Injections to Diagnose Facet Joint Pain? There Must be a Better Way!
“Even fictional characters sometimes receive unwarranted medical opinions. Doctors have diagnosed Ebenezer Scrooge with OCD, Sherlock Holmes with autism, and Darth Vader with borderline personality disorder.”
– Sam Kean
Diagnosis means identifying what is behind a person’s symptoms. The word diagnosis goes back to ancient Greece. The prefix dia means “apart” and the root gignoskein means “to recognize or know.” A physician making a diagnosis recognizes a condition by analyzing (taking apart) the problem in order to know what’s wrong. This involves asking a lot of questions about the patient’s history and recent past, physically examining the patient, and any necessary tests or imaging.
I found the opening quote humorous. Author Sam Kean is something of a diagnostician himself as he “takes apart” scientific discoveries, analyzes their history, and presents us with information in a way we can recognize and understand.
Diagnosing facet joint pain
In medicine, some conditions or diseases are harder to diagnose than others. Chronic lower back pain, for instance, can result from a number of isolated or intertwined conditions. If you have ever had lower back pain – and at one time or another, most people have – you may recall how it interfered with physical movement, made sitting or lying down uncomfortable, and even clouded your ability to think and concentrate. You may have unwittingly compensated for the pain in terms of posture or activity, putting stress on muscle groups and joints that weren’t meant to go rigid or assume a distorted position.
The spine is a stack of backbones (vertebrae) that house the trunk of nerves (spinal cord) from the brain to the rest of the body. One cause of lower back pain is arthritis of the facet joints, which are very small, cartilage-covered points of contact between each backbone. When the cartilage becomes arthritic, meaning it is worn thin, pain occurs as the result of compression on branch nerves that run adjacent to the joint, as well as from bone spurs in the joint. Ouch!
In terms of diagnosis, the doctor can make an educated guess by asking a lot of questions and examining/manipulating the spine. Up to this point in time, the definitive diagnostic standard has been an invasive procedure: x-ray guided injections of a numbing substance into the suspected joint(s). If the pain goes away for several hours, it is assumed that the diagnosis is a degenerative condition called facet joint arthritis (also called facet joint osteoarthritis, facet joint arthrosis, or facet joint arthropathy).
If diagnosed as the cause, treatments range from things like postural correction/physical therapy, anti-inflammatories, injections a few times per year, or procedures to deaden the nerves so pain isn’t felt.
An alternative to diagnostic injections
A brand new study by D’Aprile et al. (Jan 2018)1 reports the efforts of this Italian team to diagnose facet joint arthritis using Magnetic Resonance Imaging (MRI). One of the great things about MRI is that it is capable of various imaging sequences that can highlight different characteristics of tissue. Because MRI can define both soft tissue and bone, some sequences highlight anatomy in amazing, 3-dimensional detail. Other sequences can define tissue differences based on elasticity, density, and blood flow.
The authors began with 2820 patients who had lumbar (lower back) pain. Each patient underwent standard MRI imaging, plus an imaging sequence called T2 weighted Fat Saturation (T2w FS). Out of this initial cohort, 987 patients also had an additional sequence using a contrast medium for added enhancement (CE T1w FS).
The researchers were successful in diagnosing a number of conditions as follows, with many patients having more than one condition at the same time:
- 646 patients (65$) had active-inflammatory intervertebral osteochondrosis
- 462 patients (47%) had degenerative-inflammatory changes in facet joints
- 69 patients (7$) had spondylolysis
- 245 patients (25%) had degenerative-inflammatory changes of the flava, interspinous and supraspinous ligaments
- 84 patients (8%) had inflammatory changes of posterior perispinal muscles.
The authors concluded that “… the implementation of T2w FS and CE T1w FS sequences to the standard MR protocol could allow a better identification of degenerative-inflammatory changes more likely associated to the pain.”
This is very good news. Before turning to diagnostic injections, going through a noninvasive MRI with the abovementioned two additional sequences could eliminate needless guesswork and even an unpleasant invasive procedure using x-ray guidance (exposure to radiation).
MRgFUS for low back pain
There’s even more good news. When medication, physical therapy, heat/cold applications, etc. are no longer effective, MRI is useful for guiding a noninvasive treatment to deaden the nerves. It is called MRI-guided Focused Ultrasound (MRgFUS). MRI is used to identify the painful joint, then plan and guide treatment using “beams” of ultrasound energy from different directions. This energy passes through skin and other tissues without creating harm, but when they meet at the target, they generate enough heat to destroy a pain-transmitting nerve that is not needed for any other function.
Learn more about the Sperling Medical Group’s use of MRgFUS to control facet joint pain, or contact us for an evaluation.
1 D’Aprile P, Nasuto M, Tarantino A, Cornacchia S et al. Magnetic Resonance Imaging in degenerative disease of the lumbar spine: Fat Saturation technique and contrast medium. Acta Biomed. 2018 Jan 19;89(1-S):208-219
- Facet Pain