FACET JOINT PAIN AND TREATMENTS
Peter Zheng, MD
Board Certified in Pain Management
Board Certified in Physical Medicine and Rehabilitation
New York State Certified in Acupuncture
One of most common reasons for neck, mid-back and low back pain comes from facet joints. This pain is referred to as facet joint syndrome, or facet arthropathy. It is also called spinal osteoarthritis, facet arthritis or facet joint pain syndrome. These conditions are considered degenerative arthritis that affects the facet joints.
Facet joints are also called zygapophyseal, apophyseal, or Z-joint. The facet joints are tiny small joints between every two vertebrae. There are two facet joints in each level. Facet joints are located in the back of spine. Facet joints are named based on location. Cervical facet joints are located in the neck, thoracic facet joints are located in the mid back and lumbar facet joints are located in the low back. There are synovial joints between the vertebrae of our spine, similar to our knee joint, but it is much smaller than our knee joint. Facet joints allow spine to move.
There are a number of disorders that can affect the joints. The most common cause of facet joint pain is inflammation of the joint, i.e. osteoarthritis, and degenerative joint disease. Traumatic joint injury is also a common cause of pain.
The lumbar facet joint pain is commonly located in the low back. It may radiate down into buttocks and the back of thighs. However, it rarely radiates below the knee or into the foot.
Cervical facet joint pain is commonly located in the neck. It may radiate to the shoulders or upper back. It rarely radiates down the arms or fingers.
Thoracic facet joint pain is commonly located in the mid-back. It may radiate to the flank. Thoracic facet joint pain much less common than cervical and lumbar facet joint pain, because thoracic facet joint is stabilized by the rib cage.
The pain is usually tight, stiff, dull, or achy on one or both sides of neck, mid-back or low back.
Bending forward may alleviate the pain. Bending backward, sideway, or twist may make the pain worse. Pain from facet joint arthritis is usually worse after prolonged resting or sleeping and better with moving around and hot shower.
Facet joint is synovial joint similar to knee joint. However, it is much smaller that the knee joint. The picture on the upper left is normal joint and the one below is arthritic joint with inflammation and joint destruction.
The patient may have tenderness on the paraspinal muscle regions overlying the painful facet joints.
The mobility of spine is reduced. The patient may have pain with spine movement.
There is pain or discomfort while a patient bends backward and rotates the spine.
There should be no neurological deficient if the patient just has pain from facet joint.
Diagnosis starts with history and physical examination and typically followed up with X-rays, CT scan or MRI. Or occasionally diagnostic injection may be performed to confirm that the pain comes from facet joint.
X-rays can show bony change of the facet joints and spine. X-ray does not give a detail bony change. However, it can be a good screen test to find out if the spine is stable or rule out other conditions, such as occupied lesion.
A computed tomography (CT) scan can be ordered if more detail bony structure is desired. The image of CT Scan can show more detail bony structure and its change. For example, CT Scan can show enlarged joints, eroded surface of the joints, or bone spurs.
MRI can show enlarged joint and synovial cyst as well as a clearer image of soft tissue vs. X-Ray or CT Scan. MRI may not be ordered first if we only consider bony structure condition.
The facet joint injection or nerve block is the most definitive diagnosis of facet joint pain. Local anesthetic can be injected into a facet joint, or block the nerve innervated in the joint under the guidance of fluoroscope. It may confirm that the pain comes from the facet joint if the patient has significant pain relief for at least 6 hours. Injections or/and blocks are usually done before medial branch nerve ablation or surgery.
The treatment for facet joint pain includes conservative pain management, interventional pain management with minimally invasive procedures, and surgery. Currently there are more options for treating facet joint pain than in the past.
Conservative Pain Management
Home exercise program
Interventional Pain Management with Minimally Invasive Procedures:
Facet joint injection
Medial branch nerve block
Medial branch nerve ablation (Radiofrequency, RF)
Conservative Pain Management:
Nonsteroidal anti-inflammatory drug (NSAID) can be taken to reduce inflammation initially. Muscle relaxants can be helpful to reduce spasm if exiting. Opioid pain medication is reserved for severe pain for a short period time only.
Acupuncture is a key component of traditional Chinese medicine. It involves the insertion of thin needles into specific points on our body to treat variety of medical condition. The acupuncture treatment for facet pain syndrome can provide pain relief, reduce inflammation and reduce muscle spasm.
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Physical therapists may evaluate the patient first and then design a program specifically for the individual patient. The program may include modalities, therapeutic exercise, and home exercise program. Modalities include ultrasound, electric stimulation, traction, paraffin bath. Therapeutic exercise will be strengthening, stretching and endurance exercise. The patients will be instructed to do home exercise as part of the treatment. Home exercise is also very important to physical therapy treatment because just two to three times of formal physical therapy treatment in the facility is not enough.
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Massage can be another way to relax muscle and reduce facet joint pain. It improves circulation and nutrition status locally.
Neck braces and back braces can stabilize the neck and back and limit their movement to help reduce the neck facet pain and back facet joint pain respectively. However, use of the brace should be limited to one week and for acute pain only. It may cause muscle atrophy if it is used too long.
There are a number of home treatments a patient can do to alleviate the pain.
Home exercise program as discussed above. However it has to be guided by physical therapist or healthcare providers.
Maintaining good posture
Heat or cold pad
Adjust daily activities
Interventional Pain Management with Minimally Invasive Procedures:
Intervention pain management with minimally invasive procedures is indicated if patients do not respond to conservative pain management, or the pain is severe and intolerable. The procedures for treatment of facet join pain are facet joint injections, medial branch nerve block, and medial branch nerve ablation or radiofrequency.
Facet Joint Injection:
Facet joint injections entail injection of steroid and local anesthetic into facet joints under the guidance of fluoroscope. There are two purposes for the injection: diagnosis and treatment. Local anesthetic injections can confirm diagnosis and steroid injections can reduce inflammation and alleviate the pain.
The needle is in an facet joint.
Facet joint injection: the needle in arthritic joint.
Medial Branch Nerve Block:
Medial branch nerve block is a diagnostic test. This procedure injects long acting local anesthetic to the medial branch nerve areas under the guidance of the fluoroscope. Medial branch nerve is the nerve innervated to the facet joints. When the nerve is blocked with local anesthetic, the pain from the facet joint can be stopped or reduced because the pain from facet joints cannot passes the blockade to brain any more. Therefore, our brain does not feel the pain, or feels less pain.
Medial branch nerve block: the needle is adjacent to the nerve.
Medial Branch Nerve Ablation (Radiofrequency, RF):
Radiofrequency is indicated if patients have significant pain relief for several hours after medial branch nerve block. It is also indicated if patients have facet joint injection with short term significant pain relief, but pain relief does not last long. The radiofrequency can ablate the medial branch nerve and give significantly longer pain relief. This procedure is also called facet rhizotomy. It is different from surgical facet rhizotomy. Radiofrequency uses heat to ablate the medial branch nerve. The surgical facet rhizotomy uses a knife to cut the nerve.
Medial branch nerve ablation: the needle is adjacent to the nerve and the other end is connected with radiofrequency machine.
Intractable facet joint pain is relatively indicated for surgery. Some of patients may need surgery after they failed all the conservative pain management and interventional pain management. There are many ways a surgeon can reduce the pain, with the most common procedures including facet rhizotomy and fusion. Surgeons can review the case and recommend a best approach individually.
For more information about spine related conditions and treatments, visit our Website at comprehensivepainNY.com.
This article is not intended as a substitute for the medical advice of physicians. The reader should regularly consult a physician in matters relating to his/her health and particularly with respect to any symptoms that may require diagnosis, medical attention or treatments.