Jump to content
We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Facet Joint Pain

From WikiSM
(Redirected from Facet Arthropathy)

Other Names

  • Facet Arthritis
  • Facet Arthropathy
  • Facet Syndrome
  • Zygapophyseal Joint Pain
  • Facet joint syndrome
  • Facet Joint Osteoarthritis (OA)

Background

  • This page refers to pain originating from the Zygapophyseal Joint, often referred to as a facet joint (FJ)

History

  • First described by Goldthwaite in 1911[1]
  • Ghormhley used the term “facet syndrome” to describe a symptom originating from the FJ in 1933[2]

Epidemiology

  • Reviews estimate facet joints as the primary pain generator in back pain at 10-15% in young adults and as high as 45% in older adults[3]
  • Another study estimated the prevalence to be between 27-40% in patients with chronic lower back pain[4]
  • Facet osteoarthritis is the most frequent form of facet pathology[5]
    • Eubanks et al found universal facet joint OA in a study of 647 cadavers[6]
    • Kalichman et al showed FJ OA increases with age and reaches 89% in individuals over 60

Pathophysiology

Patterns of facet joint pain[7]
Typical Z (zygapophyseal/ facet) joint. Each facet joint has articular cartilage, the synovium where synovial fluid is produced, and a meniscus.[8]
Facet joint illustration[9]

General

  • Facet joint pain is a commonly encountered mechanical, nociceptive cause of back pain but can be challenging to diagnose
  • Pain is typically lozalized axial pain that can radiate in a non-dermatomal pattern
  • There are no pathognomonic signs or symptoms and imaging findings have limited specificity
  • Treatment is generally non-surgical involving medications, injections, and nerve blocks

Etiology: Degenerative

  • Most frequent form of FJ pain
  • Continuum of joint space, narrowing, loss of synovial fluid and loss of cartilage and bony overgrowth
  • Pain believed to be caused by inflammation of surrounding tissues as joint space collapses
  • Synovial cysts can develop and exacerbate symptoms

Etiology: Spondylolisthesis

  • Generally thought to be related to degeneration and loss of normal ROM of FJ
  • Subluxation of FJ may occur
  • In addition to degenerative process, can also be due to congenital abnormalities, acute or stress-related fractures or isthmic spondylolisthesis

Anatomy of the Zygapophyseal Joint

  • Small synovial joints located in the spine between the superior/inferior articular processes of adjacent vertebrae
    • Form the postero-lateral articulation between Vertebrae
  • They concurrently provide stability to the spine and facilitate movement
  • Extends from C2 to S1 with regional variability
  • Only synovial joint of the spine including hyaline cartilage, subchondral bone, a synovial membrane and a joint capsule

Associated Injuries

Risk Factors

Differential Diagnosis

Differential Diagnosis Back Pain

Clinical Features

Starting and finishing position of the Kemp Test[10]
Radiation pattern of thoracic facet pain[11]

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 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

  • Palpate for segmental tenderness (PST)
    • Palpate the paraspinal muscles overlying the facet joints bilaterally
    • Positive finding is incidated by increased baseline or referred pain
  • Extend and rotate the affected segments which should provoke pain

Special Tests

  • Kemp Test: patient is brought from flexion into extension
  • Spurling Test: Can load facet joints without reproduction of radicular symptoms
  • Spring Test: apply pressure to SP and TP in the prone position

Evaluation

Degenerative facet joint osteoarthritis (FJOA): Sagittal (a) and axial (b, c) CT views. Hypertrophy of the posterior articular process (black arrow). Joint space narrowing (thin white arrow). Joint capsule calcification (arrow head) and vacuum phenomenon (white arrow)[12]
A-D Four grades of facet joint osteoarthritis on MRI (TR = 570 ms/TE = 15 ms, 5 mm thickness). A Grade 1: normal. B Grade 2: joint space narrowing or mild osteophyte. C Grade 3: sclerosis or moderate osteophyte. D Grade 4: marked osteophyte[13]
Method used to measure the posterior facet joint space with plain radiography (A) and computed tomography (B). (1) Consider the oblique projection or overlapping of bone images before measuring. (2) Choose one side of the facet joint at every level (C2–7). Determine the anterior and posterior margins of the facet joint (anterior margin: anterosuperior corner of the superior articular process of the lower vertebra [black arrows]; posterior margin: posteroinferior corner of the lateral mass of the upper vertebra [white arrows]). (3) From these points, draw lines perpendicular to the joint space (lines A and B). (4) At the center of the space between the two lines, draw a line (C) parallel to lines A and B. The length of line C is the joint space of the facet joint. Post.: posterior, Ant.: anterior. [14]

General

  • 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
    • 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
  • Preferred method for imaging FJ osteoarthritis[15]

MRI

  • Best to evaluate soft tissues
  • Role in evaluating FJ disease is not entirely clear
  • Controversial when compared to CT[16]
  • Findings
    • Active synovial inflammation,
    • Adjacent bone edema
    • Facet joint effusion
    • Subchondral bone edema
    • Enhancement of the FJ rim (synovitis)
    • Wraparound bumper osteophyte formation

SPECT

  • Role in workup unclear
  • It has been shown that patients present better improvement after FJ injection in case of positive SPECT findings[17]

Classification

Pathria’s Radiographic Classification[18]

  • 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

Management

Lumbar Support Cushion

Main characteristics of the denervation procedure[12]
Facet joint injections

Nonoperative

Other Modalities

Procedures

  • Facet Joint Nerve Block
    • Only reliable tool to aid in confirming FJ is cause of back pain[21]
    • Relief estimated to be between 50-80% reduction in pain, ability to perform previously painful movements[22]
    • 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[23]
  • 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[24]
    • Drefuss et al: 60% of patients experience 90% reduction in pain, 65% lasting 12 months[25]
    • Is not definitive, nerve will eventually regenerate
    • Recommend max of 2 procedures per year.
  • Endoscopic denervation/ neurotomy
    • May offer superior and sustained pain relief compared to other radiofrequency treatments[26]

Operative

  • Indications
    • Unknown
    • Surgical outcomes are not great and there is no clear guidance for which patients require intervention
  • Technique
    • Surgical fusion is not recommended

Rehab and Return to Play

Cervical facet syndrome rehab[27]
Facet joint pain stretches

Rehabilitation

  • Cervical facet pain[28]
    • Cervicothoracic and upper extremity strengthening
    • Stretching
    • endurance
  • Lumbar facet pain protocol[29]
    • Supervised exercise
    • Corte strengthening
    • Stretching
    • Endurance
    • Stabilization
    • Range of motion

Sample Rehab Progrom

  • Weeks 1-4: Initiate low-impact exercise, range-of-motion training, graded activity
    • Consider massage or spinal manipulation
  • Weeks 4-12: Progress exercise intensity; add yoga, pilates, or tai chi
    • Incorporate CBT or mindfulness-based stress reduction if needed
  • Beyond 12 weeks
    • For inadequate response, consider diagnostic medial branch blocks followed by radiofrequency ablation if positive
    • Implement multidisciplinary rehabilitation for refractory cases

Rehab Exercise Program PDFs

Return to Play

  • Prior to return to play, athlete should demonstrate
    • Full, pain free and symmetric range of motion
    • Able to complete sport-specific training without significant discomfort
    • Unrestricted back flexibility and range of motion

Complications and Prognosis

Prognosis

  • General
    • Prognosis is generally favorable
    • Long term disability is uncommon
  • Conservative management
    • Many experience improvement with conservative management[30]
    • Radiofrequency ablation has been shown to provide significant relief up to 6-12 months in about half of patients[31]
  • Surgical
    • Surgical outcomes are not great
    • No convincing evidence for any surgical intervention in FJ Disorders
  • Prognostic factors predicting better outcomes
    • Imaging findings of facet joint arthropathy, positive SPECT scans, and appropriate pain duration are consistently associated with favorable results[32]
    • Younger age and smoking are frequently associated with less favorable clinical outcomes

Complications

  • Chronic axial pain
  • Reduced spinal mobility
  • Functional impairment
  • Post procedural risks
  • Rarely
    • Radiculopathy
    • Synovial cysts
    • Severe osteoarthritic changes

See Also

Internal

External

References

  1. ↑ Goldthwait JE. The lumbosacral articulation: an explanation of many cases of lumbago, sciatica, and paraplegia. Boston Med Surg J. 1911;164:365–372.
  2. ↑ Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933;101:773.
  3. ↑ Saravanakumar K, Harvey A. Lumbar zygapophyseal (facet) joint pain. Rev Pain. 2008;2(1):8–13.
  4. ↑ Datta S, Lee M, Falco FJ, Bryce DA, Hayek SM. Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician. 2009;12(2):437–460
  5. ↑ 5.0 5.1 Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976) 2008;33(23):2560–2565.
  6. ↑ Eubanks JD, Lee MJ, Cassinelli E, Ahn NU. Prevalence of lumbar facet arthrosis and its relationship to age, sex, and race: an anatomic study of cadaveric specimens. Spine (Phila Pa 1976) 2007;32(19):2058–2062
  7. ↑ Manchikanti, Laxmaiah, et al. "Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines." Pain physician 23.3S (2020): S1.
  8. ↑ Steilen, Danielle, et al. "Chronic neck pain: making the connection between capsular ligament laxity and cervical instability." The open orthopaedics journal 8 (2014): 326.
  9. ↑ Image courtesy of deukspine.com/
  10. ↑ Stuber, Kent, et al. "The diagnostic accuracy of the Kemp’s test: a systematic review." The Journal of the Canadian Chiropractic Association 58.3 (2014): 258.
  11. ↑ Van Kleef, Maarten, et al. "Thoracic pain." Evidence‐Based Interventional Pain Medicine: According to Clinical Diagnoses (2011): 62-70.
  12. ↑ 12.0 12.1 Perolat, Romain, et al. "Facet joint syndrome: from diagnosis to interventional management." Insights into imaging 9.5 (2018): 773-789.
  13. ↑ Fujiwara, Atsushi, et al. "The relationship between facet joint osteoarthritis and disc degeneration of the lumbar spine: an MRI study." European Spine Journal 8.5 (1999): 396-401.
  14. ↑ Choi, Sung Hoon, et al. "Radiological parameters of undegenerated cervical vertebral segments in a Korean population." Clinics in Orthopedic Surgery 9.1 (2017): 63.
  15. ↑ Schwarzer AC, Wang SC, O’Driscoll D, Harrington T, Bogduk N, Laurent R. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine (Phila Pa 1976) 1995;20(8):907–912.
  16. ↑ Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106(3):591–614.
  17. ↑ Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: prediction of short-termoutcome of facet joint injection with bone scintigraphy. Radiology. 2006;238(2):693–698.
  18. ↑ Pathria M, Sartoris DJ, Resnick D. Osteoarthritis of the facet joints: accuracy of oblique radiographic measurement. Radiology. 1987;164:227–230
  19. ↑ Chiarotto, Alessandro, and Bart W. Koes. "Nonspecific low back pain." New England Journal of Medicine 386.18 (2022): 1732-1740.
  20. ↑ Flynn, Diane M. "Chronic musculoskeletal pain: nonpharmacologic, noninvasive treatments." American family physician 102.8 (2020): 465-477.
  21. ↑ Falco FJ, Manchikanti L, Datta S, et al. An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician. 2012;15(6):E869–E907.
  22. ↑ Manchikanti L, Manchikanti KN, Manchukonda R, et al. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician. 2007;10(3):425–440.
  23. ↑ Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic non-specific low back pain. Eur Spine J. 2006;15:S192–S300.
  24. ↑ Bogduk N, Dreyfuss P, Govind J. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Pain Med. 2009;10(6):1035–1045
  25. ↑ Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine (Phila Pa 1976) 2000;25(10):1270–1277
  26. ↑ Park, Soyoon, et al. "Radiofrequency treatments for lumbar facet joint syndrome: a systematic review and network meta-analysis." Regional Anesthesia & Pain Medicine 50.11 (2025): 879-890.
  27. ↑ Image courtesy of https://protailored.com/
  28. ↑ Hurley, Robert W., et al. "Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group." Pain Medicine 22.11 (2021): 2443-2524.
  29. ↑ Chiarotto, Alessandro, and Bart W. Koes. "Nonspecific low back pain." New England Journal of Medicine 386.18 (2022): 1732-1740.
  30. ↑ Hellinga, M. D., et al. "7. Cervical facet pain: Degenerative alterations and whiplash‐associated disorder." Pain Practice 25.2 (2025): e70005.
  31. ↑ Cohen, Steven P., Julie HY Huang, and Chad Brummett. "Facet joint pain—advances in patient selection and treatment." Nature Reviews Rheumatology 9.2 (2013): 101-116.
  32. ↑ Julbe, José I. Acosta, et al. "Predictors of outcomes after lumbar intra-articular facet joint injections and medial branch blocks: a scoping review." Spine 48.20 (2023): 1455-1463.
Created by:
John Kiel on 17 June 2019 16:43:15
Authors:
Last edited:
23 January 2026 02:21:54
Categories:
Retrieved from "https://wikism.org/w/index.php?title=Facet_Joint_Pain&oldid=40108"