What are facet (Zygapophysial) joints?

The facets are small paired synovial joints which reside at the back of the vertebral bodies in the cervical, thoracic, and lumbar spine. These joints prevent the vertebrae from sliding backward and forward upon one another and they can occasionally be a source of back or neck pain.

What is a medial branch block or facet arthrogram?

Because the facet joints are very small, pain deriving from them cannot be accurately diagnosed by imaging studies or a physical examination. In order to determine if a particular facet joint is painful a series of two fluoroscopically guided diagnostic injections must be performed. This typically involves introducing several small needles next to the nerves innervating the facet joint and anesthetizing them on two separate occasions. The medication may also be placed directly into the facet joints. In rare instances the facet joints may develop cysts and your referring doctor may ask us to drain them.

What will happen to me during the procedure?

An IV will be started to ensure your safety. You may receive intravenous relation medication but general anesthesia is not used and you will be awake throughout the procedure. You will be positioned face down on the table and the skin over your spine will be well cleaned with iodine or alcohol. The physician will numb a small area of skin with an anesthetic, which stings for a few seconds. Next, the physician will use x-ray guidance to direct several very small needles either into the facet joints or adjacent to the nerves that innervates the joints. He will then inject contrast material to confirm that the medicine flows around the joint in the proper distribution. This may increase your usual pain for about 30 seconds. Lastly, a small amount of numbing medicine and, perhaps, cortisone will be injected.

What should I do after the procedure?

Twenty-thirty minutes afterwards you will try to provoke your usual pain. You will report your percentage of pain relief and also record the relief you experience during the next several hours on a "pain diary" which we will provide to you. You should bring the completed pain diary with you when you see your referring physician. You will wait 30-60 minutes before going home. No driving for eight hours because you may experience temporary numbness or weakness. A telephone visit will be schedule for you with one of our staff after the procedure to assess the results of the injection and, if indicated, to schedule the second in the series.

Potential Complications

With any procedure there are potential complications. You and your doctor should discuss these before being referred for an epidural. We believe that in carefully selected patients the potential benefits from an epidural outweigh the potential harms. Potential complications or risks may include, but are not limited to:

1. If you are a diabetic your blood sugar will increase for 48 hours after the cortisone injection and you will need to monitor this.
2. If the spinal needle punctures the spinal sack and spinal fluid escapes this is referred to as a ‘wet tap’. A wet tap is not dangerous, but it will result in postponement of the epidural. Approximately 25% of patients who have a wet tap will develop a spinal headache. This may require treatment with an “epidural blood patch”. The incidence of wet taps with fluoroscopically guided procedures is less than 1%.
3. Infection is a remote possibility whenever a needle is introduced under the skin. To prevent this complication your skin will be disinfected and carefully prepared using strict sterile technique. If an infection in the spinal canal or vertebrae occurs, this is a serious complication and it will require intensive antibiotic treatment and possibly surgery.
4. Local bleeding can rarely be serious and require further treatment.
5. There is potential for nerve injury which can lead to permanent pain and /or weakness.
6. You may have an allergic/adverse reaction to medications and substances used during the procedure: Betadine (contain iodine), anesthetics, contrast agents, corticosteroids. Side effects of corticortisteroids include increased blood sugar, increased blood pressure, mood swings, fluid retention that can exacerbate existing heart failure, local fat atrophy, facial flushing, skin discoloration, gastritis or peptic ulcer disease, bone demineralization and necrosis of the hip.
7. For cervical procedures, on rare occasions, there is a risk of spinal cord injury that may result in quadriplegia/paraplegia, impaired breathing, prolonged headaches, seizures, stroke, and possible death associated with the procedure.
8. For thoracic (mid-back) procedure, there is a risk of lung puncture and collapse of the lung(s), which may require placement of a chest tube to re-expand your lungs.
9. Risk of conscious sedation, which include, but not limited to allergic reactions to medications, post-procedure psychological problems such as hallucination, potential for over sedation, potential breathing problems, lack of blood flow and oxygen to vital organs such as the brain and the heart, which creates the risk of major complications such as stroke, heart attack or potentially even death.
10. Although most patients will benefit from the procedure, there is no guarantee of the desired results. Some patients will have a severe flare up in their pain for 1-2 weeks after an injection. In some individuals, this increase in pain can last longer, or in rare cases, even be permanent.

General Pre/Post Procedure Instructions

1. You should REFRAIN FROM EATING AND DRINKING 8 HOURS prior to the procedure EXCEPT for taking sips of plain water with medication (see below).
2. If you are taking oral (pill form) diabetes medication, DO NOT take this medication the morning of the procedure.
3. Take all other routine medications before the procedure (such as high blood pressure medication and insulin injection), including the morning of the procedure, with sips of water. If you are taking insulin injection, inject only HALF of the usual scheduled dose the morning of the procedure.
4. STOP ASPIRIN and any medication that contains aspirin, such as Excedrin, 7 DAYS PRIOR to the prodecure.
5. STOP ALL ANTI-INFLAMMATORY MEDICATIONS (e.g. Motrin/Ibuprofen, Naprosyn/Naproxen, Aleve, Relafen/nabumetone, Lodine/etodolac, Daypro, Indocin, Celebrex, Trilisate, Feldene etc.) 5 DAYS PRIOR to the procedure.
6. If you are taking St. John’s Wort, Ginkgo, Ginseng, or Garlic supplements, you will need to stop these 5 days prior to the procedure. All of your routine medicines and supplements can be re-started after the procedure on the same day. You may take your regular pain medicine as needed before/after the procedure.
7. If you are taking Coumadin/Warfarin, heparin, Lovenox/Enoxaparin, please call the Coumadin Clinic at your local Kaiser facility or the physician who prescribed the medication prior to your visit.
8. If you are taking Plavix/Clopidogrel, Ticlid/Ticlopidine, or Pletal/Cilostazol, you must notify our office no later than 2 weeks prior to the procedure so that the timing of stopping these medicines can be explained.
9. You will need to bring a driver with you who is available to wait for you during the procedure. You may return to your current level of activities the next day, including return to work.
10. If you are on antibiotics, please notify our office, we may postpone the procedure until you have finished the medicine.
11. If you have an active infection or fever, we will not perform the procedure.
12. If you are a woman of childbearing age and you know or suspect that you may be pregnant, we will not perform the procedure.
13. If you have a known allergy – rash, hives, or anaphylaxis – to iodinated contrast agents, please contact our office 1week prior to your procedure.
14. You will be in the hospital for 2-3 hours even though you will see the physician for only 20 to 30 minutes.
15. You may return to your current level of activities the next day, including return to work.
16. If you have a recent spine MRI which was performed outside Kaiser Permanente you must hand carry it with you to your visit. Failure to do so may result in rescheduling of the procedure.

Cortisone inhibits the body’s response to fight infection. Cortisone injections should not be given if there is an active infection elsewhere in your body. This is an elective procedure. If you have fever, chills, have a cold or flu or any infection, you should call to cancel the procedure. You should also call to cancel the procedure if you have recent (since booking this procedure) exacerbation of heart failure, heart attack, stroke or transient ischemic attack.

For cancellation or rescheduling procedures: Call (510) 675-4540

IF YOU NEED TO CANCEL THE PROCEDURE THE DAY OF YOUR APPOINTMENT, PLEASE CALL THE KAISER FREMONT AMBULATORY SURGERY CENTER DIRECTLY AT (510) 248-5650.

Place of Procedure

Your procedure will be performed at the Kaiser Fremont Ambulatory Surgery Center, located on the ground floor of the Embarcadero Building, Kaiser Fremont Hospital, 39400 Paseo Padre Parkway, Fremont, CA 94538.

Appointment Date:_____________________________________________________

Appointment Time:_____________________________________________________

Physician: ____________________________________________________________

NOTE: Please arrive ONE HOUR PRIOR to the appointment time to allow necessary preparation for the procedure. Failure to do so will result in rescheduling of the procedure.