Facet joints are small, paired connections located on the posterior side of the vertebrae that provide stability and guide motion throughout the spine. Pain from these joints, often described as a dull ache in the lower back or neck, may radiate to the buttocks, hips, or shoulders and typically worsens with extension or twisting movements. Facet joint injections deliver a local anesthetic and anti-inflammatory steroid. The anesthetic confirms the facet joint as the source of discomfort, while the steroid aims to reduce inflammation and provide longer-lasting relief. When this initial intervention does not yield lasting improvement, a clear pathway of subsequent steps exists to identify the true pain generator and move toward effective management.
Re-evaluating the Original Diagnosis
The failure of a facet joint injection often signals that the original source of pain was misidentified. A thorough re-evaluation is the necessary next step to pinpoint the actual cause of the persistent discomfort. This process frequently begins with a review of advanced imaging studies, such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans, to visualize soft tissues and bony structures. These scans help rule out other potential pain sources with similar symptoms, including herniated discs, nerve root compression, or spinal stenosis, which would require a different treatment approach.
A definitive diagnostic tool in this re-evaluation is the Medial Branch Block (MBB). The facet joints are innervated by the medial branch nerves, and the MBB involves injecting a local anesthetic directly onto them. If the patient experiences a significant, but temporary, reduction in pain (typically 50% to 80% relief) following the injection, it confirms that the medial branch nerves are carrying the pain signal from the facet joint. This positive response is required before proceeding with more definitive, long-term treatments that target these nerves. If the MBB does not provide relief, the investigation must shift away from the facet joints to other spinal structures.
The Role of Radiofrequency Ablation
If diagnostic medial branch blocks confirm the facet joints are the source of pain, the next procedural step is typically Radiofrequency Ablation (RFA), also known as radiofrequency neurotomy or rhizotomy. RFA is a minimally invasive, outpatient procedure that uses heat to temporarily disable the nerves transmitting the pain signals. This procedure is distinct from the steroid injection because it targets the nerve itself rather than delivering anti-inflammatory medication into the joint capsule.
During the RFA procedure, a specialized needle is placed near the medial branch nerves under fluoroscopic (X-ray) guidance. A radiofrequency current is then delivered through the needle tip, heating the targeted nerve tissue to a temperature between 80°C and 90°C. This controlled heat creates a lesion on the nerve, effectively interrupting its ability to send pain signals from the facet joint to the brain. The entire process usually takes between 30 and 60 minutes and is performed with local anesthesia and light sedation.
Patients may experience mild soreness at the injection site for a few days, but recovery time is generally short, allowing a return to normal activities within a day or two. Pain relief from RFA is not immediate and may take up to a week or more to become noticeable as the nerves heal from the treatment. The relief provided by RFA is long-lasting, typically ranging from 6 to 12 months, and in some cases, up to two years. Because the ablated nerves eventually regenerate, the procedure can be safely repeated when the pain returns.
Maximizing Conservative and Medication Approaches
Even with procedural interventions, a comprehensive pain management strategy must include maximizing conservative and pharmacological approaches for sustained improvement. Physical therapy is a fundamental component, designed to address the underlying biomechanical factors contributing to facet joint stress. This includes a tailored program focused on strengthening the core and paraspinal muscles, which helps to stabilize the spine and reduce the load on the painful facet joints.
A therapist will also work on improving posture, enhancing flexibility, and correcting movement patterns that may aggravate the joints. Complementary therapies may also be included, such as chiropractic care to restore proper spinal alignment or massage therapy to relieve muscle tension surrounding the spine. These approaches support the long-term goal of functional recovery and self-management.
Pharmacological management is also optimized to provide background pain control and reduce inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to manage localized pain, while muscle relaxers can help alleviate spasm and tightness in the supportive musculature. For pain that has a neuropathic component, medications targeting nerve signals may be introduced. The strategic use of these medications works in conjunction with physical therapy to improve overall comfort and facilitate participation in rehabilitation.
When Surgery Becomes Necessary
Spinal surgery is considered the final option for patients with chronic, debilitating facet joint pain that has failed to respond to conservative treatments and minimally invasive procedures, including RFA. The primary surgical intervention for this condition is spinal fusion, also known as arthrodesis. This procedure is designed to permanently stabilize the painful facet joint by fusing two or more adjacent vertebrae into a single, solid bone segment.
The goal of fusion is to eliminate the motion at the affected joint, thereby stopping the pain signals that originate from the joint’s movement and degeneration. This is a major operation requiring a lengthy recovery period and carries inherent risks associated with spinal surgery. Because of its invasive nature and the potential for long-term complications, such as increased stress on adjacent spinal segments, fusion is reserved for the most severe cases. A surgeon will only recommend this step after confirming that the facet joints are definitively the pain source and that the patient’s quality of life is severely compromised.