What is the protocol for a 2-level lumbar facet injection under fluoroscopy using 0.5 cc of 1% lidocaine (local anesthetic) and 20 mg of DepoMedrol (methylprednisolone) in each facet joint?

Lumbar Facet Injection Procedure Template

Lumbar facet joint injections should be performed using a standardized protocol with fluoroscopic guidance to ensure accurate needle placement and optimal therapeutic outcomes. 1, 2

Pre-Procedure Documentation

• Patient name: ________________
• Date of procedure: ________________
• Diagnosis: Facet-mediated lumbar pain at ________ levels (Right/Left/Bilateral)
• Previous conservative management: At least 6 weeks of conservative treatment 1, 2
• Indication: Chronic low back pain consistent with facet syndrome 3, 1
• Informed consent obtained: Yes/No

Procedure Setup

• Patient position: Prone on fluoroscopy table with pillow under abdomen 4
• Monitoring: Vital signs, pulse oximetry 5
• Sterile preparation: Betadine/Chlorhexidine skin preparation 5
• Local anesthetic: 1% lidocaine for skin and subcutaneous infiltration 5

Target Levels

• Level 1: L_____ (Right/Left/Bilateral)
• Level 2: L_____ (Right/Left/Bilateral)

Procedure Technique

1. Obtain AP fluoroscopic view of lumbar spine 4, 6
2. Identify target facet joint(s) 4
3. Rotate C-arm obliquely 10-30° toward the side to be injected 4
4. Identify "Scotty dog" appearance with facet joint representing the eye 4
5. Mark skin entry point 6
6. Infiltrate skin and subcutaneous tissues with 1% lidocaine 5
7. Advance 22-25 gauge spinal needle toward superior recess of facet joint under intermittent fluoroscopic guidance 4, 6
8. Confirm needle position with lateral fluoroscopic view 4
9. Inject small amount of contrast medium (0.2-0.5 mL) to confirm intra-articular position (arthrogram) 4, 7
10. Inject 0.5 cc of 1% lidocaine mixed with 20 mg depomedrol into each facet joint 5
11. Remove needle and apply sterile bandage 5

Post-Procedure Documentation

• Levels injected: L_____ (Right/Left/Bilateral)
• Injectate: 0.5 cc of 1% lidocaine + 20 mg depomedrol per facet joint 5
• Complications: None/_____ 5, 7
• Post-procedure instructions provided: Yes/No
• Follow-up appointment scheduled: Yes/No

Technical Considerations

• Superior recess approach has been shown to be highly successful and well-tolerated 4
• Interlaminar approach with loss-of-resistance technique may be considered for severely osteoarthritic facet joints 6
• Presence of posterior osteophytes may limit joint accessibility 7
• Successful joint entry is confirmed by arthrogram showing contrast flowing from superior recess through joint space 4

Expected Outcomes and Follow-up

• Pain reduction may last up to 3-6 months 5
• Consider reassessment at 3 months for potential repeat injection if beneficial 5
• Document response using validated pain scales (VAS, ODI) 5, 8
• Consider medial branch blocks or radiofrequency ablation for longer-term relief if diagnostic blocks are positive 1, 2

Cautions and Limitations

• Diagnostic facet blocks should use double-injection technique with 80% improvement threshold for accurate diagnosis 3, 1
• Intra-articular facet injections have limited evidence for long-term benefit 3, 1
• Consider only one invasive procedure at a time for low back pain 9
• Avoid relying solely on imaging findings of facet arthropathy to justify intervention 1, 2