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
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Associated 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
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SPECT

  • 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
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