Physical Medicine and Rehabilitation

Overview and Indications for Procedure:

Thoracic Facet Steroid Injections are performed to reduce mid-back pain. Facet injection can help localize the pain generator, improve flexibility, enhance function, enabling patient to pursue PT and return to work or leisure activities. Its main mechanism is to decrease inflammation of the facet joint(s) which may be related to degenerative changes injury or deformity (scoliosis/kyphosis/remote fracture).

Painful facets often cause pain on one side of the spine. At times, the presentation is on both sides in which case each side is treated separately (1-2 weeks apart). It is encouraged to couple facet injections with organized physical therapy program, improved desk ergonomics, proper lifting techniques, and modification in pillow and sleeping surfaces for optimal outcome.

Risk Associated with procedure:

It is important to know risks associated with any medical or surgical treatment. , There are few risks associated with facet steroid injections but they tend to be rare. The potential risks include, but are not limited to:

• Immediate or delayed allergic reaction to medications used
• Infection
• Bleeding
• Nerve Injury
• Dural Puncture
• Pneumothorax
• Temporary increase in pain
• High blood sugar levels
• Transient vaginal spotting
• Transient facial flushing
• Vascular uptake of particulate steroid, cord ischemia

Infection rate is less than 1% in patients receiving spinal injections performed under sterile conditions. The bleeding complication is more common in patients with history of bleeding disorder, patients being treated with anticoagulant/antiplatelet medications and patients taking over the counter medication like Motrin and Aspirin.

The frequency of injury to the nerve roots or spinal cord has substantially reduced with use of fluoroscopy and contrast material. It is rare to encounter nerve root or spinal cord Injury with epidural injections. The rate of nerve injury and spinal cord injury is higher in obese patients due to poor visualization of the target on lateral X-rays. Dural puncture is an infrequent complication and may cause a positional headache (headache in seated and standing position but not on laying down position). This type of headache is often self-limiting, although in persistent cassis, a blood patch may be necessary to alleviate the headache. Pneumothorax: When injections are done in the thoracic area, there is a possibility that the spinal needle reaches the covering of the lungs and creating a condition called pneumothorax which is entrapment of air outside the lungs. When facing this complication, often close Inpatient Hospital monitoring and in some cases chest tube is necessary to allow for proper lung expansion. Elevated blood sugar is a known effect of steroid medication and may last for 2-4 days after the injection of steroids. Patients on insulin will be following sliding scale to adjust for elevated sugar levels. Patients on oral medication should follow primary care advice regarding temporary increase in oral medication to accommodate for blood sugar levels

Following side effects tend to be rare, though they become more common when steroids are taken daily for several months. These risks and side effects may include:

• A transient decrease in immunity
• Stomach ulcers
• Severe arthritis of the hips (Avascular Necrosis)
• Cataracts
• Increased appetite
• Agitation and irritability
• Decreased bone density and fractures
• Increased appetite
• Agitation and irritability
• Decreased bone density and fractures

Who should avoid Facet Steroid Injections? 

Facet Injections should not be performed following conditions:

• In individuals with known allergies to local anesthetics, or steroids
• Patients with local or systemic bacterial infection
• Pregnant Patients
• Patients with bleeding disorders
• Patients suffering from a tumor of spine or infection of the spine
• Uncontrolled congestive heart failure or diabetes

Prepare for your Procedure:

Certain medications have to be held before elective spinal procedures. A list of such medications is on the last few pages of this education al material. Do not hold such medication on your own and ask your PCP /Cardiologist if it is safe to stop such medication before the procedure. Continue to take all other medications, especially your Blood Pressure and diabetes medications. .

A sample of medications that has to be held includes:

1. Aggrenox® (dipyridamole)

2. Aspirin

3. Coumadin® (warfarin)

4. Effient® (prasugrel)

5. Fragmin® (dalteparin)

6. NSAIDS (see below)

7. Herbal blood thinners

8. Heparin

9. Lovenox® (enoxaparin)

10. Plavix® (clopidogrel),

11. Pradaxa® (dabigatran)

12. Ticlid® (ticlopidine)

NSAIDS (such as ibuprofen, naproxen, nabumetone, diclofenac, etodolac, indomethacin, ketorolac, meloxicam, piroxicam, ketoprofen, oxaprozin)

Please let us know if you have had fevers, antibiotic treatment, any illnesses, or hospitalization within the last 4 weeks. You must be healthy and off all antibiotics on the day of the procedure

Make sure you are not Pregnant at the time of procedure. Do a Urine Pregnancy test the night before your spinal injection and report the results to the nurse before the procedure. Exposure to X-ray (used during spinal procedure) is known to result in birth defects and possible miscarriage. If in doubt, cancel and reschedule your procedure until you can confirm that you are not pregnant.

Day of your Procedure:

• Please take a shower, wash the skin with normal soap and DO NOT put skin lotions or mediated creams in the area of the injection .Wear dark and loose clothing and undergarment. If you have long hair, bring a hair-band to tie your hair up and away from your neck.
• Arrive 30 minutes early and come with someone that can give you a ride home. Your procedure should take less than 30 minutes and your total time from greeting to end should be less than 90 minutes
• Bring your latest MRI /CT /imaging studies and the report with you
• Bring an updated list of your medications and allergies. Please point out if you allergic to Contrast, Iodine or Latex.
• Do not eat or drink for 2 hours before your appointment. Diabetics may have a light meal.
• After check-in, an ID wristband containing your name and ALLERGIES will be placed on your wrists. A nurse or medical assistant will go over your meds and allergies and ask few screening questions. Then a nurse will go over final preparation before the procedure. If necessary an IV line will be placed particularly if this is your first cervical procedure.
• In rare cases, oral sedation is needed to reduce anxiety associated with procedure. This will slow down the entire process. Take prescribed medication 1 hour before the procedure and you must have someone drive you to and from the procedure to your home. Without the ride, your procedure may be canceled.

During the procedure:

• You will be escorted to the procedure by a nurse and a consent form will be reviewed/ signed before the procedure. An IV line may be started if it is your first time having an injection. You will be asked to lay on your stomach and rest your forehead onto a cut out pillow. Then you will position your arms on your sides.
• Blood pressure monitor and pulse oximeter will be placed on your arm/finger. Every medical equipment produces loud noises (beeping, alarms) and you should not be concerned.
• Intermittently your doctor will talk to staff in the procedure room and instruct them to perform a task. Your physician will guide you through the procedure step by step.
• After standard time out, your skin will be disinfected with a cool iodine solution, and sterile sheet of paper or plastic will be placed on your skin.
• When your physician is ready, X-ray unit is placed over your spine to identify the target facet joints. Skin will be marked and anesthetized (you will feel small pinch and burning sensation at each spot).
• For each facet injected, a separate needle is used to perform the injection, It is normal to feel pressure or muscle twitching as needles are advanced to the final target.
• Once needle is at radiographic target, a small amount of contrast is injected to confirm final needle position before injecting steroid medication. You may feel transient pressure in each spot.
• Once procedure is completed, needle is removed, skin is cleaned and Band-Aids are applied. You are then transferred back to the recovery area for observation.

Right after the procedure:

• You will be observed for 15-45 minutes.
• If you have an IV line, it will be removed.
• A nurse will check your vitals and review the discharge instructions with you and will answer any questions you may have. A responsible adult must be present to drive you home after discharge.
• You will leave along with a pain log and a copy of the discharge instruction which contains Emergency contact numbers. Please do not discard your discharge instructions.
• A responsible adult must drive you home.

Discharge instructions:

• Make a follow-up 2-3 weeks after the procedure and bring your pain log with you.
• You may resume your normal diet and medications.
• Diabetics should monitor blood sugar levels 3 times a day for 3 days after the procedure.
• Resume your Blood Thinners/ Anticoagulants / Antiplatelet as instructed by PCP /Cardiologist. You may need to check INR/PT/PTT 2-3 days after your procedure. Contact your primary care and ask when you should have blood work.
• Do not participate in strenuous activity on the day of procedure.
• After the procedure, do not drive or operate machinery for at least 24 hours.
• If sedated, do not make financial or important life decisions until the effect of such medication is cleared (24 hours).
• It is okay to shower after procedure. No bathing /submerging under water for 48 hours.
• You may remove the bandages 24 hours after the injection. Call us immediately if there is excessive redness or swelling or infection sign like warmth, discharge or collection of puss at the site of injection.

Call your doctor if you develop these symptoms. You may be directed to ER:

• Shortness of breath or palpitation after procedure
• Sudden weakness
• Fever over 101°F within 5 days after procedure
• Persistent redness, increased localized pain or discharge from the site of injection.
• Possible allergic reaction within 5 days of the procedure
• Intractable headache
• Significant increased pain not responding to ice, NSAIDS and pain meds or associated with fever
• Newly developed weakness in the legs, face or arm following procedure
• Newly developed incontinence of urine or stool following procedure

Insurance:

Most insurance require prior authorization to cover this procedure. Your doctor will provide information to insurance company for approval. It takes anywhere between 3-15 days for approval (Medicare beneficiaries require no authorization).

You would likely have a copay and deductible for this type of treatment.

You would also receive two medical bills related to your treatments (a Hospital bill and a doctor bill).

Please call your insurance company to understand your benefits. The codes used for this procedure are:  CPT: 64490, 64491, 64492 and 77003

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