Which particular procedure you may need is determined by a neurological examination.


Indications: Lower back pain or neck pain.

What are lumbar facet joints?
Lumbar facet joints are small joints located in pairs in your lower back. These joints provide stability and guide motion in your spine. Source of pain in 20 to 40% of lower back pain or neck pain depending on age.

Why are facet joint injections helpful?
If the joints become painful due to arthritis (degenerative joint disease or spondylosis), injury, or mechanical stress, they can cause pain in various areas. The lumbar facet joints can cause pain in your lower back, hip, buttock, or leg.

A facet joint injection serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief you experience will help confirm or deny the joint as a source of your pain. That is, if you obtain complete relief of your main pain while the facet joints are numb, then these joints are likely your pain source. Furthermore, time-release cortisone will be injected into these joints to reduce any presumed inflammation, which can, on many occasions, provide long-term pain relief.

What will happen to me during the procedure?
Adequate relaxation medicine can be given, if needed. After lying on an x-ray table, the skin over the area of the spine to be treated will be well cleansed. Next, the physician numbs a small area of skin with numbing medicine (anesthetic), which stings for a few seconds. Next, the physician will use x-ray guidance to direct a very small needle into the joint. He then injects several drops of contrast dye to confirm that the medicine only goes into the joint. A small mixture of numbing medicine (anesthetic) and anti-inflammatory cortisone is then slowly injected.

What should I do after the procedure?
20-30 minutes after the procedure, you move your area of usual discomfort to try to provoke your usual pain. You report your remaining pain (if any) and record the relief you experience during the next week in a "pain diary" we provide*. You may or may not feel improvement during the first few hours after the injection. This depends on if the joints injected are your main pain source. The pain diary is an important component of your care. It helps your treating physician to be informed of your results so future tests and/or needed treatment can be planned.

How will I feel after the procedure?
Most patients feel better after a procedure, because of the effect of the local anesthetics. On occasion, the part of your treated spine may feel slightly odd for a few hours after the injection. You may notice a very slight increase in your pain lasting for a day or two day, as the numbing medicine wears off before the cortisone becomes effective. Ice is typically more helpful than heat during the first 2-3 days after the injection, although most patients do not need anything other than mild analgesics. You may begin to notice an improvement in your pain 2-5 days after the injection. If you do not notice improvement within 10 days after the injection, it is unlikely to occur.

Can I take my regular medications after the procedure?
You may take your regular medications after the procedure, but try to limit any pain medications for the first 4-6 hours after the procedure. This will ensure that the diagnostic information obtained from the procedure is accurate.

You may be referred for rehabilitation after the injection while the numbing medicine is effective and/or over the several weeks while the effect of the medication is working.

When can I resume activity?
On the day of the injection you should not drive and should avoid any strenuous activities. On the day after the procedure, you may return to your regular activities. When your pain is improved, start your regular exercise in moderation. Even if you are significantly improved, gradually increase your activities over 1-2 weeks to avoid recurrence of your pain.


Indications: Radicular pain with or without lower back pain.

As the spinal nerves emerge from the spinal cord, they travel laterally 1-2 cms before they exit the spine. It is at this exit (Intervertebral foramen) that these nerves are most likely compressed or "pinched" by either a herniated or slipped disc, bone spurs or more rarely tumors, narrowing of the exit of the nerve and "pinching it". This pressure on the spinal nerves causes inflammation and pain. The pain could affect the back alone or can irradiate to the legs, which is known as sciatica. Conservative treatments for these conditions includes analgesics, anti-inflamatories; however, epidural steroid injections are most effective in the presence of nerve root compression.

Scientific studies often demonstrate inflammation of the spinal nerves following prolonged compression, which leads to irritation and swelling. This irritation occurs at the level of the root of the lumbar nerves. The injection of steroids, which are potent anti-inflamatories, is made into the epidural space, close to the affected nerve roots. These injections are given by pain management specialists who are well trained in this technique. Improvement of the symptoms appears to correlate well with the resolution of the nerve root inflammation. These injections are most effective when given in the first weeks of the onset of pain. Usually, two to three injections one to two weeks apart are required. Only a single injection is given if complete pain relief is achieved.

Physicians limit the number of epidural steroid injections to a maximum of three to avoid systemic side effects of the steroids. Side effects are minimal and consist mainly of mild tenderness in the area of injection which disappears in 1-2 days. Success is dependant on the cause of the pain and how long the pain has existed. The sooner the treatment is instituted, the better are the chances of getting well. This treatment, along with analgesics and physical therapy has brought relief to thousands of patients, avoiding , in the majority of cases, the need for surgery.


Indications: Neck or lower back pain after determining which levels are involved in the generation of pain.

Is there anything worse than neck pain? If you ask someone who suffers with chronic neck pain, the chances are their reply is a resounding "No"! Neck pain often radiates into the shoulders and upper back and may be accompanied by other symptoms such as headaches and extremity tingling and numbness.

Chronic neck pain sufferers may wonder, "What causes neck pain and how can this aggravating pain be stopped?" One cause is dysfunction or disease affecting the cervical facet joints. The cause, combined with a treatment called Pulsed Radiofrequency Neurotomy (PRFN) (or Pulsed Radiofrequency Rhizotomy), is the topic of this section. A similar procedure is also frequently performed for lower back pain, for example when facet injections prove insuficient for pain control (see above facet injections).

What is a cervical facet joint?
Facets are the spine's system of joints that enable movement. Some of this was discussed above when describing "Facet injections". Another term for the facet joints are Zygapophyseal or Apophyseal Joints. At the back of each vertebra are two sets of facet joints. One pair faces upward and one downward; with one joint on the left and right sides of each vertebra. Facet joints allow flexion (bend forward), extension (bend backward), and twisting motion. In general, the spine is made more stable due to the interlocking nature of the facet joints to the adjacent vertebrae.

Similar to other joints in the body, each facet joint is surrounded by a capsule of connective tissue and produces fluid to nourish and lubricate the joint (synovial fluid). The joint surfaces are coated with a thick spongy material termed articular cartilage that enables the bones of each joint to smoothly move against the other.

What causes the cervical (or lumbar in lower back) facet joints to become painful?
Osteoarthritis is probably the most common cause of cervical facet joint pain. This degenerative disease causes progressive cartilage deterioration. Without the spongy cartilaginous cushion, joint bones begin to rub against each other when at rest and during movement. Another condition, Degenerative Disc Disease (DDD) or spondylosis may compromise the structural integrity of the intervertebral discs causing discs to lose normal height. Loss of disc height may cause the affected facet joints to become positioned too closely thereby disrupting the joint's ability to function normally.

In addition, rheumatoid arthritis, ankylosing spondylitis, spinal stenosis, injury, poor posture, and wear and tear may also contribute to a painful facet joint disorder.

How can RFN relieve symptoms?
Radiofrequency Neurotomy (RFN) is a minimally invasive procedure that disables and prevents a specific spinal nerve from transmitting pain signals. This are "sensory" nerves carrying pain signals to the brain without relevant motor functions (as opposed to the nerves that go to muscles to make your arm or leg move). The pain specialist will accurately identify them based on imaging and stimulation techniques. RFN is a modified version of a procedure termed Radiofrequency Therapy (RT), a procedure developed more than 30 years ago. RFN is still fairly new, but more and more pain management specialists are performing this procedure to treat painful facet joints.

In the past, nerves used to just be cut. This technique has been abandoned because nerves developed abnormal growths called neuromas and during this process, patients used to develop pain that was even worse than the original pain.

What are the possible complications with RFN?
As with any medical procedure, there are risks and potential complications. Although complications rarely occur, patients need to know what could happen. The following list is not conclusive: bleeding, infection, nerve or spinal cord injury, increased pain, allergic or other reaction to medications used (e.g. anesthetic). Dr. Pappolla has performed this procedure hundreds of times without complications and provided substantial pain relief to many patients.

Is the pain relief permanent?
For many patients who suffer chronic neck pain, RFN is an effective treatment that may provide relief for months or longer. Even when normal function returns to the target, pain relief may continue. If the patient responded well to the first RFN, a repeat procedure may be considered if pain resumes. Of course, each patient is unique and it must be remembered that what works well for one person, may not work well or at all for another.

How is the procedure performed?
Medicine to relax the patient is administered and the patient is positioned on a comfortable x-ray exam table. The skin over the injection site is thoroughly cleaned and then numbed using an anesthetic. The entire RFN is performed using fluoroscopic guidance. Fluoroscopy is similar to a real-time x-ray and allows the physician to see the patient's anatomy while guiding and positioning a special needle (radiofrequency electrode) into place.

Using gentle electric pulses through the needle, the physician can cause muscle twitches or tingling sensations that confirm that the needle is properly and precisely positioned next to the targeted spinal nerve branch. Electric energy is then applied for the next 2 to 4 minutes to "stun" the nerve.

What should patients expect?
Like other minimally invasive outpatient procedures, some patients may have minimal post-procedural pain or discomfort for a day or two. Usually an over-the-counter NSAID is sufficient to relieve this discomfort. In general, patients can expect a significant reduction of their pre-procedural pain in one to four weeks.


St Michael's Neurology and Pain Medicine
2646 South Loop West, Suite 106
Texas Medical Center

Houston, TX 77054
Phone: 713-364-0087
Fax: 281-822-0480
Office Hours

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