Ugh! More Fake Facet Injections

One of the things that drives me crazy is to perform a consult on a patient who has done their homework and research but still got scammed by a prolotherapist performing faked facet injections. While I’ve blogged on this issue in the past, I want to make sure everyone’s clear on this as we continue to see patients who have wasted thousands of dollars. Let’s dig in.

What Is a Facet Joint?

Your spine is built from vertebrae or spine bones. These stack one on top of the other like legos. They have a disc in the front and facet joints in the back. Those facet joints are made up of half from the upper vertebra and half from the lower. These joints are about the size of finger joints and they can get injured or become arthritic as the patient develops degenerative disc disease (DDD).

What’s the Problem?

Facet joint injections with things like PRP or bone marrow stem cells can help patients avoid destructive procedures like radiofrequency ablation. However, for that to work, you actually have to confirm with imaging guidance that you’re inside the facet joint. Once that happens, you can then inject whichever orthobiologic makes sense. However, all too often, patients are told they’re getting their facet joints injected, but this never happens.

What Is a Real Facet Joint Injection?

Likely a good place to begin is to go over what a real facet injection involves. Here are the steps:

•    The doctor usually uses fluoroscopy or real-time x-ray. It’s also possible to use ultrasound imaging, but there is less certainty of being inside the joint.
•   A doctor uses the x-rays to guide the needle into the joint opening. This isn’t trivial as the joint can be 2-4 inches deep.
•   Once the joint is entered, a small amount of radiographic contrast that can be “seen” on the x-ray is injected inside the joint to make sure that any orthobiologic injection will also go inside the joint.

After the contrast, the orthobiologic is injected and a “wash-out” picture is performed, double-checking that the stuff injected actually went into the joint.

Who Is Doing Faked Facet Joint Injections?

We typically see these performed by prolotherapists and naturopaths using x-ray guidance. It’s that last part which is confusing to patients, so we’ll dig in on that below.

Prolotherapy is a great early regenerative medicine technique that commonly uses injections of hypertonic dextrose to cause a brief inflammatory reaction. This gives the patient another bite at the proverbial healing apple. In the spine, these procedures were initially taught blind, meaning the doctor palpates the bones and directs the needle toward where he believes specific points lie under the tissue. For example, these are what’s called “Hackett Points” below (image credit-Journal of Prolotherapy):

You can see these many points simply drawn on the skin to represent deeper points that the doctor should try to inject on the underlying bone. This is what those points look like on the bony structures:

Note that none of these spots are “inside” the facet joint like you see above. They are simply near the facet joints. No radiographic contrast is used and these needles come in at an angle where it would be very hard to inject inside the joint.

The Training Difference Between these Two Techniques Is Stark

I could teach a physician to perform the Hackett prolotherapy technique above in 5 minutes and most could master it in 15 minutes. That’s for all body areas including the cervical (neck), thoracic (upper back), and lumbar (lower back).

However, teaching a real intra-articular facet injection with contrast would take months to years to master. While young healthy facet joints would take a novice a few weeks to months to consistently show contrast spread patterns that confirmed that they were in the joint, older arthritic joints take years to finesse. And that’s just in the low back.

Thoracic facets are another matter, as you can’t see their entry point like you can in the low back. Hence, only about 2 in 10 properly trained spine interventionalists have much experience in injecting those. Why? They take years to get good enough so that the doctor no longer breaks into a sweat during the procedure. You also have the added difficulty of the lungs being in close proximity.

Cervical facets can’t be tried by anyone who hasn’t first mastered the lumbar facets. After that, it’s a good 6 months to a year to get good. The top two cervical facets are so difficult to master (C0-C1 and C1-C2) that 99.9% of trained spinal interventionalists haven’t injected those more than a handful of times. In addition, only about 100 US physicians have injected these joints more than a few dozen times.

The Faked Facet Joint Injection?

A faked facet joint injection happens when the provider tells the patient that he or she is injecting the facet joint, but all that happens is that the physician uses the Hackett technique above with x-ray guidance. There is no attempt made to enter any facet joint and to confirm that entry with contrast. Why is this tough to hear? Let me give an example.

I performed a Telemedicine evaluation of a patient who was initially treated with radiofrequency ablation (nerve burning) of his facet joints. This worked well for 2 rounds, so he clearly had pain coming from those facet joints. After the third round, he initially felt better, but then months later, he could no longer walk and stand due to what he can only describe as “instability”.

In obtaining a history, he relayed that he went to a doctor who performed a stem cell injection using x-ray guidance into his facets. Since I know to make sure that this was a real versus faked facet injection, I first asked for the doctor’s name. It turns out that the “doctor” wasn’t a physician, but a naturopath in Oregon. Given some Google research and knowing where he was practicing, it quickly became clear that this provider had only used the Hackett technique with fluoroscopy described above. Hence, despite paying ten thousand dollars or more, the naturopath he saw didn’t have the expertise to inject stem cells into his facets, so now that needs to be repeated.

I also see this happen quite a bit when patients get prolotherapy from physicians. The physicians will tell them that they are injecting the upper neck facet joints (C0-C2), but when I review the notes, all they did was the Hackett technique above. So despite the patient spending thousands of dollars to get PRP or stem cells injected into those joints, they have never been injected properly. Hence, the patient has to pay additional money to get them injected for real.

Is There a Single Question I Can Ask to Make Sure I Don’t Get Scammed?

The single biggest question is the following:

1. Will the doctor use x-ray guidance (fluoroscopy) and radiographic contrast to make sure they are in my facet joints before they inject the [PRP, stem cells, or whatever it is that’s being injected]?

If the answer is “No” with any explanation or justification, then you’re about to get scammed. While there are a handful of providers out there skilled enough to inject these joints accurately using ultrasound only, the problem there is that they aren’t confirming with each injection that they are actually in the joint.

Another corollary is who is performing the injection. Meaning if it’s a physician who also performs procedures like radiofrequency ablation or other x-ray guided pain management injections, you’re likely to get the real deal. However, if it’s a naturopath (NMD), then by law, the naturopath is not usually permitted to inject radiographic contrast nor would there be any training program worth its salt that would admit a naturopath for training. The same holds for a chiropractor or acupuncturist.

The upshot? I hope that patients share this blog as I’m getting really frustrated trying to explain to otherwise very educated patients why they got ripped off if they believe that they had their facet joints injected. Buyer beware out there!

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile