Facet Joint Injections
What Is a Facet Joint Injection?
A facet joint injection is a procedure that delivers medication — typically a combination of local anesthetic and corticosteroid — directly inside the facet joint itself. This is different from a medial branch block, which targets the nerves on the outside of the joint. With a facet joint injection, the needle goes into the joint space itself.
If you have read our post on medial branch blocks and radiofrequency ablation, you may be wondering how facet joint injections fit into the picture. The short answer is that they serve a different purpose and are used in a more specific set of circumstances — most commonly when a facet joint cyst is identified on imaging.
A Quick Refresher: What Are Facet Joints?
Your spine is made up of bones called vertebrae stacked on top of each other. In the back of your spine, there are small joints called facet joints that allow your spine to move and stay stable. Like any joint in the body, they are lined with cartilage, enclosed in a capsule, and filled with a small amount of fluid.
Over time — from arthritis, injury, or normal aging — these joints can degenerate. The cartilage wears down, the joint space narrows, and the joint capsule can thicken and become inflamed. This is the same process that causes arthritis in your hips or knees, just happening in the small joints of your spine.
What Is a Facet Joint Cyst?
One of the most common reasons a direct facet joint injection is performed is the presence of a facet joint cyst — also called a synovial cyst or ganglion cyst of the spine.
Here is how it develops. As the facet joint breaks down from arthritis, the joint can become unstable and begin to produce excess fluid. That fluid can push through a weak spot in the joint capsule and form a small fluid-filled sac — a cyst — just outside the joint. Because the facet joints sit right next to the spinal canal, these cysts often bulge inward and press on a nearby nerve root or the spinal cord itself.
When a facet cyst compresses a nerve, it can cause symptoms very similar to a herniated disc — pain, numbness, tingling, or weakness that travels into the arm or leg. In the lumbar spine, this often mimics sciatica. In the cervical spine, it can cause arm symptoms similar to a pinched nerve.
Facet joint cysts are a direct result of facet joint arthritis. You cannot develop one without underlying degeneration in the joint.
How Is a Facet Joint Cyst Diagnosed?
Facet joint cysts are typically identified on MRI. They appear as small, well-defined fluid collections adjacent to a facet joint, often with evidence of surrounding arthritis at the same level. Your doctor will correlate the MRI findings with your symptoms to determine whether the cyst is the likely cause of your pain and nerve symptoms.
The Facet Joint Injection: What to Expect
What is it?
A direct facet joint injection places a small amount of local anesthetic and corticosteroid inside the facet joint capsule. When a cyst is present, the goal is to reduce inflammation in the joint, decompress the cyst by changing the pressure inside the joint space, and in some cases rupture the cyst so that the fluid disperses and the pressure on the nerve is relieved.
This is not always successful on the first attempt, and some cysts require more than one injection or ultimately need a different treatment approach. However, for many patients — particularly those who are not surgical candidates or who want to exhaust non-surgical options first — it is a reasonable first step.
What happens during the procedure?
You will lie face down on a procedure table. The skin over the target joint will be cleaned and numbed with local anesthetic. Your doctor will use fluoroscopy (live X-ray) or CT guidance to place the needle precisely into the small joint space. The facet joint is a very small target, and image guidance is essential for accurate placement.
Contrast dye is injected first to confirm the needle is inside the joint before any medication is given. You may feel pressure or a brief familiar reproduction of your usual symptoms as the joint is entered — this is normal. Once placement is confirmed, the steroid and anesthetic are injected. If a cyst is being targeted, your doctor may use slightly higher pressure during the injection in an attempt to rupture or decompress it. The procedure typically takes 15 to 30 minutes.
After the procedure
Some soreness at the injection site is expected for a day or two. Ice applied for 15 to 20 minutes at a time can help with discomfort. Avoid heat to the area for the first 48 hours and strenuous activity for 24 to 48 hours. You can return to light daily activities the same day or the following day.
When Will I Feel Relief?
If a cyst is successfully decompressed or ruptured during the injection, some patients notice fairly prompt improvement in their nerve symptoms within days to a week. For injections performed primarily for joint inflammation without a cyst, the steroid typically takes 3 to 7 days to take full effect.
Hours 1–6: Possible early relief from local anesthetic
Days 3–7: Steroid begins to reduce inflammation
Week 1–2: Most patients who respond will notice meaningful improvement by this point
Weeks to months: Duration of relief varies; cyst recurrence is possible over time
It is worth noting that even when a facet joint injection successfully decompresses a cyst, the underlying arthritis that caused the cyst remains. Cysts can recur, particularly if the joint continues to be unstable or inflamed. Your doctor will discuss what to expect in your specific case.
An Important Note About Insurance Coverage
Facet joint injections are frequently not covered by insurance. This is one of the most important things to understand before scheduling this procedure, and it is worth a direct conversation with your doctor's office and your insurance provider before moving forward.
Here is why coverage is often denied. Insurance companies generally view direct facet joint injections as lacking sufficient evidence to support routine use for axial back pain — meaning back or neck pain without a specific structural finding. As a result, many payers have policies that exclude them from coverage or require extensive prior authorization that is rarely approved.
The exception — and the primary clinical scenario where facet joint injections are performed in this practice — is when a facet joint cyst has been clearly identified on MRI and is believed to be causing nerve compression. Even in this situation, coverage is not guaranteed and varies significantly by insurance plan.
What this means practically:
Before your procedure, ask the office to verify your benefits and check whether prior authorization is required
Be prepared for the possibility that you may be responsible for the full cost of the procedure out of pocket
If cost is a concern, discuss this openly with your doctor — there may be alternative approaches worth considering depending on your specific situation
This is not a reason to avoid the procedure if it is the right treatment for you. But going in with clear expectations about cost avoids surprises and allows you to make an informed decision.
What If the Injection Does Not Work or the Cyst Comes Back?
If a facet joint injection provides only temporary relief or the cyst recurs, there are other options worth discussing with your doctor:
Repeat injection: A second injection is sometimes performed, particularly if the first provided meaningful but short-lived relief or only partially decompressed the cyst.
Surgery: For patients with significant or worsening neurological symptoms — such as progressive weakness, loss of bladder or bowel function, or severe pain that is not responding to injections — surgery to remove the cyst is an effective option. This is typically performed as a minimally invasive procedure. Because facet cysts are caused by underlying joint instability and arthritis, some surgeons will perform a fusion at the same level at the time of cyst removal to address the root cause, though this is not always necessary and depends on the individual case.
Your doctor will help you weigh these options based on how severe your symptoms are, how well the injection worked, and your overall health and goals.
Blood Thinners and Facet Joint Injections
Facet joint injections are generally considered a low-to-intermediate risk procedure for bleeding. In most cases, over-the-counter pain relievers such as ibuprofen or naproxen do not need to be stopped beforehand.
If you are taking a prescription blood thinner — such as warfarin (Coumadin), rivaroxaban (Xarelto), apixaban (Eliquis), or clopidogrel (Plavix) — your doctor will review your specific medication before the procedure and give you individualized guidance. Do not stop any prescription blood thinner on your own without speaking to your doctor first. If your procedure is being performed in the cervical spine, please refer to the additional cautions outlined in our cervical epidural post, as bleeding risk considerations are more significant in the neck.
Risks and Complications
Facet joint injections are safe procedures and serious complications are uncommon. Possible risks include:
Temporary soreness at the injection site — very common, resolves within a few days
Temporary pain flare — some patients notice increased pain for one to two days before improvement begins
Incomplete cyst decompression — the cyst may not fully rupture with a single injection
Cyst recurrence — because the underlying arthritis remains, cysts can reform over time
Infection — rare, as sterile technique is used throughout
Bleeding — uncommon; discuss your medications with your doctor beforehand
Nerve injury — very rare when performed under image guidance
Questions to Ask Your Doctor
Is a facet joint cyst confirmed on my MRI, and is it likely causing my symptoms?
Is a direct joint injection the right first step, or should we consider other options?
Will my insurance cover this procedure, and what should I expect to pay out of pocket?
What is the likelihood the cyst will recur after the injection?
If the injection does not work, what are the next steps?
At what point would you recommend considering surgery?
Do I need to stop any medications before the procedure?
This article is for educational purposes only and does not replace a conversation with your physician. Treatment decisions should always be made together with your care team based on your individual history, exam findings, and imaging. If you have questions about whether this procedure is right for you, please schedule a consultation.