Cervical and Lumbar Facet Arthropathy2
David M. Sibell
Description: Zygapophyseal (facet) joints are synovial diarthroses from C1 to S1. These diarthroses are innervated by the medial branch of the primary posterior ramus of two surrounding segmental spinal nerves. Facet syndrome (Facet Arthropathy) is a condition in which the zygapophysial joint in the back of the spine degenerate and subsequently cause pain.
Geriatric Considerations: Geriatric populations are more prone to cumulative stress injuries and osteoarthritis.
Pediatric Considerations: Facet arthropathy is uncommon in children.
Prevalence: True prevalence unknown. Facet arthropathy estimates: cervical: 55% lumbar: 31%.
Risk Factors: There're multiple markers for osteoarthritis. HLA-B27 gene is associated with most inflammatory spondyloarthropathies.
Pathophysiology: facet joints in dynamic areas, such as C2-C4, C6-C8, and L4-S1, are subject to macrotrauma (fracture), microtrauma (endplate injuries, hemarthroses), and osteoarthritis. Joint degeneration occurs in inflammatory arthritides.
Etiology: Pain from facet arthropathy comes from injury to the articular cartilage, synovium, and/or surrounding bony structures.
✓ Minimization of ballistic spinal motion and extreme axial loading
✓ Treatment of underlying inflammatory arthritides
✓ Maintenance of posture and myofascial conditioning
- Traumatic and degenerative changes
- Internal disc degeneration
- Inflammatory arthritides
- Ankylosing spondylitis
- Rheumatoid arthritis
Signs and Symptoms: Considerable controversy surrounds the value of clinical examination. Although examination does not result in specific diagnosis, it is necessary to assess related disorders and to decide which patients go on for confirmatory testing.
History: Mechanical chronic axial spinal pain; if extremity symptoms are present, they do not predominate. Cervical facet arthropathy radiates to the occiput, posterior neck, shoulders, and scapulae. Cervicogenic headache is quite common for Cervical Facet Arthropathy, whilst lumbar one radiates to the low back, buttocks, hips, and rarely, to the popliteal fossae.
Physical Exam: Axial cranial, cervical, or upper thoracic pain with extension and/or rotation of the neck is present. Axial lumbar and/or buttock and/or hip pain with extension and rotation of the trunk at the hips is also typical for facet arthropathy. Besides facet arthropathy may also present with pain on flexion. Tenderness over spinous processes and facet joints at involved levels. Concomitant myofascial tenderness are not so far.
Interventional Diagnosis: Radiologically guided anesthetic blockade of the medial branches of the primary posterior rami of the involved joints. Intra-articular injections have low sensitivity and specificity.
Lab-Tests: if indicated, rheumatological laboratory evaluation
Imaging: Radiographs, CT, and MRI: osteoarthritic change (these findings are insensitive and nonspecific). Facet joint fracture in posttraumatic pain
Diagnostic Procedures/Surgery: Degenerative findings may present during open surgical procedures.
Pathological Findings: Decreased joint space, subchondral sclerosis, joint hypertrophy, and osteophytosis
- Internal disc degeneration
- Myofascial pain syndrome
- Inflammatory and/or autoimmune arthritides
First Line: No medications are demonstrated to be effective.
Second Line: Consider acetaminophen, NSAIDs and opioid analgesics
Interventional: After diagnosis with comparative local anesthetic medial branch blocks, radiofrequency medial branch denervation produces lasting reduction in arthralgic pain and associated symptoms. Typical duration of effect is 12 to 18 months, after which nerve regeneration may result in recurrent symptoms. No cumulative risk occurs with repeating the procedure, should symptoms recur at 12 to 18 months; radiofrequency facet denervation has a low initial risk of morbidity. Pulsed radiofrequency has yet to duplicate the results of traditional radiofrequency, and it is not a first-line therapy. Intra-articular steroid injections have not demonstrated benefit past approximately 2 weeks' duration.
- Range of motion exercises
- Independent home exercise program training
- Passive modalities have no proven role in the treatment of this entity.
- Enhance self-management skills
- Cognitive behavioral approach to spinal health
- Biofeedback/relaxation therapy
- Spinal fusion with facetectomy
- Possible role for disc replacement
Complementary and Alternative Medicine: No recommendations are specific for this disorder, but acupuncture and massage may be useful.
Prognosis: The natural history of facet arthropathy is continued pain and possibly eventual spontaneous fusion.
Issues for Referral: For patients with continued pain despite active treatment, referral to a pain management specialist capable of performing medial branch denervation is recommended.
Complications: Reduced range of motion, secondary myofascial pain, spontaneous fusion
- Aigner T, Dudhia J. Genomics of osteoarthritis. Curr Opin Rheumatol. 2003;15(5):634-640.
- Dreyfuss P, Baker R, Leclaire R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine. 2002;1;27(5):556-557.
- Dreyfuss P, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000;15;25(10):1270-1277.
- Kornick C, et al. Complications of lumbar facet radiofrequency denervation. Spine. 2004;29(12):1352-1354.
- Lord SM, et al. The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain. 1995;11(3):208-213.
- Lord SM, et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996;335:1721-1726.