Facet joint arthritis

Definition

Facet joint arthritis, or facet syndrome, is a degenerative lesion of the intervertebral joints, manifested by chronic pain syndrome without signs of nerve root compression. The disease occurs due to age-related changes in the spinal column, congenital joint tropism, whiplash, and rotational back injuries. Facet syndrome is manifested by dull pain in the affected parts of the spine and paravertebral areas, increasing with standing, turning, and extensor movements. CT of the spine and functional tests with local anesthetic are used for diagnosis. Treatment includes medication, analgesic therapy, and physical therapy methods.

General information

Facet syndrome is recognized as one of the most frequent causes of back pain, especially among elderly patients, in whom the prevalence of pathology reaches 85-90%. The facet joints are affected in 30-60% of cases of long-term pain syndrome at the lumbar level, 42-48% – at the thoracic level, and 49-60% – at the cervical level. Unlike spondyloarthritis, which manifests with a combined lesion of joints and periarticular tissues, the disease only affects intervertebral joints. The second difference is the absence of neurological deficits and root compression signs.

Causes

The formation of facet syndrome is associated with functional overload of the posterior spine, which provides stabilization during anteroposterior movements and twisting. Under the influence of pathological processes, the axial load on the intervertebral joints increases from 30% to 47-70%, contributing to the development of synovitis, degeneration of hyaline cartilage, and deformation of the joint capsule. The main risk factors of facet syndrome:

• Joint tropism. In 20-40% of people, congenital anomalies occur in the configuration of intervertebral joints, and their asymmetry is within one vertebral-motor segment. As a result, the spine is subjected to additional rotational load.
• Age-related changes. Degenerative processes in the intervertebral discs (IVD), characteristic of older people, contribute to chronic traumatization of facet joints and sharply increase the load on them. The situation is aggravated by dystrophic processes in other components of the vertebral-motor segment.
• Sitting. Office workers, seamstresses, and drivers are typically seated with a slightly tilted head, slumped back, and without proper lumbar support. This position is unphysiological for the spine, contributes to an imbalance of muscle tone, and earlier appears to cause degenerative changes.
• Spine trauma. Facet syndrome can be formed acutely with “whiplash” injury of the cervical spine, traction, or rotation. Such situations are more common in young patients, especially if they have a hereditary predisposition and instability of the vertebral-motor segment. 

Symptoms

The primary manifestation of facet syndrome is moderate pain in the area of the affected spinal segment. It manifests itself in the form of exacerbations several times a year for 1-3 months. Unpleasant sensations are provoked by sharp turns and extensions in the spine, increase with prolonged standing, and change the position of the body from horizontal to vertical. After a small warm-up for the back, discomfort is significantly reduced.

Pain in facet syndrome tends to spread locally. When the cervical spine is affected, pain is reflected to the shoulder girdle and the upper arm (up to the ulnar fossa). For the pathology of the upper lumbar segments, pain sensations are typically irradiated to the lateral surfaces of the abdomen and the lower part of the chest. Facet syndrome of the lower lumbar vertebrae is fraught with pain in the coccyx, hip joint, and groin area.

Most patients complain of morning stiffness in the back, difficulty in flexion-extension, and trunk rotation. Symptomatology lasts no more than one hour after getting out of bed. There is also an increase in pain at the end of the day, especially in people who do sedentary work or need to stand in one place for a long time. Such a sign indicates progressive instability of the spinal column.

Unlike radiculopathy, facet syndrome causes aching or pressing pain that does not reach a high intensity. Complaints of paresthesias, a feeling of numbness in the fingers or toes, and a feeling of “electric shock” in the spine are symptoms of compression of nerve roots and the development of the classic variant of spondyloarthritis. Muscle weakness and movement disorders are also uncharacteristic of facet syndrome.

Complications

Pain sharply reduces motor activity, impairs performance, and creates limitations in everyday life. Progressive hypodynamia against the background of degenerative processes is fraught with myofascial syndrome, aggravation of existing lesions of intervertebral discs, and accession of neurological deficit. Chronic pain worsens the emotional state of patients and can cause depression and anxiety-phobic disorders.

Diagnosis

Examination of patients with complaints of various back pain is in the competence of a neurologist. Physical examination determines flattening of the physiologic lordosis of the spine, the tension of the back muscles on the side of the lesion, and localized pain over the altered facet joint. To make a diagnosis, the results of the following examination methods will be required:

• CT scan of the spine. Computed tomography helps determine degenerative changes in the facet joints. Radial imaging data do not always correlate with the clinical manifestations and intensity of back pain, so this method is mainly prescribed for differential diagnosis.
• Functional tests. The only way to confirm the connection of back pain with the presence of facet syndrome is to block the posterior primary branch of the spinal nerve medically. Disappearance of pain shortly after the procedure indicates pathology of the intervertebral joints, which receive innervation from the above-mentioned branch.

Treatment of facet syndrome

Conservative therapy

The main task during an exacerbation of the disease is to relieve the pain syndrome as quickly as possible. Selective non-steroidal anti-inflammatory drugs (NSAIDs), which have fewer side effects, are used as first-line drugs. In facet syndrome, patients require long-term courses of NSAID therapy, which, when indicated, are combined with the intake of gastroprotectors.

In addition to analgesic therapy, myorelaxants are used, which eliminate the tension of the back muscles and break the vicious circle of “pain – muscle spasm – pain.” Pharmacotherapy is reinforced with chondroprotectors to slow the progression of joint changes. In case of intense pain syndrome, blockades with local anesthetics and corticosteroids are indicated, quickly relieving symptoms and restoring the person’s ability to move normally.

Physiotherapy methods play an important role in pain relief and patient rehabilitation. After the pain is reduced, sports, therapeutic massage, and manual therapy are prescribed. Cognitive-behavioral therapy can be used to teach ways to combat unpleasant manifestations of facet syndrome.

Surgical treatment

Neurosurgeons are required to assist in cases of ineffective conservative tactics and the development of complications of facet syndrome. The most common minimally invasive method is radiofrequency destruction of branches of spinal roots that innervate facet joints. The method does not require anesthesia, skin incisions, or a rehabilitation period. Radiofrequency denervation is 80% effective in eliminating pain; its effect lasts over 12 months.

All these treatment options are available in more than 320 hospitals worldwide (https://doctor.global/results/diseases/facet-joint-arthritis). For example, Radiofrequency rhizotomy  can be performed in 12 clinics across Turkey for an approximate price of $2.7 K (https://doctor.global/results/asia/turkey/all-cities/all-specializations/procedures/radiofrequency-rhizotomy). 

Prognosis and prevention

Facet syndrome is characterized by a recurrent course, with each subsequent episode being more severe than the previous one. Pathology does not pose a direct threat to health but acts as a basis for developing more dangerous diseases of the spine and reduces patients’ quality of life, so the prognosis is doubtful. Proper sitting and standing posture, back and neck exercises, and regular swimming lessons are recommended for prevention.