Facet Arthropathy

Facet Arthropathy

By Lori Montgomery, MD, CCFP and John Clark, MD, FRCPC

Introduction

The facet (say: FAS-it) joints (more properly called zygapophyseal joints) are the places where the vertebrae in the spine connect. They keep the vertebrae from moving too much as you flex, extend, and rotate the spine. Facet arthropathy means pain coming from the facet joints. If it occurs in the neck, it is called cervical facet arthropathy (say: ar-THROP-uh-thee). If it occurs in the low back, it is called lumbar facet arthropathy.

How often facet arthropathy occurs

There is some controversy about how much neck and low back pain is caused by facet arthropathy, because we do not have a reliable way of diagnosing it. However, some studies suggest that less than 10% (1 out of 10) of people with low back pain have facet arthropathy.

There is less research on how common this condition is in people with neck pain. However, the studies that exist suggest that in about half of the people with neck pain, facet arthropathy may be part of the problem.

It appears to be more common in people over the age of 50.It most likely affects equal numbers of men and women.

Signs and symptoms

There are few signs and symptoms that set facet joint pain apart from other causes of neck and back pain. The pain is most often worse on one side or the other (as opposed to the middle of the spine), and may or may not go into the arms or legs. There is most often no weakness or numbness in the arms or legs. Cervical facet arthropathy can cause headaches as well as neck pain.

Causes

We do not know exactly why people develop pain coming from the facet joints. Stretching of the joint capsule may be part of the problem. There are also pain-enhancing chemicals that are released in the joint when it is under stress. There are a series of nerves around the joint, which may also be irritated. Diseases like osteoarthritis or rheumatoid arthritis may make facet arthropathy more likely.

Diagnostic tests

Part of the diagnosis of facet joint-related pain rests on your description of symptoms and a physical exam. X-ray, magnetic resonance imaging (MRI), and other imaging tests can sometimes suggest degenerative changes in the joints, similar to arthritis. We do not know whether there is any connection between these findings on X-rays and how much pain people have. Many people with severe degenerative changes on X-rays have no pain at all, while others with a lot of pain have fairly normal X-rays.

One way to help make the diagnosis is to inject the facet joint with a local anaesthetic in an attempt to block the pain signal. However, if the pain improves, it is very brief, often no more than a few hours. It is an invasive test with some risks attached. It may not be needed if the results are not going to change the treatment plan.

Treatment approach

Physiotherapy and home exercise program

Physiotherapy and a home exercise program are the most important parts of the treatment of this condition. This can help to increase range of motion in the joints and improve the strength of the muscles and ligaments around the spine to give the joints more support.

Medicine

Over-the-counter medicines such as acetaminophen (Tylenol) or ibuprofen can be useful in order to manage pain while rehab is taking place. Some people may use weak opioids like tramadol or codeine for more severe pain. If there are symptoms that suggest nerve irritation, some medicines may be useful such as:

  • tricyclic antidepressants
  • gabapentin or pregabalin
  • serotonin-norepinephrine reuptake inhibitors

For some people with severe pain, symptoms can improve with strong opioids like morphine.

Injections

As mentioned, injections of local anaesthetic into the facet joint have very short-term results so they are mainly used for diagnosing facet arthropathy. Sometimes steroids can be injected into the joint as well, to try to prolong the effect. Sometimes it is possible to disrupt the nerve that supplies the facet joint, in an attempt to stop pain signals from being sent. These procedures (radiofrequency ablation or cryoablation) do not destroy the nerve forever. Therefore, the results are most often short-lived. They may need to be repeated after six to nine months. There is also a risk that pain can become worse in the short term after these procedures instead of better. The research that has been done in this area does not tell us for sure how likely the injections are to help.

For more information

Web sites

National Institutes of Arthritis and Musculoskeletal and Skin Diseases (Back pain)
www.niams.nih.gov/Health_Info/Back_Pain/default.asp#4

eMedicine (Cervical Facet Syndrome)
http://emedicine.medscape.com/article/93924-overview

eMedicine (Lumbar Facet Syndrome)
http://emedicine.medscape.com/article/310069-overview

Familydoctor.org (Low back pain)
www.familydoctor.org/online/famdocen/home/common/pain/treatment/117.html

Spine-health.com
www.spine-health.com

References

Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106(3):591-614.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse. National Institutes of Health. Handout on health: Back pain. Bethesda, Maryland.