Facet Joint Disease


Article Author:
Lindsay Curtis
Neal Shah


Article Editor:
Devang Padalia



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Orawan Chaigasame
Carrie Smith
Abdul Waheed
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Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/22/2019 10:45:38 AM

Introduction

Facet joints form from the superior and inferior articular processes of two adjacent vertebrae. They are synovial joints as a fibrous capsule encompasses the bone and articulating cartilage and is continuous with the periosteum. The joint also contains synovial fluid which is kept in place by an inner membrane. The function of these joints is to allow for flexion and extension of the spine while limiting rotation and preventing the vertebrae from slipping over each other. The sensory nerve of these joints is the medial branch of the dorsal spinal ramus. Facet joint disease, also known as facet syndrome, is a condition in which these joints become a source of pain. Facet joint mediated pain is a common source of disability amongst our population with significant economic impact. Chronic low back pain often results from facet joint disease, with a prevalence of 15 to 41%.[1]

Etiology

The most common cause of facet joint disease is degeneration of the spine, also known as spondylosis. When the degeneration of the joint is secondary to natural wearing and abnormal body mechanics the condition is known as osteoarthritis (OA). The pathophysiology of OA is not entirely understood but is a complex one involving various cytokines and proteolytic enzymes as well as personal risk factors. Other causes of facet joint disease include trauma secondary to injury or sporting activities. Inflammatory conditions such as rheumatoid arthritis and ankylosing spondylitis may also contribute due to the inflammation of the synovium. Subluxation of the facet joints due to spondylolisthesis can also contribute to the development of facet joint disease. Those with facet joint disease show signs of cartilage erosion and inflammation, which can lead to pain. The body will also undergo several physical changes in response to this process. Ligaments, such as the ligamentum flavum, can become thickened and hypertrophic. New bone formation around the joint can occur with the development of osteophytes or “bone spurs.” There can also be an increase in the subchondral bone volume with hypomineralization.[2]

Epidemiology

The lifetime adult prevalence of low back pain in the United States is 65 to 80%.[3] This prevalence is consistent with the idea that degeneration is the leading contributory cause of facet joint disease, as the elderly population is more often affected. There have been no studies that confirm that males are affected more often than females. However, having a history of doing heavy work before age 20 increases the likelihood of developing facet joint osteoarthritis.[4] Obesity also largely contributes to osteoarthritis; thus, it is likely a contributing factor in the development of facet joint disease.

Spondylolisthesis caused by degeneration is most often caused by facet joint osteoarthritis, and typically occurs at the L4-L5 level. Spondylolisthesis that presents in a younger population (30 to 40years old) is due to congenital abnormalities, stress or acute fractures.[4] Cervical facet disease and pain has a prevalence rate of 29 to 60% following whiplash injuries; although overall trauma is still a rare cause.[5]

History and Physical

Facet joint disease is often a clinical diagnosis, and therefore the history and physical exam are extremely important. Patients who present with chronic back pain have symptoms that often overlap with other diagnoses. Facet mediated pain is typically non-radicular. The pain is often described by patients as worse in the mornings, upon awakening or during periods of inactivity. It may also worsen with spine extension, facet joint palpation, and rotary trunk motion. Pain can be elicited by facet joint palpation and axial loading. Reproduction of the patient’s pain with Kemp’s maneuver, lateral rotation, lateral bending, and back extension, is suggestive of facet joint disease and arthropathy. In the lumbar area, this pain can be unilateral but is typically axial with occasional radiation into the buttock, groin, and thighs and down to the knee.[6] There are reports of radiation of pain to the abdominal and pelvic areas; however, this is less frequent.[7] This “pseudo-radicular” pain does not have any associated neurological deficits. When this radiating pain is present, it can mimic sciatic pain, but this is most often in cases of osteophytes or synovial cysts.[4] It is important to rule out other causes of low back pain, such as disc herniations, vertebral body fractures, and neoplastic causes of the patient’s pain.

Evaluation

It is often challenging to isolate facet joint disease as the sole cause of a patient’s complaint of neck or back pain. Imaging has not been proved to have much if any diagnostic validity. X-ray, CT, and MRI may show degeneration, joint space narrowing, facet joint hypertrophy, joint space calcification and osteophytes; however, these findings may be present in both symptomatic and asymptomatic patients. Data shows that 89% of patients in the 60 to 69 years of age population studied have facet joint osteoarthritis, although not all were symptomatic.[8]  Diagnostic medial branch blocks are considered the gold standard approach to diagnose facet joint pain. A positive response to a set of 2 diagnostic blocks done on two separate occasions at two or more levels can confirm the source of pain. High false positive responses are more likely to occur if only 1 level is blocked.[9]

Treatment / Management

Conservative management is used as first-line therapy to treat facet mediated pain. Anti-inflammatory medications, weight loss, muscle relaxers, physical therapy, and massage are therapies used in conjunction with one another as a multimodal approach to treating the pain. When conservative measures fail, interventional procedures are considered to reduce pain, improve functionality and reduce side effects from medications.[10] Diagnostic medial branch blocks are often performed to confirm the generation of the pain is from the facet joints. Two diagnostic medial branch blocks are often an option secondary to the high (30 to 45%) false positive success rate reported after a single block.[11] If a patient has a positive response to a set of two diagnostic blocks, radiofrequency ablation can then be done to ablate the medial branch nerves. Improved function and decreased pain have been shown to last from 6 to 12 months following lumbar medial branch radiofrequency ablation.[8] Radiofrequency ablation uses heat to temporarily destroy the medial branch of the sensory nerve, thus providing a reduction of pain. The procedures mentioned above are done usually under local anesthesia and fluoroscopic guidance. Because nerves regenerate eventually, the procedure is repeatable when the patient’s pain returns, typically in 6 to 12 months.

There are currently no guidelines available to support arthrodesis when interventional procedures fail to provide pain relief. Surgery may be indicated for grade I or grade II spondylolisthesis; however, this is not first line management and may not result in the reduction of pain.[4]

Differential Diagnosis

  • Sciatica
  • Hip osteoarthritis
  • Sacroiliac impingement
  • Lumbar radiculopathy
  • Myofascial pain
  • Compression fractures
  • Disc herniation
  • Osteophytes
  • Rheumatoid arthritis

Prognosis

Facet joint disease is a chronic process that can cause pain for the remainder of an individual’s lifetime. Facet joint disease is a progressive disease. The spinal and joint degeneration typically progresses as the patient ages. It is essential to prevent the degeneration from progressing by maintaining a healthy weight and active lifestyle. Physical therapy and core strengthening exercises can strengthen the spine and reduce the stress on the facet joints. Interventional procedures such as medial branch blocks and radiofrequency ablations do not treat the underlining cause of the patient’s pain but allow the patient’s pain to be more manageable. Patients can have a reduction in their pain for months at a time, but some studies have shown even longer-term decrease in pain of up to 2 years after radiofrequency ablations.[12]

Complications

Complications of treatment of facet joint pain with medial branch blocks or radiofrequency ablation are rare. Patients may have a transient increase in their pain following radiofrequency ablations and medial branch blocks due to the heat denervation and needle entry. Post-dural headaches, transient numbness or weakness, bleeding, infection and increased post-procedural pain are all potential but rare complications of facet interventions.

Deterrence and Patient Education

Patient education is of the utmost importance with patients treated for pain. Patients should receive information that facet joint disease is a lifelong and progressive disease. Complete resolution of the patient’s pain is typically not observed, and this is a crucial component of any discussion with the patient. Prevention of disease progression through a healthy lifestyle, diet, and exercise is imperative; this can help reduce the stress on the facet joints, therefore reducing inflammation and pain.

Enhancing Healthcare Team Outcomes

Treating patients in pain can often be challenging. It is vital for the healthcare workers (i.e., the primary care provider, nurse practitioner, internist, and an orthopedic surgeon) to listen to the patient to obtain a solid history and perform a complete physical exam to diagnose the source of the patient’s pain and more importantly rule out more serious causes for the pain.   Although complications from the previously discussed procedures are rare, prompt follow up after procedures are necessary to ensure no negative side effects from the procedures have occurred. To help prevent facet joint disease, the orthopedic nurse should educate the patient on the importance of lifestyle changes.

Facet joint arthrosis requires a collaborative interprofessional approach that includes physicians, nurses, therapists, and pharmacists who are engaged and communicating all aspects of the patient's case to bring about the best possible outcome. [Level V]


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Facet Joint Disease - Questions

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A 57-year-old former construction worker reports severe neck and low back pain to his primary physician. He states the pain has progressively gotten worse over the past five years, but he feels that he has always had some pain in his spine. There is minimal radiation of pain into his shoulders and buttocks. Which of the following physical exam maneuvers is most likely to reproduce some of this patient's pain?



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A 65-year-old overweight female presents with a six-year history of non-radiating low back pain. She describes the pain as a deep ache that is worse upon waking in the mornings and gets slightly better as the day progresses. She denies pain radiating down into her lower extremities. She denies any falls, or trauma contributing to this pain. She has been taking over the counter ibuprofen and acetaminophen and completed 8 weeks of physical therapy, which was not helpful. She is ambulatory without using assistance but reports the pain has a significant impact on her quality of life. Lumbar x-rays show degenerative disc disease and facet joint hypertrophy at multiple levels. There is no reported history of fevers, chills, weight loss, or cancer. Examination reveals lumbar spine pain with extension and rotation and axial spine tenderness with palpation. Straight leg raise testing is negative. She demonstrates equal and normal strength and sensation in the lower extremities. Which of the following should be the next treatment option for this patient?



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A 72-year-old female with a history of osteopenia and chronic low back pain presents to her primary care provider with complaints of continued aching in her thoracic and lumbar spine with radiation into her hips. She describes the pain that radiates into her lateral hips as a sharp, shooting pain that worsens with activity and improves with rest. Recent radiographs of her hips are normal and lumbar x-rays are pending. She denies falls or trauma. On physical examination of the lower back, there is axial pain with rotation and extension, and no tenderness with palpation of the spine. No extremity weakness is noted. She is ambulatory without assistance. What would her lumbar X-ray most likely show?



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A 65-year-old male patient presents with low back pain of 3 years duration. In the last 5 months, he experienced some pain in the lower back with back extension. He also complains of intermittent pain radiating from the lower back to his bilateral knees. On straight leg raising test with the patient supine, he shows pain in the back and the posterior thigh at 100 degrees of elevation. Which of the following is the likely cause of the patient’s pain?



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A 65-year-old female patient presents for a follow-up visit to the pain clinic. She has a history of lumbar pain of 3 years duration, for which she has had several bilateral lumbar medial branch radiofrequency ablations with excellent pain relief. In the last two months, she complains of some tingling in the right buttock and posterior thigh and leg with radiation of pain to the right great toe. The right extensor hallucis muscle shows slight weakness, which was not present 6 months ago on a previous visit. What is the next best step in managing this patient?



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A 72-year-old male presents to an outpatient pain management clinic complaining of a 3-year history of low back pain. The pain is in the middle of his low back and is exacerbated by movement. He denies any initiating event or trauma to his back. He has just completed an 8-week course of physical therapy and ibuprofen but has had continued pain. His primary care doctor ordered an MRI which showed a disc herniation at the L2-L3 level as well as facet joint hypertrophy at the L4-L5 level. Which of the following would be the most appropriate next step in management?



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Facet Joint Disease - References

References

Maas ET,Juch JN,Ostelo RW,Groeneweg JG,Kallewaard JW,Koes BW,Verhagen AP,Huygen FJ,van Tulder MW, Systematic review of patient history and physical examination to diagnose chronic low back pain originating from the facet joints. European journal of pain (London, England). 2017 Mar;     [PubMed]
Li G,Yin J,Gao J,Cheng TS,Pavlos NJ,Zhang C,Zheng MH, Subchondral bone in osteoarthritis: insight into risk factors and microstructural changes. Arthritis research     [PubMed]
Perolat R,Kastler A,Nicot B,Pellat JM,Tahon F,Attye A,Heck O,Boubagra K,Grand S,Krainik A, Facet joint syndrome: from diagnosis to interventional management. Insights into imaging. 2018 Oct;     [PubMed]
Manchikanti L,Singh V,Pampati V,Damron KS,Barnhill RC,Beyer C,Cash KA, Evaluation of the relative contributions of various structures in chronic low back pain. Pain physician. 2001 Oct;     [PubMed]
Piraccini E,Calli M,Corso RM,Byrne H,Maitan S, Abdominal and pelvic pain: an uncommon sign in lumbar facet joint syndrome. Minerva anestesiologica. 2017 Jan;     [PubMed]
McCormick ZL,Marshall B,Walker J,McCarthy R,Walega DR, Long-Term Function, Pain and Medication Use Outcomes of Radiofrequency Ablation for Lumbar Facet Syndrome. International journal of anesthetics and anesthesiology. 2015;     [PubMed]
Longo UG,Loppini M,Denaro L,Maffulli N,Denaro V, Rating scales for low back pain. British medical bulletin. 2010     [PubMed]
Kalichman L,Hunter DJ, Lumbar facet joint osteoarthritis: a review. Seminars in arthritis and rheumatism. 2007 Oct     [PubMed]
Urits I,Burshtein A,Sharma M,Testa L,Gold PA,Orhurhu V,Viswanath O,Jones MR,Sidransky MA,Spektor B,Kaye AD, Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Current pain and headache reports. 2019 Mar 11     [PubMed]
Manchukonda R,Manchikanti KN,Cash KA,Pampati V,Manchikanti L, Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. Journal of spinal disorders & techniques. 2007 Oct     [PubMed]
Cohen SP,Williams KA,Kurihara C,Nguyen C,Shields C,Kim P,Griffith SR,Larkin TM,Crooks M,Williams N,Morlando B,Strassels SA, Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology. 2010 Aug;     [PubMed]
Crosby ND,Gilliland TM,Winkelstein BA, Early afferent activity from the facet joint after painful trauma to its capsule potentiates neuronal excitability and glutamate signaling in the spinal cord. Pain. 2014 Sep;     [PubMed]

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