Facet Joint Syndrome

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Definition/Description

Lumbar facet joint syndrome is a multi-factorial process that is intimately tied to degeneration of the intervertebral discs. It’s a painful irritation of the posterior part of the lumbar spine. The swelling of the surrounded structures can cause pain and irritation of the nociceptors.

Clinically Relevant Anatomy

The capsule of the facet joint is reinforced posterioly by the multifidus muscle and anterioly by the ligamentum flavum. It is surrounded by fascia, wich itself is continuous with that covering the ligamentum flavum and the investing fascia of the vertebral body. The facet joint capsule therefore can be seen as a bridge of connective tissue between the ligaments of the neural arch and those of the vertebral body. The functions of the lumbar facet joint are flexion extension lateroratation and rotation. 

Epidemiology /Etiology

Because of an acute trauma amounting the posterior facet joints, little capsular bursts form and leads to a joint subluxation. The synovium round the joint is damaged and leads to synovitits. Secondary there will be a protective mechanism that provides a hypertonic contraction of the surrounding muscles (M. Multifidi and M. semispinales) that increase the pain. Those changes lead to fibroses and osteophyte formation. 

The most common cause is a repetitive micro trauma and chronic degradation. In daily life it can appear by a long standing of load of the lumbar spine by extension (hang out the wash, ceiling painting, etc.). Or in sports where repeated powerful hyperextension of the lumbar spine is necessary

With aging, cartilage of the facet joint can split parallel to the joint surface, pulling a portion of joint capsule with it. The split cartilage, with its attached piece of capsule, forms a false intra-articular meniscoid. Flexion normally draws the fibro adipose meniscus out from the joint, and it moves back in with extension. Fibro adipose meniscus, covered by synovium, project from the joint capsule at the superior and inferior poles and enter between the articular surfaces protect the articular cartilages in gliding joints that subluxate during normal movement.  If the meniscus fails to move back, it will buckle and remain under the capsule, causing pain.  

Characteristics/Clinical Presentation

With the clinical examination the patient has mostly low unilateral or bilateral back pain. Pressure pain at the level of the facets involved. The muscles surround the joint are hard. They also can have lower limb pain. That pain increase during rotation or torsion movements and during extension with respect to flexion. In some cases they also have pain in the transition from the seated position to the erected one. The range of movement can be reduced. The morning patient often feels greater stiffness then normal. 

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
• ...

Diagnostic Procedures

In fact, lumbar facet joint pain may be accompanied by hamstring tightness that limits straight-leg raising, further confusing the diagnosis with sciatica. After excluding other common etiologies of lower back pain including discogenic pain and nerve root impingement, unilateral or bilateral symptoms radiating to one or both buttocks, groins, and thighs and stopping above the knee may be presumed pain of facet origin.

Exacerbating factors are many and may include psychoso- cial stress, increased physical activity or inactivity, lumbar extension with or without rotation, and prolonged standing or sitting.

Although CT is the established imaging modality for the radiological diagnosis of lumbar facet joint osteoarthritis, its ability to accurately identify pain originating from the lumbar facet joints is less certain. Certain investigators have demonstrated a relationship between the degenerative changes seen on CT and facet- mediated pain by using controlled anesthetic blocks of the lumbar zygapophyseal joints.

Outcome Measures

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Examination

Intra-articular injections for the treatment of lower back pain without a pre-existing   intervention can trace their treatment rationale back to the original paper by Mooney and Robertson in 1976 describ- ing 100 consecutive patients with lower back discomfort treated with intra-articular facet joint injections consisting of depomedrol and local anesthetic. When an analysis of pooled studies on the administration of intra-articular steroids was performed nearly 30 years later, the results showed that slightly less than half of all patients with an initial positive response maintained that response for a time period of 3–6 months.

radiofrequency: We can conclude that denervation using pulsed radiofrequency is a valid procedure, well-tolerated by patients. It gives a period of wellness between 6 months and 1 year, and it may be repeated with complete safety over time.

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. 
Some evidence supports the use of spinal manipulative therapy combined with a trunk-strengthening program, which may actually reduce the need for pain medication. A study of Lilius et al. (1989) used three types of injections. A significant improvement was observed in work attendance, pain and disability scores, but this was independent of the treatment given. Movements of the lumbar spine were not improved.

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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