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Facet Joint Pain

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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

  • 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
  • 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

Pathoanatomy

  • Zygapophyseal Joint
    • Only synovial joint of the spine including hyaline cartilage, subchondral bone, a synovial membrane and a joint capsule
    • Form the postero-lateral articulation between Vertebrae

Associated Injuries

Risk Factors

Differential Diagnosis

Clinical Features

  • 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
    • Facet tenderness
  • Special Tests

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)[7]
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[8]
  • 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[9]

MRI

  • Best to evaluate soft tissues
  • Role in evaluating FJ disease is not entirely clear
  • Controversial when compared to CT[10]
  • 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[11]

Classification

Pathria’s Classification

  • Radiographic classification[12]
  • 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

Nonoperative

  • First line therapy
  • Medications
  • Physical Therapy
  • Other modalities
  • Facet Joint Nerve Block
    • Only reliable tool to aid in confirming FJ is cause of back pain[13]
    • Relief estimated to be between 50-80% reduction in pain, ability to perform previously painful movements[14]
    • 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[15]
  • 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[16]
    • Drefuss et al: 60% of patients experience 90% reduction in pain, 65% lasting 12 months[17]
    • Is not definitive, nerve will eventually regenerate
    • Recommend max of 2 procedures per year.
  • Future considerations

Operative

  • Surgical outcomes are not great
    • No convincing evidence for any surgical intervention in FJ Disorders
  • Indications
  • Technique

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

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

Complications

  • Chronic back pain

See Also

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. ↑ Perolat, Romain, et al. "Facet joint syndrome: from diagnosis to interventional management." Insights into imaging 9.5 (2018): 773-789.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106(3):591–614.
  11. ↑ 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.
  12. ↑ Pathria M, Sartoris DJ, Resnick D. Osteoarthritis of the facet joints: accuracy of oblique radiographic measurement. Radiology. 1987;164:227–230
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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
  17. ↑ 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
Created by:
John Kiel on 17 June 2019 16:43:15
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Last edited:
5 October 2022 23:59:06
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