Facet Joint Arthritis
INTRODUCTIONArthritis of the spinal facet joints can be a source of significant neck and low back pain. Aligned on the back of the spinal column, the facet joints link each vertebra together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the lumbar facet joints can be affected by arthritis.
ANATOMY:The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body's main upright support.
The back portion of the spinal column forms a bony ring. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.
Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back. The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without friction.
CAUSESWhy do I have this problem of neck and back pain?
Normally, the facet joints fit together snugly and glide smoothly, without pressure. If pressure builds where the joint meets, the cartilage on the joint surfaces wears off, or erodes.
Each segment in the spine has three main points of movement, the intervertebral disc and the two facet joints. Injury or problems in any one of these structures affects the other two. As a disc thins with aging and from daily wear and tear, the space between two spinal vertebrae shrinks. This causes the facet joints to press together. Wear and tear of the facet joints leads to the pain of arthritis casuing back pain.
The body responds to this extra pressure by developing bone spurs. As the spurs form around the edges of the facet joints, the joints become enlarged. This is called hypertrophy. Eventually, the joint surfaces become arthritic. When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. The joint becomes inflamed, swollen, and painful.
Facet joint arthritis develops slowly over a long period of time. This is partly because spinal degeneration in later life is the main cause of facet joint arthritis. Symptoms rarely develop immediately when degeneration is causing the problems.
However, rapid movements, heavy twisting, or backward motions in the spine can injure a facet joint, leading to immediate symptoms.
Facet joints can also become arthritic due to a neck or back injury earlier in life. Fractures, torn ligaments, and disc problems can all cause abnormal movement and alignment, putting extra stress on the surfaces of the facet joints.
SYMPTOMSWhat does the condition feel like?
Pain from facet joint arthritis is usually worse after resting or sleeping. Also, bending the neck or trunk sideways or backward usually produces pain on the same side as the arthritic facet joint. For example, if you lie on your stomach on a flat surface and raise your upper body, you hyperextend the lumbar spine. Similarly if you tilt your head upwards, you hyperextend ghe cervical spine. This increases pressure on the facet joints and can cause pain if there is facet joint arthritis.
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cervical facet pain
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lumbar facet pain pattern
thoracic facet pain pattern
Pain may be felt in the center of the low back and can spread into one or both buttocks. Sometimes the pain spreads into the thighs, but it rarely goes below the knee. Numbness and tingling, the symptoms of nerve compression, are usually not felt because facet arthritis generally causes only mechanical pain. Mechanical pain comes from abnormal movement in the spine. For the cervical area, pain is localized the back of your neck and can spread to the shoulder blades or can cause headaches. For the thoracic or midback area, pain is localized at the level of joint involvement.
However, symptoms of nerve compression can sometimes occur at the same time as the facet joint pain. The arthritis can cause bone spurs at the edges of the facet joint. These bone spurs may form in the opening where the nerve root leaves the spinal canal. This opening is called the neural foramen. If the bone spurs rub against the nerve root, the nerve can become inflamed and irritated. This nerve irritation can cause symptoms where the nerve travels. These symptoms may include numbness, tingling, slowed reflexes, and muscle weakness in either the legs or the arms.
DIAGNOSISHow do doctors diagnose the problem?
Diagnosis begins with a complete history and physical examination. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about where you feel pain and if you have numbness or weakness in your legs or arms. Your doctor will also want to know what positions or activities make your symptoms worse or better.
Then the doctor performs a physical exam to determine which neck or back movements cause pain or other symptoms.
Your skin sensation, muscle strength, and reflexes are also tested.
X-rays can show if there are problems in the bone tissue in and near the facet joints. The images can show if degeneration has caused the space between the vertebrae to collapse and may show if bone spurs have developed near the facet joints.
When more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the facet joints to see whether they are enlarged or swollen. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle.
A computed tomography (CT) scan may be ordered. This is a detailed X-ray that lets your doctor see slices of bone tissue. The image can show whether the surface of the joint has eroded and whether bone spurs have developed.
A diagnostic injection done by a Physician specializing in Pain Management may be used to locate the source of pain.
The doctor uses a special needle to inject a local anesthetic (numbing medication) into either the joint or into the nerve that goes to the joint. The doctor watches the needle on a fluoroscope (live X-Ray) to make sure it reaches the correct spot. A fluoroscope is a special X-ray television that allows the doctor to see your spine and the needle as it moves. Once the doctor is sure the needle is in the right place, the medicine is injected. The results from the injection help the doctor make the diagnosis. If pain goes away, even if temporarily for a few hours, it helps confirm the source of pain.
TREATMENT OPTIONSWhat treatment options are available?
NONSURGICAL TREATMENT:BED REST: During acute pain flare-ups, facet joint arthritis is mainly treated nonsurgically. At first, doctors may prescribe a short period of rest, one to two days at most, to calm inflammation and pain. Patients may find added relief by curling up to sleep on a firm mattress or by lying back with their knees bent and supported. These positions take pressure off the facet joints.
MEDICATIONS: Your doctor may prescribe anti-inflammatory medication, such as a nonsteroidal anti-inflammatory drug (NSAID) or aspirin. Muscle relaxants are occasionally used to calm muscles that are in spasm. Oral steroid medicine in tapering dosages may also be prescribed for painflare-ups.
PHYSICAL THERAPY: Patients often work with a Physical Therapist. By evaluating a patient's condition, the therapist can assign positions and exercises to ease symptoms. The therapist may recommend traction. Traction is a common treatment for this condition. It gently stretches the neck orlow back and takes pressure off the facet joints. The therapist may also prescribe strengthening and aerobic exercises. Strengthening exercises focus on improving the strength and control of the spinal and abdominal muscles. Aerobic exercises are used to improve heart and lung health and increase endurance in the spinal muscles. Stationary biking offers a good aerobic treatment and keeps the spine bent slightly forward, a position that gives relief to many patients with lumbar facet joint arthritis.
CHIROPRACTIC: Spinal manipulation done by a Chiropractor can sometimes provide short-term relief of pain from facet arthritis. Commonly thought of as an adjustment, spinal manipulation stretches the tissues surrounding the facet joint and helps reset the sensitivity of the spinal nerves and muscles. It involves a high-impulse stretch of the spinal joints and is characterized by the sound of popping as the stretch is done. However, it doesn't seem to provide effective long-term help when used routinely for chronic conditions.
INTERVENTIONAL PAIN MANAGEMENT:FACET JOINT INJECTIONS:
Patients who still have pain after trying various treatments may require injections into the facet joint; this is done by a Pain Management Specialist. The procedure to inject the medication into the joint itself is similar to the diagnostic injection described earlier. A steroid medication is occasionally used instead of the anesthetic. Steriodal injection directly into the facet joints involved give long-term pain relief that may last months to years. Doctors often have their patients resume physical therapy treatments following an injection.
RADIOFREQUENCY ABLATION:If previous facet joint injections / blocks give releif that is significant but temporary, Radiofreqency Ablation can be done as a treatment option to inactivate the small tiny nerves that provide sensation to the facet joints involved causing pain.
This is done by using special needles positioned where those nerves are located (called the medial branch nerves to the facet joints) under flouroscopic (live X-ray) guidance. Radiofrequency energy is used to heat up the tip of these special needles to creat a lesion that inactivates / cauterizes the target nerves. Releif of pain after the procedure follows in the following weeks over a gradual onset and the pain relief provided is long term, lasting for months to years. This procedure can be repeated again if the pain recurs.
SURGERY:People with facet joint arthritis rarely need surgery. However, facet joint arthritis is a primary source of chronic neck and low back pain about 70 percent of the time. After trying other types of treatment, some of these patients may eventually require surgery. There are several types of surgery for facet joint arthritis. The two primary operations are:
FACET RHIZOTOMY: Rhizotomy describes a surgical procedure in which a nerve is purposely cut or destroyed. Facet rhizotomy involves severing one of the small nerves that goes to the facet joint. The intent of the procedure is to stop the transmission of pain impulses along this nerve. The nerve is identified using a diagnostic injection (described earlier).
Then the surgeon inserts a large, hollow needle through the tissues in the low back. A special probe is inserted through the needle, and a fluoroscope is used to guide the probe toward the nerve. The probe is slowly heated until the nerve is severed.
POSTERIOR CERVICAL OR LUMBAR FUSION: Facet joint arthritis mainly causes mechanical pain, the type of pain caused by wear and tear in the parts of the spine. Posterior cervical or lumbar fusion for facet joint arthritis is mainly used to stop movement of the painful joints by joining two or more vertebrae into one solid bone (fusion). This keeps the bones and painful facet joints from moving. In this procedure, the surgeon lays small grafts of bone over the back of the spine.
Most surgeons will also apply metal plates and screws to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.