Evaluating facet arthritis pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The spine is made up of 24 bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column.
The facet joints are located on the back of the spinal column and help the vertebra interact. Articular cartilage covers the surfaces where the joints meet. Just as with other joints in the body that are covered with articular cartilage, the lumbar facet joints can be affected by arthritis.
The lumbar facet joints can be a source of significant low back pain.
The back portion of the spinal column forms a bony ring. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, the spinal canal, surrounds the spinal cord as it passes down through the spine from the brain.
Normally, the facet joints fit together and glide smoothly. With arthritis, cartilage on the joint surfaces wears away.
Each segment in the spine has three primary areas of articulation: the intervertebral disc in front and the two facet joints in the back. Injury or problems in any one of these structures affects the other two. As a disc thins with aging and from wear and tear, the space between two vertebrae shrinks.
Extra pressure on the facet joints causes the development of bone spurs. Also, the articular cartilage wears away and the underlying bone is exposed. The joint becomes inflamed, swollen, and painful.
Pain from facet joint arthritis is usually worse after resting or sleeping. Also, bending the trunk sideways or backward usually reproduces pain on the same side as the arthritic facet joint.
Pain may be felt in the center of the low back and can spread into one or both buttocks. Sometimes the pain radiates into the thighs, but it rarely goes below the knee. Numbness and tingling, symptoms of nerve root compression, are usually not present because facet arthritis generally causes mechanical pain which is pain.
However, symptoms of nerve compression can sometimes occur in addition to the pain from facet arthritis. Bone spurs may form in the opening where the nerve root leaves the spinal canal. This opening is called the neural foramen. If the nerve root is irritated upon exiting, the nerve can become inflamed and irritated. Resulting symptoms include numbness, tingling, abnormal reflexes, and muscle weakness.
A diagnosis starts with a history and physical examination.
X-rays can show if there are abnormalities in the vertebrae near the facet joints.
An MRI gives a clearer picture of the facet joints to see whether they are enlarged or swollen.
A computed tomography (CT) scan may be ordered adn provides good bony detail.
A diagnostic injection may be used to locate the source of pain. The doctor uses a needle to inject a local anesthetic into the joint. Fluoroscopy, real-time X-ray, is used for needle guidance. Conversely, diagnostic ultrasound can also be used and since it does not use radiation, may be preferable to fluoroscopy. Once the doctor is sure the needle is in the right place, the medicine is injected. The results from the injection help the doctor make the diagnosis. If pain goes away, it helps confirm the source of pain.
A short period of rest to reduce inflammation and pain may help. Patients may find added relief by curling up to sleep on a firm mattress or by lying back with their knees bent and supported. These positions take pressure off the facet joints.
The doctor may also prescribe anti-inflammatory medications. Muscle relaxants are occasionally used to reduce muscle spasm.
Physical therapy is useful. The therapist may recommend traction. Traction is a common treatment for this condition. It stretches the low back. The therapist may also prescribe strengthening and aerobic exercises.
Spinal manipulation can sometimes provide short-term relief of pain from facet arthritis.
Radiofrequency ablation is a procedure where the nerve roots that are being irritated by the facet joint are "burned."This procedure is done at pain clinics.
People with facet joint arthritis rarely need surgery. After trying conservative measures, some patients may require surgery. There are several types of surgery for facet joint arthritis. The two primary operations are:
•posterior lumbar fusion
Rhizotomy is a surgical procedure in which a nerve is cut. Facet rhizotomy is a procedure where the small nerves that supply the facet joint are destroyed.
Posterior lumbar fusion is a surgical procedure where two or more vertebrae are joined together. This keeps the bones and painful facet joints from moving.
The surgeon places a graft of bone on the back of the spine. Many surgeons will also use metal plates and screws to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.
Clinical evaluation of intra-articular injections for lumbar facet joint pain.
Lau LS, Littlejohn GO, Miller MH.
Lumbar facet joint (LFJ) pain is a common cause of low back pain. Thirty-four consecutive patients with a clinical diagnosis of LFJ pain received injections of a local anaesthetic agent and a long-acting corticosteroid agent under radiological control. Nineteen patients experienced immediate lessening of their pain after the injection of local anaesthetic agent, their response supporting the clinical diagnosis. Twelve of these 19 patients experienced clinically significant relief of pain for more than six months. LFJ injection offers improved diagnosis and treatment of LFJ pain.Med J Aust. 1985 Dec 9-23;143(12-13):563-5.
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