Continuing Education Activity

Facet joint disease is a condition in which the joints of the spine become a source of pain. This is a very common disease process and its prevalence increases with aging. This activity reviews the evaluation and treatment of facet joint disease and highlights the role that the interprofessional team plays in treating patients with this condition.

Objectives:

• Identify the etiology of facet joint disease.
• Describe the appropriate evaluation of facet joint disease.
• Outline the treatment and management options available for facet joint disease.
• Describe interprofessional team strategies to enhance care delivery to patients with facet joint disease to help improve patient outcomes.

Introduction

Facet joints form from the superior and inferior articular processes of two adjacent vertebrae. They are synovial joints as a fibrous capsule encompasses the bone and articulating cartilage and is continuous with the periosteum. The joint also contains synovial fluid which is kept in place by an inner membrane. The function of these joints is to allow for flexion and extension of the spine while limiting rotation and preventing the vertebrae from slipping over each other. The sensory nerve of these joints is the medial branch of the dorsal spinal ramus. Facet joint disease, also known as facet syndrome, is a condition in which these joints become a source of pain. Facet joint mediated pain is a common source of disability amongst our population with significant economic impact. Chronic low back pain often results from facet joint disease, with a prevalence of 15 to 41%.[1]

Etiology

The most common cause of facet joint disease is degeneration of the spine, also known as spondylosis. When the degeneration of the joint is secondary to natural wearing and abnormal body mechanics the condition is known as osteoarthritis (OA). The pathophysiology of OA is not entirely understood but is a complex one involving various cytokines and proteolytic enzymes as well as personal risk factors. Other causes of facet joint disease include trauma secondary to injury or sporting activities. Inflammatory conditions such as rheumatoid arthritis and ankylosing spondylitis may also contribute due to the inflammation of the synovium. Subluxation of the facet joints due to spondylolisthesis can also contribute to the development of facet joint disease. Those with facet joint disease show signs of cartilage erosion and inflammation, which can lead to pain. The body will also undergo several physical changes in response to this process. Ligaments, such as the ligamentum flavum, can become thickened and hypertrophic. New bone formation around the joint can occur with the development of osteophytes or “bone spurs.” There can also be an increase in the subchondral bone volume with hypomineralization.[2]

Epidemiology

The lifetime adult prevalence of low back pain in the United States is 65 to 80%.[3] This prevalence is consistent with the idea that degeneration is the leading contributory cause of facet joint disease, as the elderly population is more often affected. There have been no studies that confirm that males are affected more often than females. However, having a history of doing heavy work before age 20 increases the likelihood of developing facet joint osteoarthritis.[4] Obesity also largely contributes to osteoarthritis; thus, it is likely a contributing factor in the development of facet joint disease.

Spondylolisthesis caused by degeneration is most often caused by facet joint osteoarthritis, and typically occurs at the L4-L5 level. Spondylolisthesis that presents in a younger population (30 to 40years old) is due to congenital abnormalities, stress, or acute fractures.[4] Cervical facet disease and pain have a prevalence rate of 29 to 60% following whiplash injuries; although overall trauma is still a rare cause.[5]

History and Physical

Facet joint disease is often a clinical diagnosis, and therefore the history and physical exam are extremely important. Patients who present with chronic back pain have symptoms that often overlap with other diagnoses. Facet-mediated pain is typically non-radicular. The pain is often described by patients as worse in the mornings, upon awakening, or during periods of inactivity. It may also worsen with spine extension, facet joint palpation, and rotary trunk motion. Pain can be elicited by facet joint palpation and axial loading. Reproduction of the patient’s pain with Kemp’s maneuver, lateral rotation, lateral bending, and back extension, is suggestive of facet joint disease and arthropathy. In the lumbar area, this pain can be unilateral but is typically axial with occasional radiation into the buttock, groin, and thighs and down to the knee.[6] There are reports of radiation of pain to the abdominal and pelvic areas; however, this is less frequent.[7] This “pseudo-radicular” pain does not have any associated neurological deficits. When this radiating pain is present, it can mimic sciatic pain, but this is most often in cases of osteophytes or synovial cysts.[4] It is important to rule out other causes of low back pain, such as disc herniations, vertebral body fractures, and neoplastic causes of the patient’s pain.

Evaluation

It is often challenging to isolate facet joint disease as the sole cause of a patient’s complaint of neck or back pain. Imaging has not been proved to have much if any diagnostic validity. X-ray, CT, and MRI may show degeneration, joint space narrowing, facet joint hypertrophy, joint space calcification, and osteophytes; however, these findings may be present in both symptomatic and asymptomatic patients. Data shows that 89% of patients in the 60 to 69 years of age population studied have facet joint osteoarthritis, although not all were symptomatic.[8]  Diagnostic medial branch blocks are considered the gold standard approach to diagnose facet joint pain. A positive response to a set of 2 diagnostic blocks done on two separate occasions at two or more levels can confirm the source of pain. High false-positive responses are more likely to occur if only 1 level is blocked.[9]

Treatment / Management

Conservative management is used as first-line therapy to treat facet-mediated pain. Anti-inflammatory medications, weight loss, muscle relaxers, physical therapy, and massage are therapies used in conjunction with one another as a multimodal approach to treating the pain. When conservative measures fail, interventional procedures are considered to reduce pain, improve functionality and reduce side effects from medications.[10] Diagnostic medial branch blocks are often performed to confirm the generation of the pain is from the facet joints. Two diagnostic medial branch blocks are often an option secondary to the high (30 to 45%) false-positive success rate reported after a single block.[11] If a patient has a positive response to a set of two diagnostic blocks, radiofrequency ablation can then be done to ablate the medial branch nerves. Improved function and decreased pain have been shown to last from 6 to 12 months following lumbar medial branch radiofrequency ablation.[8] Radiofrequency ablation uses heat to temporarily destroy the medial branch of the sensory nerve, thus providing a reduction of pain. The procedures mentioned above are done usually under local anesthesia and fluoroscopic guidance. Because nerves regenerate eventually, the procedure is repeatable when the patient’s pain returns, typically in 6 to 12 months.

There are currently no guidelines available to support arthrodesis when interventional procedures fail to provide pain relief. Surgery may be indicated for grade I or grade II spondylolisthesis; however, this is not first-line management and may not result in the reduction of pain.[4]

Differential Diagnosis

• Sciatica
• Hip osteoarthritis
• Sacroiliac impingement
• Lumbar radiculopathy
• Myofascial pain
• Compression fractures
• Disc herniation
• Osteophytes
• Rheumatoid arthritis

Prognosis

Facet joint disease is a chronic process that can cause pain for the remainder of an individual’s lifetime. Facet joint disease is a progressive disease. The spinal and joint degeneration typically progresses as the patient ages. It is essential to prevent the degeneration from progressing by maintaining a healthy weight and active lifestyle. Physical therapy and core strengthening exercises can strengthen the spine and reduce the stress on the facet joints. Interventional procedures such as medial branch blocks and radiofrequency ablations do not treat the underlining cause of the patient’s pain but allow the patient’s pain to be more manageable. Patients can have a reduction in their pain for months at a time, but some studies have shown an even longer-term decrease in pain of up to 2 years after radiofrequency ablations.[12]

Complications

Complications of treatment of facet joint pain with medial branch blocks or radiofrequency ablation are rare. Patients may have a transient increase in their pain following radiofrequency ablations and medial branch blocks due to the heat denervation and needle entry. Post-dural headaches, transient numbness or weakness, bleeding, infection, and increased post-procedural pain are all potential but rare complications of facet interventions.

Deterrence and Patient Education

Patient education is of the utmost importance with patients treated for pain. Patients should receive information that facet joint disease is a lifelong and progressive disease. Complete resolution of the patient’s pain is typically not observed, and this is a crucial component of any discussion with the patient. Prevention of disease progression through a healthy lifestyle, diet, and exercise is imperative; this can help reduce the stress on the facet joints, therefore reducing inflammation and pain.

Enhancing Healthcare Team Outcomes

Treating patients in pain can often be challenging. It is vital for the healthcare workers (i.e., the primary care provider, nurse practitioner, internist, and orthopedic surgeon) to listen to the patient to obtain a solid history and perform a complete physical exam to diagnose the source of the patient’s pain and importantly, rule out more serious causes for the pain.   Although complications are rare, prompt follow-up after facet joint interventions is necessary to ensure no negative side effects have occurred. The clinician may want to explore other pain mitigation strategies, especially those that do not involve opioids. To help slow down the facet joint disease, educating the patient on the importance of lifestyle changes is of vital importance.

Facet joint arthrosis requires a collaborative interprofessional approach that includes physicians, nurses, therapists, and pharmacists who are engaged and communicate all aspects of the patient's case to bring about the best possible outcome. [Level 5]