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Facet Joint Syndrome

The spinal column—the weight-bearing portion of the spine—is made up of flat, more or less round vertebrae alternating with supportive discs. We wouldn't get very far, though, if these structures were simply stacked up like pancakes. They must be connected somehow, yet remain flexible enough for us to do things like yank crabgrass out of the lawn or pick up Legos off the living room floor. That's where the facet joint comes in.

Facet Joint Syndrome_Figure 1

Figure 1: A pair of facet joints (pink) connects each vertebra to the one below it.

What’s a facet joint?

On the back side of most vertebrae is a bony structure called the vertebral arch. In its center is a bumpy projection – that’s the part you can feel as you run your fingers down the spine. This little knob sits at the center of the vertebral arch. Pairs of rigid projections extend upward and downward on either side (see the lower-right inset in Figure 1). A facet (fuh-SETT) joint is the point at which the downward projections of one vertebra meet the upward projections of the vertebra below it (see the upper-right portion of the illustration).

A pair of facet joints, then, connects each vertebra to the one below it, giving the spinal column strength and flexibility. Each facet joint is lined with cartilage and surrounded by a fluid-filled capsule that keeps the joint lubricated. Inside the capsule are tiny offshoots of the medial nerve, which relay pain signals to the brain when joint damage occurs. 1

What is facet joint syndrome?

The aging body is like a ’55 Chevy—to remain roadworthy, it must be carefully maintained. As a vehicle ages, rust sets in, rubber gaskets dry out, belts snap. Likewise, facet joint syndrome is a condition in which an arthritic facet joint causes pain and stiffness, reduces range of motion, or limits mobility. Remember, the facet joint may be oddly shaped, but it’s a joint all the same—just like a knee or an elbow, only smaller. Facet joint syndrome can affect any part of the spine – cervical, thoracic, lumbar, or sacral vertebrae – but it’s most common in the lumbar region.

What are the symptoms of facet joint syndrome?

Facet joint syndrome can cause back pain, tenderness, inflammation, or stiffness at or near its site of origin. You might not be able to move or bend as freely as you used to. As the muscles surrounding the joint capsule work overtime to protect the compromised area, muscle spasms can also occur. The pain may travel outward from its source like an echo, causing headaches, neck stiffness, or pain in the shoulder, leg, buttocks, arm, or hand. The pain usually occurs on one side of the body, and certain positions or movements, such as twisting around to check your blind spot in the car, may intensify it. Managing this chronic pain can make you feel anxious, stressed, or depressed. Although doctors sometimes recommend rest, long periods of inactivity ultimately aggravate the pain because the muscles that support the facet joints weaken if they’re not used.

What causes facet joint syndrome?

As we get older, our joints break down, especially if we don’t exercise enough and have poor posture or body mechanics. Years of friction erodes the smooth cartilage that lines joint surfaces, making it arthritic. In addition, injury, alcohol or tobacco use, inadequate circulation, too much sitting or standing, and the aging process itself can decrease lubrication within the joint capsule and cause inflammation of the capsule itself. Vertebral discs begin to collapse with age, putting even more pressure on the facet joints. That’s why facet joint syndrome often goes hand-in-hand with degenerative disc disease.

How common is facet joint syndrome?

You’re not alone. Facet joint syndrome is one of the most common causes of lower-back pain. Because this condition is difficult to differentiate from other causes of back pain, it’s hard to say exactly how many people have it. But every year, 25 million Americans miss least a day of work because of lower-back pain, and another 5 million people are disabled by it.

How is facet joint syndrome diagnosed?

Facet joint syndrome is surprisingly tough to diagnose. Pain can radiate out from its source, the way toothache pain does, making it tricky to pinpoint its origin—is the problem at T12 or L1? Nor is it easy to determine which anatomic structure is affected. Pain at the level of L1 (the first lumbar vertebra), for example, may be caused by a herniated disc, spinal cord compression (stenosis), or an arthritic facet joint. Spinal x-rays can identify arthritis in the facet joints. But to really figure out what’s going on, your surgeon may try to reproduce or provoke the pain. If an injection of harmless saline solution into the joint space produces pain, for example, it’s safe to assume that the pain originates there. Likewise, if an injection of anesthetic into a particular facet joint inhibits your pain, Bingo! That’s the source.

How is facet joint syndrome treated?

Treatment of facet joint syndrome focuses on one of two approaches: either managing the symptoms or addressing the cause of the pain directly. Initially your doctor will probably recommend exercise and other minor lifestyle changes to reduce pain to a manageable level. He or she might urge you to rest for a few days or apply heat or ice. If none of these straightforward measures resolves your pain and discomfort, it might be time to consider more robust treatment options aimed at eliminating the cause of your symptoms.

Physical therapy

Your doctor will probably encourage you to become more active. But if exercising on your own doesn’t help, physical therapy may be in order. A physical therapist can show you how to target the right muscles and improve your posture and body mechanics to increase your flexibility and range of motion. Physical activity tones the muscles surrounding the facet joints. As these muscles become stronger, they’re better able to support the spine, helping them bear the load of your body weight.

Medications
Nonopioid Agents

Acetaminophen and antiinflammatory drugs, such as ibuprofen (Advil) and naproxen (Aleve), are often prescribed to reduce the pain of facet joint syndrome. Muscle relaxants can ease muscle spasms associated with arthritic facet joints. Sometimes doctors even prescribe oral steroid medications to tamp down acute pain. They may also prescribe medications to treat the anxiety, sleeplessness, or depression associated with chronic pain.

Opioids

Prescribed sparingly and monitored carefully, opioid (pain relief) medications are an excellent tool for managing the symptoms of facet joint syndrome. You and your doctor can discuss the risks and benefits of opioid therapy to decide if this option is right for you.

Implantable Drug Pump

Some patients benefit from placement of a pain pump programmed to deliver medication directly into the cerebrospinal fluid (the fluid surrounding the spinal cord). The pump is a battery-operated electronic device surgically implanted into a pocket in the abdomen. It’s attached to a catheter (a long tube) that’s threaded up into the spinal canal to the level of the affected facet joint. The surgeon then verifies correct placement of the catheter using fluoroscopy (a sort of real-time x-ray).

Injections
Injection with local anesthetics or corticosteroids

Injecting local anesthetics or steroid medications into the joint space can reduce inflammation and shut down or at least weaken the intensity of pain signals to the brain. To perform the procedure, the physician uses real-time x-ray pictures to guide the needle into the joint capsule. Then the medication is released into the joint space.

Lumbar facet joint injection with autologous platelet-rich plasma (PRP)

Whoa, that’s a mouthful! Let’s break that down. A lumbar injection is, of course, an injection into the lumbar (lower) portion of the spine. The word autologous (ah-TAW-luh-guss) simply means “self.” In other words, this procedure utilizes your own blood plasma, rather than plasma from a blood bank. The phrase platelet-rich plasma (PRP) refers to a blood product containing a high concentration of red blood cells, or platelets. Platelets produce growth factors that stimulate tissue regeneration in the area. To perform an autologous PRP injection, first a small amount of the patient’s blood is collected. Then the platelets are separated from the other blood components to produce a concentrated slurry of red blood cells. In fact, PRP contains 4 to 5 times more platelets than regular (whole) blood. The last step is injecting the PRP into the joint space under x-ray guidance.

Transcutaneous Electrical Nerve Stimulation (TENS)

Transcutaneous electrical nerve stimulation is the application of a low-voltage electrical current through the skin in order to relieve pain. Pads are applied to the skin, and a battery-powered TENS unit is used to deliver mild electrical stimulation to the anatomic structures in the area.

Implantable Neurostimulator

A spinal cord stimulator is a surgically implanted, battery-operated pulse generator that produces a low-voltage electrical signal intended to mask your body’s perception of pain. The device itself is implanted within the abdomen or buttocks. It’s equipped with leads (wires) that extend through the epidural space of the spinal column to the level at which your pain originates.

Neuroablation

Neuroablation, also known as rhizotomy, radiofrequency neuroablation (RFA), or radiofrequency denervation, is a procedure in which tiny portions of the medial nerve are deliberately destroyed by applying heat in the form of an electrical current. (Thermoablation, a similar procedure, uses a surgical laser, rather than an electrical current, as the heat source.) Under x-ray guidance, the doctor inserts a tiny electrode into the facet joint capsule, zapping the nerve endings with an electrical pulse. This little jolt damages the nerve, impairing its ability to transmit pain signals to the brain.

 

Surgical Intervention

If lifestyle modification and procedural interventions provide inadequate relief, or if you’re still having trouble engaging in everyday activities like walking the dog or washing the car, it may be time to consider surgical options. The more cautious the surgical approach, the more successful the outcome, generally speaking. Keyhole spine surgery requires only a dime-size incision, minimizing damage to surrounding nerves, muscles, and other tissues and dramatically reducing the risk of infection. Keyhole surgery is often an outpatient procedure. Compared with more invasive approaches, patients enjoy a much faster recovery. The results speak for themselves. Being able to focus on a movie again, enjoy a pain-free walk at the dog park, or sit comfortably in coach for that 3-hour flight to see the grandkids is the best outcome they could’ve hoped for.

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