Facet joints are located on the back of the spine, enabling movement and providing stability. When inflamed or arthritic, they can become a source of chronic pain. A facet joint injection (FJI) is a common initial step, using a mix of local anesthetic and corticosteroid medication for diagnosis and temporary relief. If the injection provides significant, short-term pain reduction, the facet joint is confirmed as the primary pain generator. However, the therapeutic effect of the steroid is often limited, and failure to achieve long-lasting relief is a frequent outcome.
Re-evaluating the Diagnosis and Optimizing Non-Procedural Management
When a facet joint injection provides no lasting relief, the first step is re-evaluating the diagnosis, as spinal pain conditions often mimic one another. The injection failure suggests the pain may originate elsewhere. A physician will review advanced imaging, such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans, to look for other primary pain generators. These alternative sources might include a herniated disc causing nerve root compression, or spinal stenosis, which is a narrowing of the spinal canal.
Optimizing conservative care is a foundational step before considering more invasive procedures. This involves adjusting the medication regimen to manage pain and inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, or nerve pain medications may be introduced. Physical therapy (PT) is a cornerstone of management, focusing on strengthening the core and paraspinal muscles to support the spine and improve stability.
Lifestyle modifications are also important, particularly focusing on weight management to decrease the load placed on the spinal joints. Correcting poor posture and incorporating specific exercises into daily routines can significantly reduce the recurrence of facet joint pain. These conservative efforts maximize functional improvement before moving to advanced interventions.
Radiofrequency Neurotomy (RFA): The Primary Next Step
If patients experience robust but short-lived relief from the diagnostic FJI, the most logical next procedural step is Radiofrequency Neurotomy (RFA), also known as Radiofrequency Ablation. This minimally invasive procedure offers a more durable solution by targeting the medial branch nerves that transmit pain signals from the facet joints to the brain. The RFA procedure involves inserting a specialized needle, guided by fluoroscopy (real-time X-ray), near the target nerve supplying the painful joint.
A small radiofrequency current is passed through the needle’s tip, generating heat to create a small lesion on the nerve. This thermal lesion temporarily disrupts the nerve’s ability to send pain signals, effectively turning off the pain transmission from that specific facet joint. The procedure is only performed after a successful diagnostic medial branch block, which uses local anesthetic to confirm the medial branch nerve as the correct target. This requirement ensures that the patient is likely to benefit from the longer-term denervation.
The duration of pain relief from RFA often lasts from six to eighteen months, until the lesioned nerve regenerates. The procedure itself is performed on an outpatient basis using local anesthetic and typically takes less than an hour. The specific treatment area dictates the procedural codes used for billing. These codes are reported per joint, not per individual nerve, even though two medial branch nerves typically innervate each facet joint.
Exploring Advanced Interventions and Surgical Options
When pain remains refractory despite RFA, or if diagnostic blocks did not provide sufficient temporary relief, cryoablation may be explored. Cryoablation uses extreme cold instead of heat to lesion the targeted medial branch nerve. Both cryoablation and RFA interrupt the same pain pathway but use different energy sources.
Surgical options become the final consideration for patients whose pain has not responded to conservative or interventional procedures. Spinal surgery is reserved for cases where imaging reveals significant structural issues, such as instability or severe degenerative changes. Fusion surgery involves permanently connecting two or more vertebrae to eliminate all motion at the painful joint segment.
The decision to proceed with fusion is made only after exhaustive testing and a thorough assessment of spinal stability. Since surgery is the most invasive option, requiring a significant recovery period and carrying inherent risks, it is considered the last resort when all other less-invasive treatments have failed.