Continuing Education Activity

Facet joints are formed by the articulations of the superior and inferior articular processes of adjacent vertebrae. Except for the atlantooccipital and atlantoaxial joints, facet joints are lined with synovium and covered by a true joint capsule. The capsule is richly innervated. Each facet joint receives innervation from two spinal levels, one of which is from the dorsal ramus at the same vertebral level and the other of which is from one level above. This explains why facet-related pain is not easy to locate. This activity reviews the etiology, presentation, evaluation, and management of facet arthritis and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.

Objectives:

• Describe the pathophysiology of facet joint arthritis.
• Outline the components of a proper evaluation and assessment of a patient presenting with a facet joint arthritis, including any indicated imaging studies.
• Summarize the treatment options available for facet joint arthritis.
• Describe how an optimally functioning interprofessional team would coordinate care to enhance outcomes for patients with arthritis of the facet joints.

Introduction

Facet joints are formed by the articulations of the superior and inferior articular processes of adjacent vertebrae. Except for the atlantooccipital and atlantoaxial joints, facet joints are lined with synovium and covered by a true joint capsule. The capsule is richly innervated. Each facet joint receives innervation from two spinal levels, one of which is from the dorsal ramus at the same vertebral level and the other of which is from one level above. This explains why facet-related pain is not easy to locate. [1][2][3][4]

Etiology

The spine can be considered as a series of connected motion segments. In each segment, the superior articular process of the lower vertebra connects the inferior articular process of the superior vertebra. Thus, spine alignment and load distribution are thought to play an important role in the development of the degeneration of facet joints. 

Instability of the spine due to trauma or poor posture that loads extra weight on the posterior structures of the spine may also cause degeneration of the facet joints. 

Epidemiology

The prevalence of facet arthritis is age-related. The study done by Manchikanti et al. reported a prevalence of facet joint involvement of 35% to 42% in patients with neck pain. In the lumbar area, the prevalence was 18% to 44% across age groups.

Pathophysiology

Degeneration changes in facet joints will involve the articular cartilage, synovium, and capsule. Thinning of the cartilage, formation of synovial cysts, fibrocartilage proliferation of the capsules, and osteophyte formation all can be seen in facet arthritis. Topographically, the prevalence of facet arthritis is the highest at L4-L5, followed by L5-S1. In the cervical region, it is more common in the mid-cervical region, (between the C3 and C5 vertebrae). [5][6][7]

Histopathology

The joint capsule starts to have fibrosis, neovascularization, and inflammation in the early stage of the disease. Later, extensive fibrocartilage proliferation contributes to the hypertrophied capsule. Osteophytes form at the later stage of the disease, usually at the border of the capsular insertion. 

History and Physical

Painful conditions related to facet arthritis usually occur after sudden twisting or flexion/extension of the spine while lifting or after acceleration-deceleration injuries. Depending on the level of injury, the pain is usually localized over the neck or back with some degree of radiation into the upper or lower limbs in a non-dermatomal distribution. 

In the upper cervical spine, the referred pain tends to transfer up to the occipital region and may be combined with a headache. In the lower cervical spine, the referred pain tends to be down to the shoulder girdle and inter-scapular region. In the lumbar spine, the referred pain is around the buttock and thigh and rarely passes beyond the knee.

Pain associated with facet arthritis, as compared to radicular pain, is not likely to accompany neurologic findings such as motor or sensory loss or diminished reflexes. 

Physical examination, including tenderness over the facet joint and pain aggravated by extension/rotation and relieved by flexion, are indicative of possible facet arthritis. 

One clinical test that has been described to diagnose facet arthritis is the Kemp test. A patient will be asked to perform extension combined with the rotation of the spinal region of interest, with a positive test defined as a reproduction of the patient’s pain. However, the diagnostic accuracy is not high according to the systemic review performed by Kent et al. 

Evaluation

The evaluation of pain-related facet arthritis should first be focused on when ruling out conditions such as disc herniation, spinal stenosis, spondylolisthesis, infection, and neoplasm of the spine. The combination of facet arthritis with the above-described conditions is not rare. Thus, the role of conventional radiography, CT, and MRI on facet joint degeneration is not only to detect them but also to rule out other possible comorbidities. [8][4][9][10]

CT scan, when detecting facet arthritis, is the most sensitive technique. MRI, on the other hand, can best detect the surrounding soft tissues such as a disc, spinal cord, neuroforamen, nerve roots, etc. Conventional radiography can help to detect motion-related instability in flexion or extension. 

Some invasive techniques are used for evaluation as well. Facet block through intra-articular injection or medial branch block is useful in the diagnosis of painful conditions related to degenerative facet joints. 

Treatment / Management

Physical therapy, pain medications, spinal manipulation, facet block, radiofrequency lesioning, and surgical intervention all can be used to treat pain related to facet degeneration. 

Physical therapy includes education of proper posture and restoration of correct body mechanics. Positions such as excessive extension or extension with rotation should be avoided. Strengthening of deep neck flexors and abdominal muscles can help to balance the overactivated extensors of the neck and back. 

Pain medications such as steroids, nonsteroidal anti-inflammatory drugs(NSAID), or cyclo-oxygenase-2 inhibitor(COX-2) can be given orally for initial pharmacologic treatment of acute pain related to facet arthritis or following acute exacerbation of chronic pain related to facet arthritis. 

Spinal manipulation, by using the muscle energy technique or high-velocity low-amplitude maneuver to correct the type II dysfunction of the facet joints (flexion-rotation-side bent or extension-rotation-side bent postures) can help to realign the facet joints and can alleviate pain.

Landmark-guided, ultrasound-guided, or fluoroscopically guided techniques in facet block or medial branch block can be used to treat pain related to facet arthritis. Radiofrequency lesioning of the medial branch of the posterior ramus can be used if the pain is recalcitrant to the previous block. 

Surgical intervention is not the first-line treatment for the management of facet arthritis. Surgery is indicated when there is a combination of other diseases such as severe spinal stenosis or herniated discs that produce intractable pain, loss of motor function, or incontinence. 

Differential Diagnosis

Facet arthritis may be manifested like other musculoskeletal disorders. Examples of differential diagnoses include: 

• Herniated disc with impingement of the nerve roots
• Discogenic pain syndrome including internal rupture of the disc
• Radiculopathy
• Trunk muscles and ligament sprain/strain injuries
• Spondylolysis/spondylolisthesis
• Piriformis syndrome 
• Sacroiliac joint injury
• Entrapment of superior cluneal nerve
• Thoracolumbar fascia dysfunction
• Inflammatory arthritis of the spine from rheumatoid arthritis or ankylosis spondylosis
• Spinal infection
• Neoplasm of the spine

Prognosis

Laxmaiah et al. conducted a randomized control study and revealed that medial branch blocks with local anesthetic and Sarapin, with or without steroids, can bring significant relief to pain related to facet arthritis. The relief with one to three injections was 100% up to one to three months, 82% for four to six months, 21% for seven to 12 months, and 10% after 12 months.

Deterrence and Patient Education

The first step to treat facet arthritis is patient education of proper posture during daily living, relative rest, pain relief, and exercise. After physical therapy, if the pain persists, facet blocks can be done to help further understand if the pain is really from the facet joint itself, which helps the practitioner arrange further treatment if needed.

Enhancing Healthcare Team Outcomes

The diagnosis and management of facet joint arthritis is managed by an interprofessional team that includes an emergency department physician, primary care provider, nurse practitioner, orthopedic surgeon, physical therapist and a pain specialist. There are many treatments for the disorder but conservative treatment should be the first step.

Physical therapy includes education of proper posture and restoration of correct body mechanics. Positions such as excessive extension or extension with rotation should be avoided. Strengthening of deep neck flexors and abdominal muscles can help to balance the overactivated extensors of neck and back. Most patients will benefit from NSAIDs.

Other therapies include spinal manipulation, joint injections, and nerve blocks. Overall, most patients do obtain short term relief from symptoms but if the lifestyle is not altered, recurrence of symptoms is common.[11][12]