Facet syndrome: Presentation
Advanced, Clinical Subspecialties
Facet joint arthropathy presents as localized lumbosacral back pain, without radicular neuropathic symptoms. The classic presentation for lumbar facet joint pain syndrome includes maximal pain directly over the joints, pain with palpation of facet joints, and referred pain. Typically patients are elderly. Pain is classically worse with hyperextension, rotation, or rising from a chair. Pain may be referred to the flank, hip, and lateral or posterior proximal leg. Sensation of back and legs is normal. Radiographic findings from x-ray, CT, or MRI is often diagnostic for facet joint arthropathy. Typically, the onset of symptoms is gradual and not acute as with other common lower back pain syndromes due to trauma, muscle or ligament sprain, or early internal disk disruption.
In addition to facet joint arthopathy, chronic lumbosacral pain without radicular symptoms can also be caused by sacroiliac joint dysfunction as well as lumbar intervertebral disk dysfunction.
For chronic lumbosacral pain, the incidence of facet joint pain is approximately 15%, compared to 30% for internal disk disruption and 15% for SI joint pain. The gold standard for diagnosis for facet joint pain is relief with injection of local anesthetic to the block the medial branch nerves supplying sensory innervation to the facets.
Updated definition 2020:
Each level of the spine is comprised of three joints; there are two facet joints and one large intervertebral disc that make up each vertebral segment. The facet joints are synovial joints which, much like many other joints in the body, experience constant, repetitive motion. Pain that results from facet joint inflammation is known as “facet syndrome,” often caused by degenerative changes at the joint.
Cause of Pain:
These irritated facet joints then send pain signals to the brain via medial branch sensory nerves. Additionally, patients often experience concurrent muscle pain and spasm as a result of their facet joint pain, worsening their pain experience.
Patients may experience tenderness, stiffness, and generalized back pain as a result of the inflammation at the facet joints. Oftentimes, patients with facet syndrome find that their pain is worse extension, prolonged sitting or standing, and/or with first waking and activity in the morning. Some patients describe their pain as a diffuse, dull, aching pain that spreads into the lower buttocks. Pain is relieved by positions which take weight off of the joints, such as leaning forward or sitting. Facet joint pain can be chronic in nature or can occur as flares dependent on activity and inciting incidents.
Both male and female patients are affected. Patients are commonly between 40-70 years old. Those with spine injuries and proclivity for arthritis are at increased risk.
Diagnosis and Treatment:
Diagnosis depends on a thorough physical exam and may be aided by imaging studies. On physical exam, a patient with facet syndrome may demonstrate localized tenderness at palpation of the affected joint, decreased and painful extension and/or rotation at the level of the affected joint, pain in hip/bottom/back with ipsilateral leg extension, and ipsilateral referred pain not beyond the knee. A diagnostic facet joint injection will definitively determine diagnosis. Under fluoroscopy, a needle is used to inject a small dose of local anesthetic into the facet joint. The patient’s pain is monitored pre and post-intervention to determine if there is a measurable effect; if pain is significantly decreased, this is interpreted as a positive diagnostic test for facet syndrome.
Treatment varies depending on the severity of the patient's pain and responsiveness to conservative measures. Conservative measures such as improving posture, heat/ice, physical therapy, short courses of anti-inflammatory medications, and rest may improve symptoms adequately. For severe or refractory cases, additional therapeutic medications or fluoroscopically guided injections with corticosteroids may be offered. If patient’s derive significant benefit from steroid injections but without long-lasting relief, it may be reasonable to pursue a radiofrequency ablation of the affected medial branch nerves to eliminate their ability to send pain signals to the brain. Lastly, if conservative and interventional medications fail to provide adequate, durable benefit, patients should be referred for surgical intervention.