Medica 2005 introduces modern diagnostic and therapeutic procedure in Facet Joint Syndrome

Facet joint syndrome is an arthritis-like condition that can be a significant source of back and neck pain. Degenerative changes to the joints between the spine bones can cause the syndrome. The facet joint is covered by cartilage inside which can break down and become inflamed. These changes trigger pain signals in nearby nerve terminals. There are different ways to manage facet joint syndrome such as medication, physical therapy, joint injections, nerve blocks and nerve ablation. If the facet joint symptoms become chronic surgery to fuse the joint is required.

Anatomy of the facet joints

A spine is made of a column of moveable bones named vertebrae that connect to one another. Each vertebra functions as a three-joint complex consists of a large disc in the front and two facet joints in the back.

This design is robust and keeps the bones linked together while allowing our spine to bend and twist. Facets joints are lined with cartilage, lubricated in synovial fluid, and covered by a joint capsule. The facet joints when healthy glide and slide as the back moves but prevents over-twisting.

What is facet joint syndrome?

Pain that comes from one or more facet joints is called facet joint syndrome or facet arthropathy. Degenerative changes in the spine may cause uneven shifting of body weight to the facet joints. Wear and tear of the facet joints are caused by the extra burden over time: the joint capsule thins, smooth cartilage breaks down and becomes irregular, and bone spurs may form (Fig. 1). These changes make it difficult for the joint to move fluidly and it reacts by becoming inflamed and irritated. The irritated joint sends pain signals to the brain via small nerves in the capsule called medial branch sensory nerves (Fig. 2). In turn, the reflex mechanism makes the muscles in the area stiffen.

What are the symptoms?

Facet joint degeneration can be painless until an event initiates the symptoms. There are some symptoms that indicate a pain/ache is coming from the facet joints. The pain/ache is likely to be diffuse and dull located in the low back directly over the spine that can spread to the buttocks. In the neck it may be felt in the shoulders and back of the skull.

The movements of the spine such as bending backwards or twisting sideways towards the affected joint may cause pain. pain can be worsened on standing or periods of inactivity. Activities that take the weight off the joint such as sitting, leaning forward, or changing positions may alleviate the pain. Facet joint syndrome may also mimic the pain of a disc herniation. Pain may be felt travelling down the arms or legs if bone spurs form and press on the spinal nerves.

What are the causes of facet joint syndrome?

As we get older, cartilage in our joints wears down. The repetitive movements of the spine, obesity, poor posture, injury, and other spine conditions that change the way the facet joints align, and move may cause pain. The facet joints changes can begin with the deterioration of a vertebral disc. As the load of the body weight shifts to the facet joint, the cartilage breaks down, the joint space narrows, that causes the bones to rub together.

Who is affected?

Facet joint syndrome affects men and women equally. The syndrome is most common between the ages of 40 and 70 and in those prone to arthritis. It also may develop in people sustained a spine injury.

How is a diagnosis made?

Facet pain can mimic other spine conditions. A precise diagnosis is important to define whether the facet joint is the source of your pain. Evaluation consists of a medical history and physical exam. Our consultants will consider all the information provided, including any history of injury, the pain location, and problems standing or sleeping.

You may be asked to stand or move your back in different positions and point to where you feel pain. The consultants may manipulate your joints or feel for tenderness over the spine.

To rule out other related spinal conditions, imaging studies, such as X-ray, CT, or MRI, may be ordered to help the differential diagnosis.

If you need needle EMG, our consultants are qualified to exclude other peripheral nerve lesion or compression of the nerve roots.

A diagnostic facet joint injection is often carried out to confirm the source of pain. The facet joint is injected with a local anesthetic and corticosteroid medication (Fig. 3). In the medical center the injection is ultrasound-guided to ensure accurate needle placement in the facet joint. The level of pain is assessed before and 20-30 minutes after procedure and followed up over the next week. Facet joint involvement is proved if your pain level decreases by more than 75%. If your pain level does not change after the injection, it is unlikely that you suffer the facet joint pain.

What treatments are available?

Although facet joint arthritis can’t be reversed, there is evidence that exercise, lifestyle changes and careful management of your back pain can contribute to better quality of life. If conservative therapies fail to control the pain, our consultants may recommend injections, ablations, or surgery.

Self-care: You can prevent painful episodes using correct posture and keeping your spine in alignment. Adjustments to your daily standing, sitting, and sleeping habits may be required. Losing weight will reduce the load on the facet joints and ease pain.

Physical therapy. Exercise is very useful for a painful facet joint, and it can help you repair faster. Physical therapists can instruct you on right lifting and walking techniques, and you will together strengthen and stretch your lower back, leg, and stomach muscles.

Medications: Some patients may require anti- inflammatory medications or topical patches, creams, salves, or mechanical bracing. Sometimes muscle relaxers are prescribed if there are muscle spasms.

Steroid joint injections: A facet joint injection is a minimally invasive procedure that involves an injection of a corticosteroid and an analgesic-numbing agent into the painful joint (Fig. 3). Steroids can decrease the swelling and inflammation of the nerves. The pain relief can last from days to years, allowing your condition to improve with physical therapy and an exercise program. In case of a recurrence of pain, the procedure could be repeated.

Nerve radiofrequency ablation: If steroid joint injections are successful but pain recurs frequently, an ablation procedure to burn the small nerves of the joint capsule may be suggested. A diagnostic nerve block test is carried out first to define which nerves are to be treated. Anesthetic is injected along the nerve to “block” pain (Fig. 4). If the block is efficacious, more lasting pain relief is likely to be provided by a radiofrequency ablation.

A nerve ablation procedure is performed like the nerve blocks. Once the needle is placed in the joints, an additional electrode is inserted, and a radiofrequency current destroys some of the medial branch nerve (Fig. 5). Pain relief may last from 9 months to more than 2 years. However, it is possible the nerve will regrow through the burned lesion that was created recurrent pain.

Surgery: If the above-mentioned procedures do not provide pain relief, spine fusion surgery may be an option. This usually happens when there is compression of the nerve roots from enlarged facet joints, or spinal instability.