Facet Joint Syndrome

This article requires improvement to meet Physiopedia's quality standards. The reasons have been specified in the page's Discussion. Please help improve this page if you can. #qualityalert

Original Editors - Niels Cloet, Jonas Vangindertael, Anke Jughters

Lead Editors  

Definition/Description

<span lang="EN-US" />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

<span lang="NL-BE" />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

<span lang="EN-GB" />

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

<span lang="EN-US" /> 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

add links to outcome measures here (also see Outcome Measures Database)

Examination

<span lang="EN-US" /> 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

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.(Cohen S.P 2007 (D))(Lilius G. 1989 (A2))(Manchikanti L., 2007 (A2))

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.

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Clinical Bottom Line

add text here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.

Van Eerd M., Patijn J., lataster A., Rosenquist R.W., van Kleef M., Mekhail N., Van Zundert J. Evidence-based medicine 5. Cervical facet pain. Pain Practice. 2010; 10;2;113-123.

Van Kleef M., Vanelderen P., Cohen S.P., Latster A., Van Zundert J., Mekhail N. Evidence-based medicine 12. Pain originating from the lumbar facet joints. Pain Practice. 2010;10;5;459-469.

Cohen S.P., Raja S.N. Pathogenesis, diagnosis and treatment of lumbar facet joint pain. Anesthesiology. 2007;106;591-614.