Not all back pain is the same. One of the most common — and most often missed — sources of lower back pain is the facet joints: the small, paired joints that connect the bones of your spine at the back. Research suggests these joints are behind the pain in as many as one in three people with long-lasting lower back pain.
The encouraging news? Most people with this kind of pain never need major surgery. We follow a step-by-step approach, always starting with the simplest option — and moving up only if you need more.
What Are Facet Joints?
Facet joints are small joints, about the size of a thumbnail, found in pairs at the back of every level of the spine. They guide and limit motion as you bend and twist. Like the joints in your knees or hands, they can develop arthritis and wear over time — most often in the lowest part of the back, just around the beltline.
What Does Facet Joint Pain Feel Like?
Facet joint pain has a fairly recognizable pattern. You may notice:
- Pain across the waistline — a band of aching across the lower back rather than one sharp spot.
- Worse when you lean backward — standing for long periods or arching the back tends to aggravate it.
- Better when you slouch or lean forward — many people find themselves hunching because it simply feels better.
- Pain that stays in the back — it does not usually shoot down the legs the way a pinched nerve does.
How We Confirm the Diagnosis
Each facet joint gets its feeling from tiny nerve branches called medial branches. To find out whether the facet joints are truly the source of your pain, we perform a medial branch block: using X-ray guidance, a small amount of numbing medicine is placed precisely on these nerves.
If your pain improves dramatically after the injection, we’ve found the culprit — and that opens the door to treatments that last much longer. Sometimes we repeat the block a second time to be certain before moving ahead. And if the block doesn’t help? That’s valuable too: it tells us to keep looking, so you’re never treated for the wrong problem.
Treatment Options: A Step-by-Step Ladder
We believe in the least invasive treatment that actually works for you. Each option below is chosen based on your examination, your response to earlier steps, and your goals — and the early steps don’t “burn any bridges” for the future.
| Step | Option | What it involves | What to expect |
|---|---|---|---|
| 1 | Medication + physical therapy | Anti-inflammatory medicine and core-strengthening therapy | The starting point for nearly everyone — and often all that’s needed |
| 2 | Medial branch block | A numbing injection of the small facet nerves, guided by X-ray | The most reliable way to confirm the facet joints are the problem |
| 3 | Radiofrequency ablation (RFA) | Gentle heat quiets the small nerve branches; no incision, no implant | About 2 in 3 patients get significant relief, often lasting six months to a year — and it can be repeated |
| 4 | Facet joint steroid injection | Steroid placed inside the joint when there is extra fluid or a cyst | Helpful for select patients with those specific findings |
| 5 | Endoscopic rhizotomy | The nerve is divided under camera vision through a ~7 mm incision; same-day | Relief tends to last longer than RFA — often a year or more |
| 6 | Peripheral nerve stimulation | A hair-thin temporary electrode worn for about 60 days, then removed | About 3 in 4 patients improve, and relief often continues after removal |
| 7 | Interlaminar spacer (select cases) | A small device supports the segment after a decompression | An alternative to fusion for carefully selected patients |
| 8 | Minimally invasive fusion | Reserved for a slipped vertebra, instability, or severe stenosis | For true structural problems, stabilizing the spine can bring lasting relief |
1. Anti-Inflammatory Medication and Physical Therapy
Treatment almost always begins here. Anti-inflammatory medicines and a physical therapy program focused on core strength and posture are enough for many people — and they stay part of the plan even when other treatments are added.
2. Radiofrequency Ablation (RFA)
If the test block confirms facet pain, radiofrequency ablation is usually the next step. Using a specialized needle guided by X-ray, we apply gentle, controlled heat to quiet the small nerves carrying the pain signal. It’s an outpatient procedure — no incision, no implant, and you go home the same day.
About two out of three patients get significant, lasting relief — often for six months to a year, sometimes longer. Because the nerves slowly recover, the pain can eventually return. The good news: the procedure can be safely repeated for people who responded well the first time.
3. Facet Joint Steroid Injections
Some people have extra fluid in the joint or a small cyst in the joint lining. In those cases, placing steroid medication directly inside the joint can calm the inflammation and ease pain — and a cyst pressing on a nearby nerve can sometimes be treated at the same time. We use this option selectively, for patients with these specific findings.
4. Endoscopic Medial Branch Rhizotomy
If relief from RFA was good but didn’t last — or injections didn’t help — we offer an endoscopic option. Through an incision of about 7 millimeters (roughly the width of a pencil), a tiny camera lets us see the nerve directly and divide it completely. It’s a same-day procedure, and because the nerve is fully divided rather than heated through a needle, the relief tends to last considerably longer — often a year or more.
5. Peripheral Nerve Stimulation (PNS)
Instead of quieting nerves with heat, stimulation calms them with gentle electrical signals. A hair-thin electrode is placed near the nerves and connected to a small stimulator worn outside the body for about 60 days — then everything is removed. Nothing is permanently implanted. About three out of four patients improve during treatment, and for many, the relief continues well after the device is gone.
6. Supportive Spacer Devices
When the disc at the front of the spine wears down, extra pressure shifts onto the facet joints behind it. In selected patients who also need a decompression, a small spacer device can be placed to share that load and take pressure off the joints. This suits a specific group of patients, which we determine through careful evaluation.
7. Minimally Invasive Fusion — Reserved for Specific Problems
Surgery is rarely needed for facet pain alone. Fusion is reserved for a true structural problem — a slipped vertebra (spondylolisthesis), significant instability, or severe narrowing (stenosis) — where the painful segment has little useful motion left. In those situations, stabilizing the spine can bring real, lasting relief. When fusion is the right choice, we use ultra-minimally invasive techniques designed to work through small incisions with far less disruption to the surrounding muscles than traditional open surgery.
Every spine is different, and no single treatment works for everyone. Our promise is honest guidance: we’ll tell you what your examination shows, which options fit your situation, and what degree of relief is realistic — never a one-size-fits-all answer.
Frequently Asked Questions
More common than most people think — it may account for up to a third of long-lasting lower back pain, and it becomes more likely as we get older. Yet it is often overlooked, because it doesn’t show up dramatically on scans.
Absolutely. Facet joint pain often shows little on an MRI beyond mild arthritis — the discs can look perfectly fine. Scans alone can’t confirm or rule out this diagnosis. That’s why we rely on your story, a hands-on examination, and a simple test injection to find the real source.
It’s a quick office-based procedure. Using X-ray guidance, a small amount of numbing medicine is placed on the tiny nerves that carry pain from the facet joints. You go home the same day and simply pay attention to your pain over the next hours. Dramatic relief — even briefly — tells us the facet joints are the culprit. Sometimes we repeat the block once more to be certain.
For carefully selected patients, about two out of three experience significant relief — commonly lasting six months to a year, and for some people considerably longer. It’s not permanent, because the small nerves slowly recover — but that also means nothing has been lost if the pain returns.
Yes. If you had good relief the first time, repeating the procedure is safe and tends to work again. Many patients return every year or so for a repeat treatment and stay comfortable that way for years.
Standard RFA treats the nerve through a needle placed using X-ray landmarks. Endoscopic rhizotomy goes one step further: a tiny camera through a pencil-width incision lets the surgeon actually see the nerve and divide it completely. Because of that, relief tends to last notably longer. It’s still a same-day procedure, and it’s a good option for people whose RFA relief kept wearing off.
No. The system we use is temporary: a hair-thin electrode sits under the skin while you wear a small external stimulator for about 60 days. At the end of treatment, everything is removed — nothing stays in your body. About three out of four patients improve during treatment, and for many the benefit lasts well beyond it.
For most people, the block-then-ablation pathway works better. We reserve injections into the joint itself for specific situations — extra fluid in the joint or a small cyst — where they can be genuinely helpful.
Rarely. Surgery is not a treatment for facet pain by itself — it’s reserved for structural problems like a slipped vertebra, an unstable segment, or severe narrowing. The overwhelming majority of people with facet joint pain get better without ever needing a fusion.
This page is for general education only and is not a substitute for professional medical advice, diagnosis, or treatment. Please consult a qualified physician about your specific condition.