are done only for :

• Back Pain without Leg pain/ numbness/ tingling

• Back pain with treated Leg pain/ numbness/ tingling (through injections, surgeries etc)

• and in association with rehabilitation (exercise + therapy)

Facet Joint Injections or Medial Nerve Branch Blocks:

To be used for diagnosis/ testing and also for treatment. It involves injection of dye ( contrast) under x-ray guidance at the facet joint or the nerves supplying the facet joint. This is followed by injection of local pain medicine (anaesthetic), with or without additional steroid ( to decrease inflammation at pinched nerve). This is to be done only when/ for:

Your pain is severe and there is no/ minimal pain relief after medicines and 6 weeks of medically directed Exercises (including physical therapy, Doctor’s office given exercises or physical therapy), unless pain worsens, or your Doctor has a reason why they could not be done. This is needed even after failed back surgery.

Your exam shows that the pain may likely be from facet joint problems

Rest of your symptoms, exam, tests do not show other causes or they have been treated

MRI/ CT / CT Myelogram shows facet joint cyst pressing on a nerve that is thought to be causing your pain/ problem

Radiofrequency procedure is being considered

Repeated injections for treatment :

• are only typically needed if there has been >50% pain relief, increase in function/ activity or reduction in use of medicines or exercise services, for 2 months. These are typically done at interval of 2 months and typically do not exceed 4 ( rarely 6) / year.

• When you have good improvement of pain and function / activity level, but it lasts less than 2-3 months, consider radiofrequency

These injections should not be performed for/ when :

higher risk of bleeding due to being on certain medicines ( blood thinners), certain medical conditions etc; fracture; infection; spine (spinal canal) is blocked; if pain is thought to be from facet joint; uncontrolled diabetes and glaucoma; mostly functional ( psychogenic) pain; allergic reactions to substances used in injections; low blood volume; pregnancy. They should be cautiously used or not at all in multiple sclerosis, or any other neurological condition where worsening disease features are masked by these injections

Sacroiliac Joint injections (intra/ periarticular- into or next to the joint):

To be used for diagnosis/ testing and also for treatment. It involves injection of dye (contrast) under x-ray guidance at the facet joint or the nerves supplying the facet joint. This is followed by injection of steroid with or without a local pain medicine (anaesthetic). This is to be done only when/ for:

• buttock pain with exam suggestive of sacroiliac joint involvement

• Your pain is severe and there is no/ minimal pain relief after medicines and 6 weeks of medically directed Exercises (including physical therapy, Doctor’s office given exercises or physical therapy), unless pain worsens, or your Doctor has a reason why they could not be done. This is needed even after failed back surgery.

• Rest of your symptoms, exam, tests do not show other causes or they have been treated

They should not be done for / when:

• infection, untreated chest pain or heart problems, allergies, bleeding problem or medicines, uncontrolled diabetes or high blood pressure

Repeated injections for treatment are only typically needed if there has been >50% pain relief, increase in function/ activity or reduction in use of medicines or exercise services, for 2 months.

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