Facet Joint Pain Facet joint pain is an arthritis-like condition of the spine that can be a significant source of back and neck pain. It is caused by degenerative changes to the joints between the spine bones. The cartilage inside the facet joint can break down and become inflamed, triggering pain signals in nearby nerve endings. Typically, facet joint pain feels like a dull ache, localized to one area of the spine. The pain may be experienced on one or both sides, and often in the lower back or neck. Movements toward the affected joint will cause pain. While rare, a lumbar facet joint problem may indicate a serious underlying condition if one or more of the following signs and symptoms are present: Pain that suddenly becomes severe and intolerable. Numbness in the groin and/or genital area. Severe weakness in both legs. Other Names Facet Arthropathy Facet Syndrome Zygapophyseal Joint Pain Facet joint syndrome Facet Joint Osteoarthritis (OA) Pathophysiology Degenerative A most frequent form of FJ pain Continuum of joint space, narrowing, loss of synovial fluid, and loss of cartilage and bony overgrowth Pain is believed to be caused by inflammation of surrounding tissues as joint space collapses Synovial cysts can develop and exacerbate symptoms Spondylolisthesis Generally thought to be related to degeneration and loss of normal ROM of FJ Subluxation of FJ may occur In addition to the degenerative process, can also be due to congenital abnormalities, acute or stress-related fractures, or isthmic spondylolisthesis Pathoanatomy Zygapophyseal Joint The only the synovial joint of the spine including hyaline cartilage, subchondral bone, a synovial membrane, and a joint capsule Form the postero-lateral articulation between Vertebrae You Might Also Read Collapsed Disc Between L3 - L4 VertebraAssociated Injuries Degenerative Disc Disease Spondylolisthesis Degenerative FJ Older age Sex (M>F) Spinal level (L4-L5) Facet orientation (sagittally oriented) Presence of Degenerative Disc Disease Autoimmune Rheumatoid Arthritis Ankylosing Spondylitis Differential Diagnosis Fractures Compression Fracture Burst Fracture Chance Fracture Spinous Process Fracture Transverse Process Fracture Rib Fracture Sacral Stress Fracture Neurological Lumbar Radiculopathy Cauda Equina Syndrome Sciatica Musculoskeletal Mechanical Back Pain Scoliosis Kyphosis Herniated Disc Facet Joint Pain Sacroilliac Joint Pain Spinal Stenosis Spondylolysis Spondylolisthesis Hyperlordosis Baastrups Disease Autoimmune Ankylosing Spondylitis Infectious Spinal Epidural Abscess Osteomyelitis Pediatric Scheuermann’s Disease Symptoms History Generally not a reliable clinical diagnosis Local and pseudoradicular symptoms and signs Referred or radicular pain is not reliability reproduced L4-L5 pain often radiates to the buttock, greater trochanter Can radiate more distally mimicking sciatica Worse in the morning, inactivity Pain on movement, reclination, standing, ditting Physical Exam: Physical Exam Back Facet tenderness Special Tests Kemp Test Currently no consensus on how best to evaluate lumbar FJ osteoarthritis with imaging Radiographs First-line imaging: Standard Radiographs Lumbar Spine, Standard Radiographs Thoracic Spine Generally AP, lateral and oblique views The oblique view can show the so-called “Scottie dog” Findings Joint space narrowing Subchondral sclerosis and erosions Cartilage thinning Calcification of the joint capsule Hypertrophy of articular processes Vacuum joint phenomenon joint effusion Kalichman et al[5] Under 40: 24% of of XR have FJ OA Over 60: 89% of XR have FJ OA CT Helpful to better evaluate osseous structures The preferred method for imaging FJ osteoarthritis[7] MRI Best to evaluate soft tissues The role in evaluating FJ disease is not entirely clear Controversial when compared to CT[8] Findings Active synovial inflammation, Adjacent bone edema Facet joint effusion Subchondral bone edema Enhancement of the FJ rim (synovitis) Wraparound bumper osteophyte formation You Might Also Read Foraminotomy - Indications, Procedure, TechniqueSPECT Role in workup unclear It has been shown that patients present better improvement after FJ injection in case of positive SPECT findings[9] Pathria’s Classification Radiographic classification[10] Grade 1: facets with joint space narrowing are classified Grade 2: facets with narrowing and sclerosis or hypertrophy Grade 3: facets with severe degenerative disease encompassing narrowing, sclerosis, and osteophytes Treatment Prognosis Nonoperative First line therapy Medications NSAIDS Acetaminophen Muscle Relaxants Antidepressants Physical Therapy Other modalities Acupuncture Cognitive Behavioral Therapy Facet Joint Nerve Block Only reliable tool to aid in confirming FJ is cause of back pain[11] Relief estimated to be between 50-80% reduction in pain, ability to perform previously painful movements[12] Can be intra-articular or target medial branch, medial branch appears superior May require several blocks or several FJ blocked at once for higher diagnostic yield Corticosteroid Injection Most injections include corticosteroids in addition to local anesthetic Efficacy is not well supported in the literature Lilius et al: No difference in outcomes between intra- and periarticular injections[13] Neurolysis or Neurotomy Indicated in patients who responded well to diagnostic block Technique varies: heat (radiofrequency), cold (cryoneurolysis), chemical (alcohol/phenol) Research suggests achieves pain relief, improves disability, reduces need for oral analgesics[14] Drefuss et al: 60% of patients experience 90% reduction in pain, 65% lasting 12 months[15] Is not definitive, nerve will eventually regenerate Recommend max of 2 procedures per year. Future considerations Platelet Rich Plasma Laser Radiation Operative Surgical outcomes are not great No convincing evidence for any surgical intervention in FJ Disorders Indications Technique You Might Also Read Loss of Disc Height Between C6 - C7 Vertebra