The most important part of improving back and neck pain long term is by observing spine hygiene (changing the way you move) and incorporating regular exercises to support the spine. Some people will have ongoing chronic spine pain despite making these changes to their lifestyle habits. Others will have short term exacerbations (worsening) of their pain that makes it hard to function. In these cases there may be a role for injections.

There are different kinds of injections for different structures in the spine. Choosing injections depends on what the pain generating structure is, access to these injections, and acceptance of risks. These injections include injections related to the facets(spine joints connecting one level of the spine to the next), SI joints (which connects the lumbar spine (low back) to the pelvis), and muscles around the spine which may be tense/painful.

Benefit of doing these injections?

Often these injections provide some short term relief of weeks to months. Without changing movement habits or improving strength/endurance of spine supporting muscles, the pain will often return requiring repeated injections. Is a short term worsening (exacerbation) of the pain, injections can give some needed temporary relief to improve the function and quality of life. Sometimes in chronic pain, injections can temporarily improve pain and allow people to more aggressively apply exercise solutions to these problems for more longterm benefit.

What is the likelihood of success?

Some parts of a patient’s pain experience (where they feel their pain, how certain movements trigger their pain), as well as findings on a physical examination, will give the doctor clues as to which structures (if injected) might have the best chances of providing pain relief. Often there may be a process of trial and error where the doctor tries treating the different structures to see which one is causing the pain. Even after trying all of the different treatments some patients won’t find improvement in their pain. So the likelihood of success is dictated by several factors including which structure is causing the pain, and how effectively you are able to make changes to spine movements, strength, and endurance.

Injections that target compressed nerves inside the spine (epidural injections) are not usually beneficial for isolated pain in the back and neck. These injections are usually done for pain radiating down the neck or leg related to the pinched nerve.

There are other structures in the spine that cause pain and can’t be helped by injections. These include pain possibly coming from the damaged disc itself, or pain related to the main bones (vertebra) of the spine. People with this kind of back pain usually have pain across the whole back without it being more left or right.

Facet (spine joint) procedures

While the facets are joints, it is uncommon that people would have injections inside them(intra-articular). It used to be that patients would have steroid medications injected into a joint. Now the most common facet related procedure is a medial branch block/facet rhizotomy. There are tiny nerve branches that connect to these facet joints and transmit nerve signals to our brains. One way of treating facet related pain is to treat these nerve branches to stop the pain signals. Sometimes a local anesthetic injection of this small nerve (medial) branch will be trialled to see if the pain is coming from the facet. If successful the doctor will then often proceed to rhizotomy. A rhizotomy procedure a procedure where the nerve branch is intentionally damaged in order to block pain signals from the joint. This is most often accomplished by a procedure called radiofrequency ablation(RF). RF is performed using a needle like probe placed in the region of the nerve. The probe is then heated in order to “burn” this small nerve branch. This joint requires some kind of needle guidance (ultrasound or fluoroscopy) in order to ensure the needle is accurately placed. When successful these treatments can relieve pain for as long as 6-12 months.

Muscle (trigger point) injections

Most people have experienced having a sore tight neck muscle often described like having a knot in the muscle. These “knots” in muscles can occur all over the body and are called myofascial trigger points. These tight knots in the muscle can be tender to touch and can cause pain to radiate up/down the spine or into the arm/leg.

Treating these tight knots with injections is usually done as a series of trigger point injections. These injections are done (usually) by injecting local anesthetic (like freezing you would get at the dentist), into different parts of the trigger point. It is a mechanical kind of treatment breaking up the knot in the muscle.

Pain relief can be immediate or after a few days and often lasts for a few weeks. These injections are often performed as a series of injections every 2 -4 weeks.

Risks of these injections include allergic reaction to local anesthetic, bleeding, and rarely infection that requires an antibiotic.

Sacroiliac (SI) joint injections for low back pain

The SI joint is a large joint located where the spine connects to the pelvis. People with SI joint related pain will usually cause pain either to the left or right low back (rather than central back pain or pain across the low back). Certain signs on a physical examination may point to this structure as a source of pain but it will often require an injection trial to see if it is a pain source. This joint usually requires some kind of needle guidance (ultrasound or fluoroscopy) in order to ensure the needle is accurately placed in the joint. Once the correct placement is confirmed, usually a combination of local anesthetic and corticosteroid (“Cortisone”) medication is injected.

Like all corticosteroid injections, the effects usually last about 3 months and must be repeated for continued effect.

The risks of this kind of injection includes :

• Allergic reaction to local anesthetic
• Infection in the joint requiring IV antibiotics (1/5000 chance)
• Corticosteroid related side effects (short term mood/sleep disturbance, facial flushing/warmth)