Facet Joint Syndrome
Every spinal vertebra has an upper and lower facet joint and a lower facet joint that connects it to the vertebra above and below. Like other joints in the body, such as the knee or the shoulder, facet joints are covered with a cartilage material that allows them to slide and by a small sac of synovial fluid that bathes the joint and adds moisture. The facet joints slide, enabling motion in the spine, but also limit excessive motion, especially with bending and twisting.
Any of the three spinal regions may be affected by facet joint syndrome, but the thoracic spine is generally immune because its main functions are related to structure, support, and protection instead of to motion. The cervical and lumbar spines are highly flexible, making them more prone to facet joint syndrome. The cervical spine has a wide range of motion and is a common site for facet joint syndrome due to the range of motion and frequency of movement in the neck. The lumbar spine is also commonly afflicted by facet joint syndrome due to the range of motion, frequency of movement, and body weight-related stress placed on the lumbar spine.
There are seven cervical vertebrae in the neck. Each is connected to two other vertebrae via facet joints, except the first cervical vertebrae. These joints add some motion to the cervical spine, but also limit extremes in range of motion to prevent injury. Over time and with more movements, the facet joints begin to wear. The body tries to repair the damage, developing bone spurs to try to prevent motion at the damaged joint, but bone spurs can create more pain with motion leading to cervical facet joint syndrome.
There are five lumbar vertebrae in the lower back. Each is connected to two other vertebrae via facet joints. This helps works with intervertebral discs to add motion in the spine while also preventing extremes of motion and further damage to the spine. Over time, with repetitive movement, and/or increased weight, the smooth joint surface roughens and the body tries to repair the damage by creating bone spurs that stop motion at the joint. These bone spurs then create pain with motion and lead to lumbar facet joint syndrome.
Facet joint syndrome is a degenerative disease in the spinal vertebrae’s facet joints. Like other joints in the body, the facet joints are covered in a cartilage and surround by a sac of synovial fluid that bathes the joint. There are multiple causes of facet joint syndrome, but they all lead to breakdown of a facet joint. This occurs most frequently in the cervical and lumbar spine due to the flexibility and motion at these areas.
The facet joints are constantly in motion and as a person ages they are subjected to a lot of wear and tear. The joint continues to move while the lining cartilage begins to thin and the synovial fluid becomes less lubricating. This leads to facet joints rubbing bone over bone, increasing the amount of friction they experience with movement. The joint develops inflammation and may produce bone spurs, or bony growths, attempting to stop further motion and limit further damage. This is the most common cause for facet joint syndrome which typically occurs in older individuals.
Extra weight on the body adds more stress on the spine, particularly on the lumbar region. If excess fat is concentrated in the abdomen, it pulls the lumbar spine forward, creating a more extended position of the lumbar spine. This extended position places stress on the intervertebral discs and on the facet joints, as they provide the necessary flexibility for the spine. Under extra stress, the cartilage around the facet joints begins to thin until the joints are rubbing bone on bone. The body’s defense to the thinning cartilage, is the development of bone spurs or bony growths, to stop further motion and limit further damage. With increased weight, facet joint syndrome can occur in younger individuals because age-related changes are accelerated.
The spine is involved in most movements, including those in high impact activities and repetitive tasks. Specific injuries can lead to facet joint syndrome, but it is more often caused as a result of repetitive tasks or injuries. During sports and high impact activities (e.g. running, ATV riding) as well as during repetitive tasks (e.g. bending, lifting, and twisting at work) places the facet joints under more stress. The surrounding cartilage begins to wear and the synovial fluid thins, which reduces its ability to lubricate the joint. This allows the joints to move bone on bone with added friction. The body tries to keep the joint from moving and sustaining further damage by developing bone spurs, or bony growths. Just as with additional weight, this can also accelerate age-related joint causes of facet joint syndrome.
Symptoms caused by facet joint syndrome range from mild to severe. The symptoms are often similar to those of other spinal conditions, making facet joint disease difficult to pinpoint as source for neck or back pain without the proper diagnosis procedure. Symptoms can be localized or radiating depending on the location of the diseased facet joint.
The main symptoms of cervical facet joint syndrome are neck pain or stiffness. Neck pain and stiffness often lead to decreased range of motion and, potentially, cracking or popping sounds as the spine moves. Pain tends to be worse upon awakening in the morning, but will likely decrease throughout the day. There are often headaches as well, that start in the neck and radiate into the head though it is uncommon to have radiating symptoms into the shoulders, arms, and hands, as with other spinal conditions. Sitting with the neck bent slightly down may provide some pain relief. Pain may occur only on occasion without clear triggers. It typically will resolve on its own and will likely recur without any warning.
Low back pain or stiffness is a common symptom in the lumbar spine facet joint disease. Pain tends to change with motion in the spine; generally it increases while leaning back (extension) and decrease while leaning slightly forward at the waist. Radiating symptoms into the buttocks and back of the legs can be common, but it is rare for any symptoms to radiate to the front of the legs or to the feet. Episodes of facet joint pain are usually intermittent and may not have a triggering activity. Often, the pain may subside with conservative or no intervention, though episode can increase in frequency and duration if untreated.
The first step in diagnosis is a clinic visit for a detailed history and physical examination. History determines the types of symptoms, duration of symptoms, factors that worsen or improve symptoms, prior treatments, and any other relevant medical problems or surgeries. Physical exam will typically consist of inspection and palpation (or pressing) over the area with pain. Other physical exam techniques include motor strength of upper and lower extremities, reflexes, range of motion, and walking.
Based on the information that is obtained during the history and physical examination, further evaluation with imaging studies may be necessary for proper diagnosis. X-rays are 2D scans that are typically obtained first to look at the overall alignment of the spine. Often, arthritic changes in the facet joints can be seen on x-ray imaging. Advanced 3D imaging studies, such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans, are also essential to proper diagnosis. More frequently, a CT scan is more beneficial with facet joint syndrome because this shows the bony elements of the spine better than an MRI would. The CT can help detect bone spur formation, increases in facet joint size (facet hypertrophy), inflammation within the joint, and the affected vertebrae. MRI is also commonly used to evaluate the soft tissue elements of the spine, such as the discs and nerves. Advanced imaging may also show other spinal disease that may be contributing to facet joint syndrome.
Evaluation of the cervical spine starts with inspection of the spine itself to look for any changes in posture, muscle bulk, alignment, or skin. Active and passive range of motion is tested as well; facet joint syndrome generally leads to decreased range of motion in the neck. Active range of motion is motion examines how far the patient can move their neck in each direction comfortably. Passive range of motion is the same comfort test, but with the physician moving the patient’s neck. Palpation, or pressing, over the spine generally reveals pain in certain areas of the neck and spasms of the neck muscles may also be felt. Motor strength and sensation throughout the arms and legs generally test normal since there are few to no radiating symptoms with facet joint syndrome in the cervical region.
Evaluation of the lumbar spine is similar to the cervical spine. The lumbar spine will first be inspected for any changes in posture, muscle bulk, alignment, or skin. Only active range of motion is tested, likely showing a reduced range of motion and pain, especially in the extended position. With palpation, or pressing, over the lumbar spine and musculature, the physician may feel tenderness or muscle spasms. Pain may radiate into the buttocks and back of the thighs, but strength and sensation in the legs will likely be normal since facet joint syndrome usually does not affect the spinal nerve roots.
After facet joint syndrome is diagnosed through history, physical exam, and imaging studies, an appropriate treatment plan can be put into place. Usually treatment begins with conservative therapies including lifestyle modifications, alternative therapy, physical therapy, and medication.
Minimally invasive surgeries are performed through a small incision with minimal disruption of the surround muscle tissues, to allow for faster healing and return to normal activities. This is a much safer option to traditional spine surgery which required a large incision and cutting muscle tissues. There are several minimally invasive procedures available to address facet joint syndrome and the best option will vary by spinal region (i.e. cervical, thoracic, or lumbar section). Stabilization procedures, which prevent further joint movement, are generally preferred because the damage caused by facet joint syndrome is irreversible and continued motion would cause further damage.
One of the main causes of facet joint syndrome is excess weight, which accelerates age related changes in the facet joints with added stress from trying to keep the spine in alignment. Weight loss through a low-calorie diet and/or exercise regimen can remove added stress on the facet joint. Even though the arthritic changes including loss of cartilage lining and bone spur formation is irreversible, the reduced weight can decrease pain and slow the progression.
Altering repetitive occupational and leisure activities may be necessary to accommodate the symptoms associated with facet joint syndrome. A change in jobs may be necessary to avoid worsening symptoms due to full labor or heavy-duty work. When changing jobs is not an option, working with equipment that may be an adjunct, proper lifting technique, use of a back brace, and proper rest breaks may all be necessary. Changing positions and avoiding extended periods of sitting may also be effective ways of reducing symptoms.
Alternative therapies include massage, chiropractic care, and acupuncture. These may also be referred to as manual therapies as they address spine with hands on technique. Massage relieves tension in the muscles surrounding the spine caused by abnormalities in walking and by changes in posture due to pain from inflamed facet joints. Chiropractic care helps to adjust the spine through range of motion of the neck and specific stretches/movements of the neck. Acupuncture may also provide pain relief as muscles are stimulated electrically.
Physical therapy focuses on changing body mechanics to improve posture and gait, as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Physical therapy may also use manual treatments, such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit.
A home exercise program may be used in conjunction with or instead of formal physical therapy. A low impact exercise regimen can help strengthen the muscles, especially the core, which can support the spine to reduce back and neck pain from facet joint inflammation. In order to prevent injuries, home exercise regimens are best done under physician supervision.
There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of facet joint syndrome. Some of these medications include Acetaminophen (Tylenol), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, and, topical medications.
Common over the counter medications are acetaminophen and NSAIDs. Acetaminophen is considered an analgesic, meaning it relieves pain but does not reduce inflammation. NSAIDs are effective at both relieving pain and reducing inflammation; they can be found in brand and generic forms over the counter. These medications are best taken with food to avoid an upset stomach. They can be taken for longer durations, as long as there is no history of kidney disease. The mechanism of both NSAIDs and Acetaminophen differ, so they are taken together often to combat pain.
Muscle relaxants are used to provide relief from muscle spasms and increase range of motion; they are best used in combination with physical therapy or an exercise/stretching regimen. Drowsiness is a common side effect of muscle relaxants and they are not recommended while driving or working. Common muscle relaxants include Flexeril, Soma, Baclofen, Robaxin, and Tizanidine.
Topical medications may also relieve pain and are available in over the counter and prescription variations. Common over the counter formulations are Salonpas, Icy Hot, Bengay, and Aspercream, which bring localized pain relief to the location where they are applied. Prescription topical medications provide localized relief and include lidocaine, a numbing medication, and Diclofenac (Voltaren), an anti-inflammatory medication. Topical medications are good options for those that want to avoid or are unable to take oral medications.
Facet Joint Injections/Facet Blocks
Facet joint injections, commonly called facet blocks, supply steroidal medication to specific facet joints in the spine via a specialized needle. The medication is used to reduce inflammation and the associated pain at the joint. Relief can last up to several months, but injections can only be done up to three times in one year to avoid muscle or tendon breakdown.
An anterior cervical discectomy and fusion (ACDF) is a minimally invasive surgical stabilization procedure. This is performed through a small incision on the front of the neck. The surgeon moves the thin neck muscles until the spinal column is reached and the old disc and any disc fragments or bone spurs around the nerve root are removed. A special implant with bone graft is then placed in the space where the removed disc was, with screws to secure the implant. At the conclusion of this procedure, the specific disc level is fused and motion is no longer possible at this level.
Transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that fixes the appropriate disc level in the lumbar spine with a specialized implant. This procedure is performed through a small incision on the midline of the lower back. After reaching the spine, small amounts of bone are removed to reach the nerve roots, and if necessary, compression is removed from the nerve until the disc space is reached. The disc is removed and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space for support. The screws are connected via rods, fusing the spinal level, and motion is no longer possible, preventing further motion, inflammation, and pain.
A lateral lumbar interbody fusion (XLIF) is a minimally invasive lumbar spine surgery that requires special positioning with the patient’s left side upward. A small incision is made on the left, between the hip and the ribs. A thin wire, called a guide wire, is placed and sequentially larger, cylindrical tubes, called dilators, are placed through the psoas muscle to reach the left side of the spine. Once the spine is reached, the disc is then completely removed. A special implant is sized, filled with bone graft, and placed in the empty disc space. Screws are placed through the implant into the upper and lower vertebral body, to provide stability for the implant. This will fuse and stabilize the level to prevent further motion. The XLIF can only be performed on certain levels in the lumbar spine because the space between the hip and lowest rib is limited, but XLIF is preferred when bony anatomy does not allow for other approaches, when disease is confined to the facet joints without any nerve root compression, or when prior lumbar surgeries have left scarring or hardware that make it difficult to approach from the back.
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