Facet Joint Syndrome

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Definition/Description

Facet syndrome is an articular disorder related to the lumbar facet joints and their inervations, and produces both local and radiating pain. Ghormley was the first who characterized the ‘facet syndrome’ by as back and/or leg pain, as a result from mechanical irritation of a lower lumbar zygapophysial joints. This is more then 20 years ago, but the facet joint has been increasingly recognized as an important cause of low back pain.

Excessive rotation, extension, or flexion of the spine can result in this injury and may involve degenerative changes to other structures including the intervertebral disc.(Level of evidence: 5) Strain of the lumbar facet joint (FJ) is highest at end-range extension.(Level of evidence: 1B)Excessive motion(repeated overuse) of the facet joint can result in degenerative changes to the cartilage of the joint.(Level of evidence: 5) Additionally, with a reduction of disc height, FJ mechanical loads will increase, which can also leads to degeneration of the FJs. (Level of evidence: 2A)

55% of facet syndrome cases occur in cervical vertebrae, and 31% in lumbar. This includes all the structures that are a part of the facet joint such as the fibrous capsule, synovial membrane, hyaline cartilage and bone.

Neck pain due to cervical facet joint involvement is known as cervical facet syndrome and low back pain due to lumbar facet joint involvement is known as lumbar facet syndrome.

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Clinically Relevant Anatomy

The facet joints are joints in the posterior aspect of the spine. In each spinal motion segment there are two facet joints. Although these joints are most commonly called facet joints, they are more properly termed zygapophyseal joints (abbreviated as Z-joints; also commonly spelled as "zygapophysial joints"), a term derived from the Greek roots zygos, meaning yoke or bridge, and physis, meaning outgrowth. This “bridging of outgrowths” is most easily seen from a lateral view, where the Z-joint bridges adjoin the vertebrae. The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint or the posterior intervertebral joint.

Further the detailed anatomy and clinical anatomy can be learned from here .

Epidemiology /Etiology

According to Binder D et al.(level2A), it has been estimated that facet joint pathology is a contributory factor in 15–52% of patients with chronic low back pain. But the prevalence of isolated facet joint pain may be as low as 4%. More important is the presence of facet joint arthrosis in different age groups. In a study from Eubanks et al.(level 2B) there was a prevalence rates of facet arthrosis on 647 cadaveric lumbar spines. 57 percent of samples between 20 and 29 years of age and 93% of the samples 40-49 years of age had evidence of facet arthrosis. By the age of 60, 100% of the samples showed prominent facet arthrosis.
The highest prevalence and moreover, the greatest severity of arthrosis, were found at L4–L5.

The hypothesis that disc degeneration and disc narrowing play a meaningful role in facet joint dysfunction via increased loading and subsequent osteoarthritis , is often cited, but has yet to be supported by sufficient evidence.
In rare cases, facet joint pain can occur secondary to a traumatic event, but more commonly, it is the result of repetitive stress and/or cumulative low-level trauma. Data from cadaveric studies have shown that anatomical changes occur more rapidly during sustained flexion than with repetitive movements. Although the studies provides a theoretical model of degeneration, cadavers cannot experience pain and the viscoelastic materials may have altered characteristics.
In the upper lumbar spine, the greatest amount of joint displacement and strain is associated with lateral-flexion or side-bending in the first three pairs of facet joints (L1-L2; L2-L3; L3-L4). The two lowest levels(L4-L5; L5-S1) experience the greatest strain during forward flexion. The resultant inflammation causes the joint to swell, leading to stretching of the capsule and subsequent pain generation. The swelling can also irritate the nearby spinal nerves, resulting in spasm of the deep postural paraspinal muscles (ex. M. Multifidus). (level of evidence 1A)
Predisposing factors for lumbar facet joint pain are spondylolisthesis, spondylolysis, degenerative disc disease and advanced age. (level of evidence 1A)

Characteristics/Clinical Presentation

Zygapophyseal joint pain is felt locally as a unilateral back pain, which when severe can spread down the entire limb. The source of pain must be confirmed by clinical examination.
The joint capsule is more likely to generate pain than the articular cartilage or the synovium. All of the lumbar facet joints are capable of producing pain that can refer to the groin (this is more common with lower facet joint pathology).(level of evidence 1B)

Cervical facet syndrome includes following symptoms:
• Axial neck pain (rarely radiating past the shoulders), most common unilaterally
• Pain with and/or limitation of extension and rotation
• Tenderness upon palpation
• radiating pain locally or into the shoulders or upper back,and rarely radiate in the front or down an arm or into the fingers as a herniated disc might.

Lumbar facet syndrome can be characterized by following symptoms:(level of evidence 1A)
• Pain or tenderness in lower back.
• Local tenderness/stiffness alongside the spine in the lower back.
• Pain, stiffness or difficulty with certain movements (such as standing up straight or getting up from a chair.
• Pain upon hyperextension
• Referred pain from upper lumbar facet joints can extend into the flank, hip and upper lateral thigh
• Referred pain from lower lumbar facet joints can penetrate deep into the thigh, lateraly and/or posteriorly
• L4-L5 and L5-S1 facet joints can refer pain extending into the distal lateral leg, and in rare instances to the foot(level of evidence 1B)

Additionally, facet joint syndrome is more common in the elderly since changes at the joints develop with aging.
Acute episodes of lumbar and cervical facet joint pain are typically intermittent, generally unpredictable, and occur a few times per month or per year. Typically, there will be greater aggravation of symptoms with lumbar extension than lumbar flexion. In lumbar cases, standing may be somewhat limited but sitting and riding in a car are most provocative. Recurrent painful episodes can be frequent and quite unpredictable in both timing and extent. Improper diagnosis can result in patients that are left with the notion that this is a psychosomatic problem. (level of evidence: 5)

Osteoarthritis is only one of many inflammatory processes that affect the facet joint. Other inflammatory conditions include rheumatoid arthritis, ankylosing spondylitis, reactive arthritis, synovial impingement, meniscoid entrapment, chondromalacia facetae, pseudogout, synovial inflammation, villonodular synovitis, and acute chronic infection.(level of evidence 1B) Intrafacetal synovial cysts can be a source of pain because of distension and pressure on adjacent pain-generating structures, calcification, and asymmetrical facet hypertrophy.(level of evidence 1A)
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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 a herniated disc and may make differentiating between the two conditions difficult.

What’s the difference between facet joint syndrome and Lumbar_Spondylosis?
Facet joint syndrome is not the same as spondylosis. The difference between those two is that spondylosis is a degeneration of the vertebrae. If we speak of facet joint syndrome, there is a degeneration of the facet joints which are the posterior aspect of the spine.

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 Discogenic Pain Syndrome
• Lumbosacral Radiculopathy
• Lumbosacral Spine Acute Bony Injuries
• Lumbosacral Spine Sprain/Strain Injuries
• Lumbosacral Spondylolisthesis
• Lumbosacral Spondylolysis
• Piriformis Syndrome
• Sacroiliac Joint Injury
• Inflammatory arthritidies (ex. rheumatoid arthritis)
• Spondylarthropathies (ex. osteoarthrosis, synovitis)

Diagnostic Procedures

Facet joint syndrome cannot be reliably clinically diagnosed (Jackson RP2 1992). The most used systems to diagnose this syndrome are X-ray, 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 facet joint syndrome, but it may help with the evaluation of the degree of degeneration. Once 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. A positive indication is when the patient experiences a 50% pain reduction after a block has been performed. 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 to reduce the pain, we can suggest that the pain comes from the facet joint. Although no single sign or symptom is diagnostic, Jackson et al demonstrated that the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular facet joint injection:

- Older age
- Previous history of LBP
- Normal gait
- Maximal pain with extension from a fully flexed position
- The absence of leg pain
- The absence of muscle spasm
- The absence of exacerbation with a Valsalva maneuver 

Medical Management

• The pharmacological therapy used by doctors for acute back pains caused by facet joint syndrome is based on administrating muscle relaxants.
• In medicine they also use nonsteroidal anti-inflammatory drugs and acetaminophen as first line drugs for the treatment of LBP, with little evidence to support one particular drug over another.
• Standard treatment modalities for facet joint syndrome pain include intraarticular steroid injections and radiofrequency denervation of the medial branches innervating the joints. Yet there is much controversy in scientific articles related to this standard treatment.

Cohen S. P. et al. (2007) investigated several publications about the effectiveness of intraarticulair steroid injections and radiofrequency denervation of the medial branches. In uncontrolled studies of people that have never been diagnosed for facet joint syndrome, the long-term relief of back pain after intraarticular steroid injection varies from 18% to 63%.In controlled trials, the results are disputable. In the largest study, the investigators reported no significant difference in outcome between the patients who received large-volume (8 ml) LA and steroids injected into facet joints or around facet joints or intraarticular saline injections. Cohen S. P. et al. (2007) also verified that radiofrequency denervation of the medial branches innervating the joints, is an effective treatment for facet joint syndrome. Unfortunately, there aren’t enough studies that follow the same protocol, to make a conclusion about it. For example the placement of the electrodes plays a very crucial role in processing the results.
There is also controversy about the long term effect of radiofrequency denervation. Further research should confirm whether radiofrequency means an effective treatment in people with facet joint syndrome.

Physical Therapy Management

The initial treatment for acute facet joint pain is focused on:
- education
- maintenance of positions that provide comfort
- relative rest
- pain relief
- exercises
The first item (education) includes explaining the problem at the height of the patient’s back, without making him anxious. Therefor a diplomatic approach is recommended in order to prevent the patient from catastrophizing. During the therapy, it’s also important that the therapist gives advice/instructions about the patient’s posture and placement of his body in daily activities. The patient must learn to take postures that will not provoke or exacerbate the symptoms.
Gerard A. Malanga et al. (2008) provided that bed rest beyond 2 days, for people with facet joint syndrome, isn’t recommended. The patient is allowed to act calmly during days when the symptoms are not tolerable, but should never be completely inactive. Bed rest beyond 2 days can have detrimental effects on the bones, connective tissues, muscles and the cardiovascular system. This is one of the reasons why therapist must strive to make the patient act as actively as much as possible.
Another goal is pain relief. Bronfort G. et al. (1996) studied the relative efficacy of three different treatments for chronic low back pain. They comprised followed combinations: spinal manipulative therapy (SMT) combined with trunk strengthening exercises (TSE) vs. SMT combined with trunk stretching exercises and SMT combined with TSE vs. non-steroidal anti-inflammatory drug (NSAID) therapy combined with TSE. During 11 weeks (5 weeks under supervising and 6 weeks alone) they examined: patient-rated low back pain, disability and functional health status. Their conclusion was that each of the three therapeutic regimes was associated with similar and clinically important improvements. For the management of facet joint syndrome, trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile.(Bronfort G. 1996 (A2))
Other scientific sources recommend treating facet joint syndrome with heat, cryotherapy and mobilizations. Those techniques appear to have a relaxing effect on the muscles. As the muscles relax, the nociceptive information will decrease. These techniques have the disadvantage that they only seek a temporary pain relieving effect, they are no final solution to treat facet joint syndrome.
Gerard A. Malanga et al. (2008) argue that 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.

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