Facet Joint Syndrome

What is facet syndrome?

Facet syndrome is characterized by pain arising from the facet joints of the spine, often worse in the morning and aggravated by leaning backward. This pain is not felt deep in the middle of the spine, it is a pain typically felt a little off to the sides of the spine. The facet joints are the guiding joints in the back of the spine and they act to restrain the rotation of the back by acting as bony bumpers that restrict the range of motion. They are the reason you don’t just keep twisting when you swing a golf club.

These small joints occur in the cervical, thoracic and lumbar spine and are positioned toward the back, or posterior, part of the spine and off to the side. In addition to acting as stops to restrain twisting motions, these small joints are important to transmit weight-bearing forces of the body. In fact, they transmit around 20% of the body weight. Since they bear significant weight, they are subject to arthritis. The physical dimensions of the facets create some of the borders of the foraminal canal. The facet joints are what pop when you twist your back and neck.

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Who gets facet syndrome?

Facet syndrome is not a young person’s disease; it primarily affects older people, and it is more common with increasing age, and can account for 40% of low back pain complaints for people approaching 70 and 80 years of age. The exception to this is when a younger person experiences a traumatic injury. Whiplash is an example of a traumatic injury that can injure the facet joint and capsular tissues.

Why do the facet joints hurt more commonly as one gets older?

When you age, you lose the water content inside of the discs. The water inside of the disc is what provides the height of the disc and when that water leaves, the height is diminished. This is most easily seen when people get shorter with age. When the discs start to collapse, the facet joints lose their original alignment and get off center. When this occurs, the covering of the joints (cartilage) begins to wear out and bone-on-bone contact can occur (arthritis) and bone spurs can form. The soft tissues that wrap around the facet joints can get stretched or pinched.

The tissues that line (synovial) or wrap around and support (capsular) the facet joints are full of sensory nerves that supply information to the brain about where the back or neck is in 3-dimensional space. The nerves in the soft tissues give various sensations as they are stretched and pulled with movement of the spine. When the facet joints are out of place (subluxation), the soft tissues register a signal of discomfort or pain.

How do you treat this annoying facet joint pain?

If you are like me, you will want to start off with trying the easy things first. Certainly rest and anti-inflammatories can be a good start, but chiropractic adjustments can be very helpful and be effective to restore facet alignment for years. Exercises, stretching and physical therapy might also be helpful.

If back pain persists in spite of these conservative efforts, you might find yourself in a pain management office. Injections of a local anesthetic mixed some cortisone might be recommended. The injections are guided with fluoroscopy to the proper location. These injections can help confirm the diagnosis of facet syndrome if the pain is relieved. The duration of pain relief may be short or long term. The injection can be directed into the facet joint or toward the pain nerves (dorsal primary rami) that supply the joint with sensation.

What if the injections don’t last very long?

If the injections don’t work for any length of time, the next level of treatment is usually radiofrequency (RF). The pain management doctor performs RF with fluoroscopic x-ray with placement of an RF (Radio Frequency) probe/needle. The radiofrequency probe inactivates the pain nerves with heat, but only on a temporary basis, which is the problem. The treatment can last from a few months to a year, and then the pain starts to come back. After a while, the RF procedure can begin to lose effectiveness.

If this sounds familiar, maybe you have tried it, and sought out a more permanent kind of solution and stumbled over the fact that one permanent solution is a fusion, which in my opinion is a very large irreversible operation with a long recovery and uncertain outcome. A fusion for this pain is a pretty dramatic type of fix that may create more problems than it solves.

The endoscopic approach to facet syndrome is quite elegant and varies from the cervical to the lumbar part of the spine. In the lumbar spine from L3 (lumbar 3) to S1 (sacral 1) the nerve anatomy of the dorsal primary nerves is very consistent. The medial branch of the dorsal primary nerve root is the sensory branch that supplies sensation to the facet joints of the lower lumbar spine. If these branches can be divided there is no further sensation felt in the facet joints even if the joints are arthritic.

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