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 a pair of joints in the posterior aspect of the spine. Although these joints are most commonly called the facet joints, they are more properly termed the 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

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

The cervical facet syndrome includes following symptoms:

• Axial neck pain (rarely radiating past the shoulders), most common unilateral
• Pain and/or limitation of extension and rotation
• Tenderness
• Cervical facet joint problems may radiate 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.

The lumbar facet syndrome can be characterized by following symptoms:

• 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
  

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.  

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 more discomfort while leaning backward than while leaning forward.Recurrent painful episodes can be frequent and quite unpredictable in both timing and extent. Patients are often left with the notion that this is a psychosomatic problem, and it may even be implied that "it's all in your head."

In the lumbar case, standing may be somewhat limited but sitting and riding in a car is the worst. So-called "limited duty" (sitting) assignments for patients with low back pain are paradoxically bad. When at its height of pain and disability, the muscle spasm is so continual that it fatigues the muscles, which in turn, repeats the cycle.

Examination

Inspection
Inspection should include an evaluation of paraspinal muscle fullness or asymmetry, increase or decrease in lumbar lordosis, muscle atrophy, or posture asymmetry.
Patients with chronic facet syndrome may have flattening of the lumbar lordosis and rotation or lateral bending at the sacroiliac joint or thoracolumbar area.
Palpation
The examiner should palpate along the paravertebral regions and directly over the transverse processes because the facet joints are not truly palpable. This is performed in an attempt to localize and reproduce any point tenderness, which is usually present with facet joint–mediated pain.
In some cases, facet joint–mediated pain may radiate to the gluteal or posterior thigh regions.
Range of motion
Range of motion should be assessed through flexion, extension, lateral bending, and rotation.
With facet joint–mediated LBP, pain is often increased with hyperextension or rotation of the lumbar spine, and it might be either focal or radiating.
Flexibility
Inflexibility of the pelvic musculature can directly impact the mechanics of the lumbosacral spine.
With facet joint pathology, the clinician may find an abnormal pelvic tilt and rotation of the hip secondary to tight hamstrings, hip rotators, and the quadratus, but these findings are nonspecific and can be found in patients with other causes of LBP.
Sensory examination
Sensory examination (ie, light touch and pinprick in a dermatomal distribution) findings are usually normal in persons with facet joint pathology.
Muscle stretch reflexes
Patients with facet joint–mediated LBP usually have normal muscle stretch reflexes. Radicular findings are usually absent unless the patient has nerve root impingement from bony overgrowth or a synovial cyst.
Side-to-side asymmetry should lead one to consider possible nerve root impingement.
Muscle strength
Manual muscle testing is important to determine whether weakness is present and whether the distribution of weakness corresponds to a single root, multiple roots, or a peripheral nerve or plexus.
Typically, manual muscle testing results are normal in persons with facet joint pathology; however, subtle weakness of the muscles of the pelvic girdle may contribute to pelvic tilt abnormalities. This subtle weakness may be appreciated with trunk, pelvic, and lower-extremity extension asymmetry.
Straight leg – raise test
This maneuver is usually normal for facet joint–mediated pain. However, if facet joint hypertrophy or a synovial cyst encroaches on the intervertebral foramen, causing nerve root impingement, this maneuver may elicit a positive response.

Special test for LBA due to facet joint

Kemp’s test positive
Springing test positive

Diagnostic Procedures

 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. 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 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
  

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 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)
  

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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