Facet joint arthropathy and its management

Dr Ashok Jadon, MD,DNB,MNAMS,FIPP

Facet joints (zygapophyseal joints) are paired synovial joints formed by articulation of the
inferior articular process of the upper vertebra with the superior articular process of the lower
vertebra. These joints allow the spine to move in flexion, extension, and rotation. Low back pain
and neck pain is very common pain disorder and the zygapophyseal (facet) joint is a potential
source of pain in these areas. The facet joints have been implicated in15% 45% of cases of axial
low back pain and 40%55% of cases of chronic neck pain. Proposed pain mechanisms include
capsular stretch, entrapment of synovial membrane between the articular surfaces, nerve
impingement by osteophytes, and release of inflammatory factors. Degenerative conditions and
trauma are the most common conditions leading to pain from facet joints. Facet joint
degeneration can result from abnormal motion associated with disk degeneration as well as
arthritis similar to other synovial joints.
Facet as Pain Generator: Facet joints are an important contributors for back pain. Injection
of hypertonic saline into the facet joints results in pain which corresponds to the tertiary of that
particular facet joint and this pain is reproducible. Maps of pain distribution after facet injections
have been made by fixed pain patterns in volunteers and patients which helps in diagnosis of
affected facet joint causing pain. Each facet joint receives dual innervation from medial branches
arising from posterior primary rami at the same level and one level above the facet joint.
Pain generators in facet joints: Facet joints have rich innervation with encapsulated, un-
encapsulated, and free nerve endings. Joint capsule are supposedly main source of pain as they
contains substance P and calcitonin gene-related peptide. In addition nerve endings in facet
capsules contains neuropeptide-Y, indicating the presence of sympathetic efferent fibers
responsible for neuropathic pain. Other areas like subchondral bone and intra-articular inclusions
also contains nerve fibers indicates that these structures are also potential places for facet related
pain besides the joint capsule. Inflammatory mediators such as prostaglandins, cytokines
interleukin-6 and tumor necrosis factor-alpha have been found in facet joint cartilage and
synovial tissue in degenerative lumbar spinal disorders indicates the nociceptive pain source.
Mechanism of facet arthropathy: Repetitive strain leads to subclinical injury and thus
degenerative changes in facet joint. Sometime whiplash injury also leads to arthropathy and
chronic cervical pain. In some cases injuries can cause cervical facet dislocations and fractures,
causing radiculopathy. Motor vehicle accidents or sports injuries may result in facet joint pain
secondary to hyper flexion, rotation, and distraction injuries.
Clinical presentation: Pain arising in cervical facet causes pain in upper or lower neck,
shoulder and also headache if upper cervical facets are involved. Thoracic facets causes pain in
lower neck, upper back and inter scapular area. Pain from lumbar facet joints causes low back
pain with unilateral radiation to the buttock and posterolateral thigh (rarely below knee) which
may be exacerbated in extension and relieved with flexion. Pain frequently is also referred into
the groin, buttocks and hip. All lumbar levels are capable of producing groin pain, though it is
most common in the lower levels. Pain from the upper lumbar facets tends to extend into the
flank, hip, and upper lateral thigh, whereas pain from the lower lumbar levels is likely to
penetrate deeper into the thigh, usually in the lateral and posterior aspects. Infrequently, the L4-5
and L5-S1facet joints can provoke pain in the lateral calf, and rarely into the foot. Patients with
osteophytes, synovial cysts, or facet hypertrophy also may manifest radicular symptoms. Pain is
often described as a "deep, dull ache" and maybe either unilateral or bilateral. On physical
examination increased pain with extension, tenderness to palpation over the affected joints, and
normal findings on neurologic examination. Facet joint pain is often worse after periods of
immobilization (difficulty in getting up in morning due to stiffness) and improves with motion.
Hyperextension and the tilt test during examination and local tenderness on direct pressure over
the facet joint during fluoroscopic correlation can also be helpful for isolating symptomatic
levels. When the facets become pain generators, it is unusual that a single joint is involved.
Bilateral involvement has been reported in about 70% of cases and includes more than 3 regional
joints in many patients
Diagnosis: Diagnosis is mostly clinical as anatomical changes due to degeneration seen on x-
rays, CT or MRI does not correlate well with symptoms. Fractures or dislocation of facets joints
due to injury and other symptomatic conditions like cysts pressing over nerves can be diagnosed
by imaging techniques (Table-1). Electrical stimulation of the medial branch nerves may also
assisted in identifying referral pain patterns. Confirmation that pain source is facet joint is done
by injection of local anaesthetic either into facet joint (intra articular injection) or by medial
branch blocks. However, No historical or physical examination findings can reliably predict
response to diagnostic facet blocks and there is high incidence of false positive (20-50%) and
false negative (11%) results. Use of serial blocks using lidocaine and bupivacaine had a high
degree of specificity (88%) but only marginal sensitivity (54%). Although a high specificity will
result in a low false positive rate, the low sensitivity predisposes patients to a false-negative
diagnosis. The reasons for false-positive facet blocks are, placebo-response, myofascial pain and
epidural spread. In lumbar area the specificity of lumbar medial branch block (MBB) increases if
volume of local anesthetic is kept low (0.5 mL) and target point of injection is kept more caudad
(site midway between the upper border of the transverse process and the mamilloaccessory
ligament). There are also other Interventions that may reduce the incidence of false-positive
lumbar facet blocks:
1. Placebo-controlled blocks, or comparative local anesthetic blocks.
2. Lower target point on the transverse process.
3. Reduced injectate volume to 0.5 mL.
4. Less amount of local anesthetic for skin infiltration.
5. Use of single-needle approach (single entry point for two or more medial branch blocks)
6. Computed tomography guidance (for intra-articular injections) in patients with severe
spondylosis.
7. Avoided use of sedation or intravenous opioids.
False-Negative Blocks also may be a result of a multiple of factors, although the predominant
mechanism(s) remains unclear, venous uptake of LA (8-33% of lumbar facet blocks) and an
aberrant innervation of facet from nerves other than branches of the dorsal rami are important
causes for false negative responses. Diagnostic image-guided medial branch nerve blocks have
the most convincing evidence (level I) for isolating the facet joint as a pain generator, even
though debate is still going on regarding the need for serial blocks or placebo-controlled blocks
before proceeding to interventional therapy.
Treatment: A multimodal approach for the treatment of facetogenic pain is essential.
Conservative therapy should be tried first which includes, medical management, acupuncture,
acupressure, tailored exercise, yoga and psychotherapy. Pharmacotherapy and non-interventional
treatments all have been tried however, evidence for their success in isolation is limited and
inconclusive. The optimal management of facet joint pain should include both non-interventional
and interventional treatment. Facet joint interventions may be considered in patients when non-
radicular axial spine pain or cervicogenic headache persistently resulting in functional disability
for more than 3 months duration and do not responds to conservative medical management or
physical therapy.
Interventional Management of Facet pain: Interventional approach to manage facet joint pain
has dual advantage as, it is a definitive diagnostic tool and also has therapeutic value.
Interventional Management of facet arthropathy is done through injection of local anaesthetic
(with or without steroid) either within the joint (intra-articular injection) or on to the medial
branches. Once diagnosis is sure than for long term effect radiofrequency ablation (RFA) of
medial nerves are done.
Medial Branch Block: To perform the diagnostic medial branch block, the patient should first
be examined to establish a baseline pain level. The facet joint is identified fluoroscopically (with
a C-arm), overlying skin is marked, prepped, and draped in usual sterile fashion. Lidocaine is
used to anesthetize the skin and subcutaneous tissues. A 22G spinal needle is then inserted
percutaneous and advanced under fluoroscopic guidance by using Anterior-posterior (AP),
lateral, and oblique projections. Target for the lumbar spine is the junction of the superior
articular process and the transverse process and for the cervical spine the target is the midpoint of
the lateral margin of the facet (Fig-2). After negative aspiration 0.2-0.5mL 2% lidocaine is
injected. The patient is then re-examined after a 20-minute interval to assess response to the
block and more than 50% reduction in pain is taken as positive response. The response to medial
branch blocks has been reported to correlate with treatment outcome however, to avoid false-
positive response dual block (lidocaine and then bupivacaine) or placebo controls have been
advocated before progressing to radiofrequency ablation.
Intra-articular Steroid Injections: Intra-articular injection of a steroid and a local anesthetic in
the facet joint is performed mainly for therapeutic purposes for relief of low back and neck pain.
The procedure may also be used for diagnostic purposes to establish the cause of pain. The joint
space can be entered directly or when direct access proves impossible or too difficult, an articular
recess can be targeted. CT guidance may be required if joint is severely degenerated and
osteophytes are present and there is inability to enter in to the joint during routine fluoroscopic
guided procedure. Once intra-articular access is confirmed (Fig-3) by contrast injection (0.2mL),
a combined solution of anesthetic and steroid can be injected. The most common long-acting
steroids include methylprednisolone, triamcinolone, and betamethasone. Intra-articular steroid
injections may be more effective when radiological evidence of joint inflammation and
degeneration is present. As with all steroid injections, attention should be given to the total
patient steroid dose during a 12-monthperiod, especially in patients with insulin-dependent
diabetes. Injection volume should also be limited to less than 2mL because intra-articular
injection may injure (rupture) joint capsule if large volume of drug is injected. Intra-articular
injection is still being used although outcomes from intra-articular injections limits conclusions
regarding their effectiveness. Recent reviews of available literature have concluded that facet
joint steroid injections have limited (level III) evidence of benefit it means either they are
ineffective, or have no benefit. However, there is general agreement among pain physicians that
therapeutic facet joint injection, per level affected, per year is reasonable if the patient has more
than 50% sustained relief for more than 3 months and RFA is contraindicated or refused by the
patient. Intra-articular facet steroid injections may also be considered if patient has posterior
fusion and access to both medial branch nerves is limited by hardware or bone graft material.
Radiofrequency ablation of Medial Branch Nerve: RFA of the medial branch nerve may be
considered to obtain prolonged pain relief when diagnostic medial branch block gives 50% to
80% pain relief in patients without previous back surgery and whereas 35% to 50% pain relief in
patients with failed back surgery syndrome. The success of medial branch RFA is variable and
position of RF needle during nerve ablation is supposed to be a contributing factor. Therefore it
is recommended that the ideal electrode position to be along the lateral neck of the superior
articular process rather than at the groove between the angle of the superior articular and
transverse processes.
Procedure: For RFA procedure, the patient is placed prone and appropriate levels are identified
under fluoroscope. The overlying skin is marked and area is cleaned and draped in sterile
fashion. Lidocaine is used for local anesthesia of the skin and soft tissues. Light sedation is
optional. At each level, a 22-ga 5- to 15-cm insulated 5- to 10-mm active-tip radio-frequency
cannula is inserted percutaneous and advanced under fluoroscopic guidance by using dorsal,
lateral, and oblique projections. Tip of needle should be directed to the base of the superior
articular process. At lumbar level medial branch nerves lies between the intervertebral foramen
and the mamilloaccessory ligament. Aspiration is performed to exclude blood or CSF. Needle
placement is also confirmed with motor and/or sensory stimulation. Once needle position is
confirmed mixture of preservative-free 2% lidocaine and steroid is injected at each level to
provide local analgesia during the heating process. The radio-frequency probes are then inserted
through the needles and heated in serial fashion either in the radio-frequency mode(80C for 1.5
minutes) or pulsed mode at (42C for 2 minutes) (Fig-4 ). After the heating cycle has finished,
the needles are removed and sterile bandages are applied. Post-procedural examination and post-
sedation monitoring are performed and documented. Documentation of pretreatment and post-
treatment pain perception, functional assessment, and analgesic/opiate requirements is must to
monitor outcome. Complications like bleeding, infection, or incomplete pain relief may occur.
Numbness or dysesthesias have been reported after RF denervation, but tend to be transient and
self-limiting.
A point to ponder: Diagnostic medial branch block is necessary to establish the diagnosis of
facet joint as pain generator in backache. It is advised that comparative block using short acting
lidocaine followed by long acting local anaesthetic bupivacaine should be done as there is high
chances of false positive response. However, when determining the need for comparative LA
blocks due to relative risk for a false-positive or false-negative diagnostic block, the
complication rate of each diagnostic and RF procedure, the anticipated dropout rate, and cost
effectiveness should be taken into account. Moreover, many patients respond with long-term
pain relief even to sham denervations therefore it is still not accepted as standard of care.
Review of efficacy: Uncontrolled trials have shown 18% to 63% success rate of intra-articular
steroid injection which could not be substantiated on randomized controlled trials. Intra-articular
steroid injections may provide intermediate-term relief to a small subset of patients with an
actively inflamed facet joint. Many prospective and observational studies have supported this.
Opinion regarding therapeutic value of medial branch block with local anaesthetic with or
without steroid is divided. However, few patients may have long relief after medial branch block
with local anesthetic irrespective of steroid is mixed or not. The results of medial branch RFA is
more definitive and sustained. Although, variable success have been claimed by various authors
the average relief is about 50% which last for 9months to 1year if conventional (thermal) RF is
done and maximum up to 6 months if pulsed RF is done. However, correct needle placement on
the target is must for good results.





Table-1 : Levels of degeneration of Facet Joints based on Magnetic Resonance Imaging

GRADE RADIOLOGIC FINDINGS

0

Normal zygapophysial joints (2-4 mm width)
1 Joint space narrowing or mild osteophyte formation or mild hypertrophy of the
articular process

2 Narrowing of the joint space with sclerosis or moderate osteophyte formation or
moderate hypertrophy of the articular process or mild subarticular bone erosions

3 Narrowing of the joint space with marked osteophyte formation or severe
hypertrophy of the articular process or severe subarticular bone erosions or
subchondral cysts