Low back pain and facet joint disruption
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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Bones of the spine articulate in front by intervertebral discs and in back by paired facet joints.
Facet joints are synovial joints with a joint space, hyaline cartilage covering, a synovial membrane, and a fibrous capsule.
Nociceptive substance P immunoreactive nerve fibers and autonomic nerves have been identified in the lumbar facet joint capsule.
The presence of nociceptive nerve fibers in the various tissue structures of facet joints and the presence of autonomic nerves indicate pain may occur under increased or abnormal loads. Substance P is an inflammatory mediator that may sensitize nociceptors, resulting in chronic pain.
Prostaglandin, a known inflammatory mediator, also is released from facet joints.
Facet joints assume an important role in resisting stress. The facet joints resist most of the intervertebral shear force and share in resisting the intervertebral compressive force
Facet joints are loaded maximally in extension of the spine. The joints are unloaded during flexion but the capsular ligaments are loaded.
The facet joint is a possible source of chronic LBP. Pain upon stresing of the joint, relief upon anesthetization of the same joint, and chronic LBP in patients with facet issues have been documented. LBP of facet joint origin is worse with extension and rotation of the spine.
Facet capsular ligaments are strained during spinal rotation.
There are certain clinical features that suggest facet disease. These signs include the following:
Groin or thigh pain
Well-localized paraspinal tenderness
Pain reproduced by extension and rotation, usually toward the symptomatic side
Microtrauma of the facet joints can produce pain.
Osteoarthritis is another cause of lumbar facet joint pain; however, not all facet arthritis is painful, as x-ray changes of osteoarthritis are equally common in patients with and without LBP. In general, severely degenerated joints are more likely to be symptomatic.
No specific lab studies are necessary when a diagnosis of lumbar facet arthropathy is considered.
Abnormalities on plain films, CT scan, and MRI are not specific for patients with back pain; degenerative changes often are found in asymptomatic persons. MRI, CT scan, and dynamic bending films do not predict lumbar facet joint pain reliably.
Use of diagnostic blocks is important to diagnosis of lumbar facet joint pain. No matter what the symptoms, one characteristic that all patients with facet syndrome have in common is relief of pain from injection of a local anesthetic. Pain relief with fluoroscopically guided blocks of the joints correlate with facet joint induced pain.
Once diagnosis of facet joint pain is confirmed and pain is brought under control, physical therapy for reconditioning and lumbar stabilization exercises is recommended.
Currently, no surgical intervention is advocated for lumbar facet joint pain.
Once diagnosis of facet-mediated pain is demonstrated, various treatments besides physical therapy can be started. These include oral nonsteroidal anti-inflammatory drugs (NSAIDs).
Steroids and/or local anesthetic can be injected into the joint to alleviate joint inflammation. The dorsal medial nerve branch that innervates the joint can be ablated through use of radiofrequency to block all sensory input from the joint. A third treatment is surgical fusion of the joint, but no published reports of such treatment exist.
As with any condition affecting the back, patients need to have a good understanding of proper body mechanics and back safety techniques to prevent worsening of symptoms.
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