Facet Joint Syndrome

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Original Editors - Niels Cloet, Jonas Vangindertael, Anke Jughters

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Search Strategy

First I searched on multiple sites for scientific articles about facet joint syndrome. Furthermore I searched for books in the libraries of the University of Brussels. This is handy so I have all my information to write a publication.
I searched on the Cochrane database for a review about the conservative treatment but I didn’t find one. Then I searched on web of science where I have found all my reviews and articles.

Definition/Description

Pain originating from the cervical and/or lumbar facet joints. This includes all the structures that are a part of the facet joint such as the fibrous capsule, synovial membrane, hyaline cartilage and bone. [Van Eerd. 2010] (A syndrome is a combination of symptoms occurring at a higher frequency in a certain population. [Van Kleef. 2010])

Clinically Relevant Anatomy

Facet joints are located at the posterior aspect of the spine. They connect the vertebral arch of one vertebra to the arch of the adjacent one. Each vertebra has four facet joints with an upper and lower pair.
In the lumbar spine, the upper facet joint is attached at the top of the lamina, where it changes in the pedicle. The processus articularis has a posterio-lateral orientation. Its articulation surface is turned towards posterior and median. The lower facet joint is attached at the bottom of the arcus, where the lamina and processus spinosus come together. The processus articularis is inferior and lateral oriented and its articulation surface is turned towards anterior and lateral.
Cervical facet joints form an angle of approximately 45° with the longitudinal axis formed by the cervical spinal column. The orientation of the facet joints is a bit more complicated, different for the vertebrae. You can find the information by using this link: Cervical. But the orientation of each facet joint to the saggitale plane can also differ between the paired facet joints at the same spinal level. This is known as tropism and is seen in 20-40% among the general population.
They consist of joint surfaces, synovial membrane and a joint capsule. This joint capsule is posteriorly thick and is supported by the fibers arising from the Multifidus muscle. Anteriorly is the capsule replaced by the lig. Flavum. The subcapsular recesses are formed superiorly and inferiorly , where the capsule attaches further away from the osteochondral margins.
Together with the intervertebrale disks they function to support and stabilize the spine. Further, they prevent injury by limiting motion in all planes of movement.
Cervical facet joints have a higher density of mechanoreceptors in comparison with the lumbar facet joints. From C3-C7, they are innervated by the ramus medialis of the ramus dorsalis of the segmental nerve. Next to this, each facet joint is also innervated by nerve branches from the upper and lower segment. This pattern of innervations is the same in the lumbar spine.
Facet joints are richly innervated with encapsulated (ex. ruffini-type endings and pacinian corpuscles), unencapsulated and free nerve endings. The presence of low-treshold, rapidly adapting mechanosensitive neurons suggests that the facet capsule also has a proprioceptive function next to its ability to transmit nociceptive information.
 

Epidemiology /Etiology

Epidemiology:
Facet joint pain in total is present in 40 % of the elderly population and 10 – 15 % of younger workers who are injured. In the literature there is a wide discrepancy in prevalence rates from 5 up to 90%. This is due to the diagnostic methodology and the perspective and conviction of the investigator.
Within a population suffering from neck pain, 25-65% of the cases are due to facet joint pain.
Patients with low back pain suffer in 5-15% from pain originating from the lumbar facet joints. But, when arthritis is included, the prevalence rate increases, because it is a common cause of facetogenic pain.
Etiology:
The hypothesis that disk degeneration and disk narrowing increase facet joint loading and consequently facet osteoarthritis, seems plausible, but has yet to be proven.
In rare cases facet joint pain can result from a specific traumatic event. But more commonly, it is the result of repetitive stress and/or cumulative low-level trauma. It is proven with cadaveric studies that damage occurs more rapidly during sustained flexion than with repetitive movements. Although the study provides a theoretical explanation, cadavers cannot experience pain and the viscoelastic materials have other characteristics. In the lumbar spine, is the joint displacement and strain associated with lateral bending for the first three facet joints (L1-L2; L2-L3; L3-L4). The two lowest joints (L4-L5; L5-S1) experience the greatest strain during forward flexion. The inflammation that may appear, causes the joint to be filled with fluid and swell. This leads to stretching of the capsule and subsequent pain generation. The inflammation can also irritate the spinal nerve and can cause reflex spasm of the deep postural paraspinal muscles (ex. M. Multifidus).
Predisposing factors for lumbar facet joint pain are spondylolisthesis, - lysis, degenerative disk disease and advanced age.

Characteristics/Clinical Presentation

Jackson RP 2 (1992) described that facet joint syndrome is not a reliable clinical diagnosis. Schwarzer et al.3 even suggested that the facet joint is an important source of pain but that the existence of a "facet syndrome" must be questioned. Due to the irritation of these joint surfaces, an inflammatory reaction arises that is characterized by a secondary pain that can cause tension in the back muscles. The cervical facet syndrome includes following symptoms: [Van Eerd. 2010] - axial neck pain (rarely radiating past the shoulders), most common unilateral - pressure at the level of the facet joints (dorsal) causes pain - pain and/or limitation of extension and rotation - absence of neurological symptoms The lumbar facet syndrome can be characterized by following symptoms:[Van Kleef. 2010] - pain or tenderness in lower back - local tenderness/stiffness alongside spine near lower back - pain, stiffness or difficulty with certain movements (such as standing up straight or getting

  up out of a chair)

- pain on hyperextension - pain originating from the upper facet joints often extends into the flank, hip and lateral thigh regions, whereas pain from the lower facet joints radiates in the posterior thigh. Pain distal to the knee is rarely associated with facet pain. Additional, facet joint syndrome is more common in the elderly since changes at the joints develop with aging.  

Differential Diagnosis

Much has been written about the diagnosis and treatment of lumbar zygapophyseal joint pain. A review of the relevant literature found conflicting evidence in support of a relationship between radiographic facet joint abnormalities and facet-mediated pain. This may partly be due to the poor reliability of the lumbar “facet joint syndrome” diagnosis given to patients presenting with primary lower back pain complaints The “pseudoradicular” referral patterns of the lumbar facet joints may mimic the pain felt from aherniated disc and may make differentiating between the two conditions difficult.

Examples of a possible differential diagnosis:

Cervical spine:
• Cervical disc injuries
• Cervical discogenic pain syndrome
• Cervical radiculopathy
• Cervical spine sprain/strain injuries
Lumbar spine:
• Lumbosacral Disc Injuries
• Lumbosacral Spondylolisthesis
• Lumbosacral Discogenic Pain Syndrome
• Lumbosacral Spondylolysis
• Inflammatory arthritidies (ex. rheumatoid arthritis)
• Spondylarthropathies (ex. osteoarthrosis, synovitis)

Diagnostic Procedures

As said before we know that facet joint syndrome can not be reliably clinically diagnosed (Jackson RP2 1992). The most used systems to diagnose this syndrome are an X-ray, a computed tomography (CT) scan of the spine or a magnetic resonance imaging (MRI) scan. Plain radiography does not provide information in establishing the diagnosis of the facet joint syndrome. But it may help with the evaluation of the degree of degeneration. Only, once the degeneration is visible on plain radiography, it has already reached an advanced stage.
The working diagnosis of facet pain, based on history and clinical examination, may be confirmed by performing a diagnostic block. This is considered positive when the patient experiences a 50% pain reduction. [Van Eerd. 2010] It involves injecting a medicine into or near the nerves that supply the facet joint. If the pain is not relieved by the injection, it is unlikely that the facet joint is the source of the pain. If these injections help and reduce the pain, we can suggest that the pain comes from the facet joints.

Outcome Measures

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Examination

There are no physical findings that are pathognomonic for diagnosis. Next to it, there is no evidence to support the relationship between the results of clinical examination and the anamnesis with pain originating from the cervical and/or lumbar facet joints. In the daily clinical practice, history and physical examination are useful to exclude serious pathology and to obtain a working diagnosis. Also an indication of the involved segmental level can be achieved.
It is widely known that lumbar paravertebral tenderness is an indicative factor for facetogenic pain, which is also supported by several clinical trials.
Wilde VE et al. 5 concluded that lumbar facet joint syndrome is present when you see a positive response to facet joint injection, localized unilateral low back pain, positive medial branch block, pain upon unilateral palpation of the facet joints or transverse process, lack of radicular features, pain eased by flexion, and pain, if referred, located above the knee. But these indications are not in line with previous studies.

Medical Management

Medical management includes painkillers and anti-inflammatory drugs.

Physical Therapy Management

The initial treatment for acute facet joint pain consists of education, relative rest, pain relief, maintenance of positions that provide comfort, exercises and some modalities. Physical therapy includes instruction about posture and placement of the body in daily living. Positions that cause pain should be avoided. Bed rest is hardly inadvisable. Heat, cryotherapy, spinal manipulation and mobilization can help to relax the muscles and reduce pain. Once the painful symptoms are controlled stretching and strengthening exercises can be initiated. These exercises are eventually incorporated into a more extended rehabilitation program, which includes spine stabilization exercises. The objective of these exercises is to teach the patient how to find and maintain a neutral spine during everyday activities.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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