. J Bone Joint Surg Am. 1941;23:481496. 7. Hirsch D, Inglemark B, Miller M. The anatomical basis for low back pain. Acta Orthop Scand. 1963;33:117. 8. Mooney V, Robertson J. The facet syndrome. Clin Orthop Relat Res. 1976;115:149156. 9. McCall IW, Park WM, OBrien JP. Induced pain referral from posterior elements in normal subjects. Spine. 1979;4:441446. 10. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician. 2001;4:308316. 11. Schwarzer AC, April CN, Derby R, et al. The relative contributions of the disc and zygophyseal joint in chronic low back pain. Spine. 1994;19:801806. 12. Schwarzer AC, Wang SC, Bogduk N, et al. Prevalence and clinical features of lumbar zygophyseal joint pain: a study in an Australian population with chronic low back pain. Am Rheum Dis. 1995;54: 100106. 13. Manchikanti L, Pampati V, Fellows B, et al. Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician. 1999;2:5964. 14. Manchikanti L, Pampati V, Fellows B, et al. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain. 2000;4:337344. 15. Manchikanti L, Pampati V, Fellows B, et al. The inability of the clinical picture to characterize pain from facet joints. Pain Physician. 2000;3:158166. 16. Barnsley L, Lord SM, Wallis B, et al. The prevalence of chronic cervical zygophyseal joint pain after whiplash. Spine. 1995;20:2026. 17. Lord SM, Barnsley L, Wallis BJ, et al. The prevalence of chronic cervical zygophyseal joint pain with whiplash: a placebo-controlled prevalence study. Spine. 1996;21:17371745. 18. Manchikanti L, Singh V, Rivera J, et al. The prevalence of cervical facet joint pain in chronic neck pain. Pain Physician. 2002;5:243249. 19. Manchikanti L, Singh V, Pampati V, et al. Evaluation of the prevalence of facet joint pain in chronic thoracic pain. Pain Physician. 2002;5:354359. 20. Bogduk N. Low back pain. In: Bogduk N, ed. Clinical Anatomy of the Lumbar Spine and Sacrum. 3rd ed. New York: Churchill Livingstone; 1997:187214. 21. Sehgal N, Shah RV, Mckenzie-Brown AM, et al. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systemic review of evidence. Pain Physician. 2005;8:211224. 22. Hadley LA. Anatomicoroent-genographic studies of the posterior spinal articulations. Am J Roentgenol Radium Ther Nucl Med. 1961;86:270276. 23. Selby DK, Paris SV. Anatomy of facet joints and its clinical correlation with low back pain. Contemporary Orth. 1981;3:10971103. 24. Maldague B, Mathurien P, Malghern J. Facet joint arthrography in lumbar spondylosis. Radiology. 1981;140:2936. 25. Lewin T, Moffett B, Viidik A. The morphology of the lumbar synovial intervertebral joints. Acta Morphol Neerl Scand. 1962;4: 299319. 26. Jackson HAC, Winkelmann RK, Bickel WH. Nerve endings in the human lumbar spinal column and related structures. J Bone Joint Surg. 1966;48A:12721281. 27. Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review. Arch Phys Med Rehabil. 2008;89:770774.
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Clinical Outcome
When performed under imaging guidance, facet joint injections are accurate and useful in both diagnosis and treatment of facetogenic back pain. The diagnostic accuracy of imaging-guided facet joint injections has been reported as strong in the diagnosis of facet jointrelated neck and low back pain, as well as moderate in the diagnosis of pain arising from thoracic facet joints.41 With regard to its therapeutic efcacy, most of the available data are based on noncontrolled and observational studies, mostly pertaining to the lumbar spine. Short-term relief from symptoms (1 to 4 wk) after lumbar facet injections has been observed in 42% to 92% of patients, whereas medium-term relief at 3 months ranges from 18% to 62%.47,48 A 2007 systemic review49 concluded that for cervical intra-articular facet joint injections, the evidence is limited for short-term and long-term pain relief; for lumbar intra-articular facet joint injections, the evidence is moderate for short-term and long-term pain relief.

SUMMARY
Chronic neck or back pain secondary to facet joint arthropathy is extremely common in elderly population. Intraarticular injections may be performed for both diagnostic and therapeutic purposes. Imaging guidance improves accuracy of needle placement and potentially reduces inadvertent injury of vital structures around the joint. Fluoroscopy and CT guidance are commonly used to provide real-time guidance for intraarticular needle placement. Given the high success rate and low complications, image-guided injection is deemed safer and more effective compared with conventional blind injections.
REFERENCES
1. Hellsing A, Bryngelsson I. Predictors of musculoskeletal pain in men. A twenty year follow-up from examination at enlistment. Spine. 2000;25:30803086. 2. Wiesel SW, Tsourmas N, Feffer HL, et al. A study of computer assisted tomography. The incidence of positive CAT scans in an asymptomatic group of patients. Spine. 1984;9:549551. 3. Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am. 1990;72:403408. 4. Goldthwait JE. The lumbo-sacral articulation: an explanation of many cases of lumbago, sciatica, and paraplegia. Boston Med Surg J. 1911;164:365372.

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28. Fairbank JCT, Park WM, McCall IW, et al. Apophyseal injection of local anaesthetic as a diagnostic aid in primary low back pain syndromes. Spine. 1981;6:598605. 29. Lippitt AB. The facet joint and its role in spinal pain: management with facet joint injections. Spine. 1984;9:746750. 30. Helbig T, Lee CK. The lumbar facet syndrome. Spine. 1988;13: 6164. 31. Peh WCG. Facet injections. Proceedings of the 23rd International Congress of Radiology, 2004, Montreal, Canada. Bologna: Medimond, 351356. 32. Gopinathan A, Peh WCG. Image-guided facet joint injection. Biomed Imaging Interv J. 2011;7:e4. 33. Manchikanti L, Singh V. Review of chronic low back pain of facet joint origin. Pain Physician. 2002;5:83101. 34. Sohaib SAA, Butler P. The vertebral column and spinal cord. In: Butler P, Mitchell AWM, Ellis H, eds. Applied Radiological Anatomy. Cambridge: Cambridge University Press; 1999:306308. 35. Eckel TS. Facet joint injections. In: Mathis JM, ed. Image Guided Spine Interventions. New York: Springer-Verlag; 2004:127. 36. Silbergleit R, Mehta BA, Sanders WP, et al. Imaging-guided injection techniques with fluoroscopy and CT for spinal pain management. Radiographics. 2001;21:927942. 37. Czervionke LF, Fenton DS. Facet joint injection and medial branch block. In: Fenton DS, Czervionke LF, eds. Image-Guided Spine Intervention. Philadelphia: WB Saunders; 2003:257286. 38. Lilius G, Laasonen EM, Myllynen P, et al. Lumbar facet joint syndrome: a randomized clinical trial. J Bone Joint Surg Br. 1989;71:681684.

39. Tsai CT, Hsieh LF, Kuan TS, et al. Injection in the cervical facet joint for shoulder pain with myofascial trigger points in the upper trapezius muscle. Orthopedics. 2009;32. doi: 10.3928/01477447-20090624-04. 40. Falagas ME, Bliziotis IA, Mavrogenis AF, et al. Spondylodiscitis after facet joint steroid injection: a case report and review of the literature. Scand J Infect Dis. 2006;38:295299. 41. Weingarten TN, Hooten MW, Huntoon MA. Septic facet joint arthritis after a corticosteroid facet injection. Pain Med. 2006;7:5256. 42. Heckmann JG, Maihofner C, Lanz S, et al. Transient tetraplegia after cervical facet joint injection for chronic neck pain administered without imaging guidance. Clin Neurol Neurosurg. 2006;108:709711. 43. Alcock E, Regaard A, Browne J. Facet joint injection: a rare form cause of epidural abscess formation. Pain. 2003;103:209210. 44. Cook NJ, Hanrahan P, Song S. Paraspinal abscess following facet joint injection. Clin Rheumatol. 1999;18:5253. + rfer B, Winterholler M. Iatrogenic (para-) spinal 45. Gaul C, Neundo abscesses and meningitis following injection therapy for low back pain. Pain. 2005;116:407410. 46. Kim SY, Han SH, Jung MW, et al. Generalised infection following facet joint injectiona case report. Korean J Anesthesiol. 2010;58:401404. 47. Lynch MC, Taylor JF. Facet joint injection for low back pain: a clinical study. J Bone Joint Surg Br. 1986;68:138141. 48. Marks RC, Houston T, Thulbourne T. Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain. Pain. 1992;49:325328. 49. Boswell MV, Colson JD, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10:229253.

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