Facet Joint Osteoarthritis and Facet Arthropathy Treatments

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

As with many of the conditions we see at our center, the initial diagnosis of Facet Arthropathy or Facet Syndrome can be confused with other problems or they can be MRI apparent, meaning the facet joint degeneration is on an MRI, but what is on the MRI is not the cause of the main pain.

This is a companion article to Prolotherapy treatments for lumbar instability and low back pain.

Summary topics of this article:

What are the facet joints?

Some of you may have heard of the term “facet joints” through the mention of “facet joint syndrome.” Perhaps you or a loved one has been diagnosed with this condition by your doctor, which essentially just means that the facet joints in your spine are causing pain. Facet joints are the small joints that connect one vertebra to the vertebrae below and above it and have been shown to be a significant generator of low back pain (and thoracic and neck pain as well). If these joints (that connect vertebrae together) suffer injury from trauma, whiplash, or poor posture, it seems reasonable to believe that they will no longer be able to hold the spine in the proper position, thus leading to instability. The typical treatment for this condition is steroid injections under x-ray guidance (fluoroscopy). This approach, however, has only temporary pain reducing effects, and long term studies have shown that steroids have a weakening effect of tissues, so this is not a good long term solution.

The facet joints are where the bones of the spine meet and connect to form the spinal column. Functionally, they are the joints that allow the spine to bend and twist. They also hold the spine in place so you do not “bend over backward.” The nerves of the spinal cord pass through these joints. If the fact joint is compromised or in a state of degenerative disc disease, the familiar numbness and pain extending into the arms (cervical radiculopathy) and legs (lumbar radiculopathy) can be seen.

Facet Joint Osteoarthritis

The above image features the causes of lumbar spinal stenosis. One cause as we will demonstrate in this article is instability in the facet joints. In the above illustration facet joint hypertrophy or bone spurs are shown. Bone spurs are a frequent result of spinal instability. Below we will address this problem by suggesting treatments to strengthen the spinal ligaments and possibly help avoid surgery.

What are we seeing in the below image?

The facet joint is at the rear of the vertebrae. The small arrows pointing away from each other in the first image and the small arrows pointing towards each other in the second image are at the point of the facet joints. What is that spring in the back? The spring represents forces.

Spinal force transmission, some people call strain on the back, is represented by the various motions of the spine. A flexion, bending forward causes the posterior or back portion of the disc to bulge outwards and the facet joint and the “tail” or protrusion of the vertebrae, the spinous process, to pull away from each other. The opposite happens with extension, bending backward. The same forces apply to banding to the side at the waist.

Spinal force transmission, some people call it strain on the back, are represented with the various motions of the spine. A flexion, bending forward causes the posterior or back portion of the disc to bulge outwards and the fact joint and the "tail" or protrusion of the vertebrae, the spinous process, to pull away from each other. The opposite happens with extension, bending backwards. The same forces apply to banding to the side at the waist.

The facet joints are then considered crucial stabilizers of the spine because they are involved with load transmission in the bending forward, bending backward, bending sideways movement of the spine. Together with the intervertebral disc, the facet joints transfer loads and prevent the spine from hyper-extension of hyper-flexion.

Facets have extra pressure placed on them for various reasons. If the discs are dehydrated or degenerated this will cause excessive pressure on the facets. Both the facets and the discs will have excessive pressure placed on them if the supporting structures of the lower back, primarily the facet ligaments and other ligaments that connect the vertebrae together because torn, stretched, and/or weakened. This can occur when a large force is applied to the lower back by an accident, fall, sports, or high velocity manipulation. Sometimes the ligaments just ‘wear out’ over time because of the lifestyle of the person (lots of activities) or their weight. The ligaments have to support the lower back and if a person is obese the pressure on the ligaments of the lower back are tremendous. People who are overweight have more chronic low back pain and I would speculate are more likely to get facet syndrome.

When the strong connective tissue that holds the facet joints in place, the spinal ligaments, are altered by injury, degeneration, or spinal surgery, the facet joints may no longer function in their role to keep the spine stable.

What to look for and how to treat Facet Syndrome

Let’s get an understanding shared among doctors of what to look for and how to treat Facet Syndrome and then let’s look at why these treatments may have not helped you and why the problems of ligament laxity causing spinal instability may have been overlooked and a simple solution to your problem may have then evolved into spinal surgery recommendations.

In the online publication StatPearls (1)  at the National Center for Biotechnology Information, U.S. National Library of Medicine, clinicians and researchers gave an update to disease recognition and treatment of Facet Syndrome in March 2021. Here are some of the learning points:

Comment: In these circumstances, your body reacts by thickening and stiffening the ligamentum flavum. The ligamentum flavum keeps your spine straight and you in an upright, shoulders back, postural correct position. At least that is what the ligamentum flavum is designed to do. When you have spinal degeneration and injury, including that of the ligamentum flavum, you start bending and curving over. This is why the ligamentum flavum is thickening and stiffening, it is trying its best to hold you upright. As it fails in this task, bone spurs develop to “naturally” fuse the spine, to prevent you from being stuck in a bent-over position or tilted. As you are well aware, the bone spur formation will ultimately fail, cause pain, and lead to surgical intervention.

The MRI may or may not show what is giving the patient their pain

Returning to the medical paper cited above, here the doctors discuss the difficulty in diagnosis. What we want to highlight here is what we have seen in almost three decades of helping people with cervical, thoracic, or lumbar spinal pain. The MRI may or may not show what is giving the patient their pain.

“It is often challenging to isolate facet joint disease as the sole cause of a patient’s complaint of neck or back pain. Imaging has not been proved to have much if any diagnostic validity. X-ray, CT, and MRI may show degeneration, joint space narrowing, facet joint hypertrophy, joint space calcification, and osteophytes (bone spurs); however, these findings may be present in both symptomatic and asymptomatic patients.

Data shows that 89% of patients in the 60 to 69 years of age population studied have facet joint osteoarthritis, although not all were symptomatic. Diagnostic medial branch blocks (if the nerve block decreases pain) are considered the gold standard approach to diagnose facet joint pain. A positive response to a set of 2 diagnostic blocks done on two separate occasions at two or more levels can confirm the source of pain. High false-positive responses are more likely to occur if only 1 level is blocked.”

Comment: It is easy to misinterpret or delay proper treatment while trying to identify what is happening in the patient’s spine. The MRI can show degenerative conditions in the fact joint but many people have no symptoms.

We cover this subject at length in our article Is your MRI or CT Scan sending you to a back surgery you do not need? In this article, we offer current research to suggest that in some or even many cases your MRI may be sending you to a spinal surgery you do not need.

The rush to surgery may be the rush to failed back surgery

In the above review paper and in our many years of experience in helping people with various spinal disorders we have seen patients who were told that surgery was the only way for them. After the surgery, they became one of the many failed back surgery syndrome patients we see. In our practice, we offer non-surgical treatments. Many times these treatments are successful in helping someone avoid surgery. In many of the medical papers surrounding spinal surgery, even the most successful procedures, doctors warn that surgery should only be the last answer after a failed program of conservative non-surgical treatments.

Let’s look at an April 2021 study published in the medical journal Clinical Spine Surgery. (2) Its focus is facet joint osteoarthritis as a leading cause of failed lumbar disk replacement surgery. The goal of this research study was to “analyze failure mechanisms after total lumbar disk replacement and surgical revision strategies in patients with recurrent low back pain. Here are the learning points, pay attention to the direct quotes.

The surgery to fix the problem:

Understanding the risks, the surgeons in this study devised a plan to perform a spinal fusion from the front. Of the study group, 41 of the 48 patients have anterior fusion. Seven of the patients had the disk replacement removed and fusion from the front and rear or posteriorly.

Why did the initial surgery fail and why was the frontal approach considered?

Conclusions: “Posterior osteoarthritis was the principal cause of recurrent low back pain in failed total lumbar disk replacement. The anterior approach for revision carried a major vascular risk, whereas a simple posterior instrumented fusion leads to the same clinical results.”

Comment: This is a very complicated surgical care case study. The cause of these problems was traced to facet joint osteoarthritis.

Treating the facet joints NOT the discs

A December 2022 paper in the Journal of craniovertebral junction and spine (x) discusses the various treatment options for patients with lumbar spinal degenerative disease, unresponsive to conservative therapy. As discussed, the most common treatment is surgical decompression and interbody fusion (removing the disc). The researchers suggest however, “Since facet joint incompetence has been suggested as responsible for the entire phenomenon of spinal degeneration, facet stabilization can be considered as an alternative technique to treat symptomatic spinal degenerative disease.” The researchers assessed previously published research on 1577 patient outcomes. The surgical techniques examined were:

The researchers found enough evidence to suggest that many patients did have pain relief and improvement in functional outcome by directing surgery at facet joint incompetence or failure as opposed to addressing problems with the disc.

Radiofrequency Denervation for Facet Joint Syndrome

Radiofrequency facet denervation is considered a minimally invasive procedure for patients with neck or back pain localized to the area of the facet joints. Radiofrequency facet denervation may also be called radiofrequency neurotomy, Radiofrequency ablation (RFA) or radiofrequency rhizotomy, or simply RFD. Many people do find success with this treatment in the short term. In this procedure, a needle is guided by an X-ray called fluoroscopy to the targeted pain-causing nerve. An anesthetic or numbing agent is then injected at the nerve site. The needle is then heated to stop the nerve from sending off pain signals. The treatment is then burning out the nerves that report pain, it is pain management, not a reparative treatment. For some people, however, pain management is what they are seeking.

In a 2021 study, (3)  researchers investigated the effect of the radiofrequency denervation procedure on pain and quality of life in forty-seven patients with facet joint syndrome and unresponsive to traditional treatments of bed-rest, physical therapy, and intra-articular steroid injection. The researchers here wrote ” denervation with radiofrequency appears to be an effective method. At least two levels must be performed for the procedure to be successful. Studies have shown that pain decreases in the long term (6-12 months) and quality of life increases.”

Radiofrequency ablation (RFA)

A February 2021 study from the Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia published in the journal Pain Medicine (4) wrote: “Radiofrequency ablation (RFA) has previously been demonstrated to provide long-term functional improvement in approximately 50% of patients, including those who had significant pain relief after diagnostic medial branch block.” Examining active-duty military patients who underwent lumbar Radiofrequency ablation (L3, L4, and L5 levels) over a 3-year period found that military personnel who had greater functional problems and more pain would likely get improvement from Radiofrequency ablation as recorded at six months follow-ups.

Ozone facet joint injections

In our article The use of Ozone in Chronic Joint Pain, we pointed out the benefits of using ozone gas or oxygen-ozone injection treatments that have been reported in medical research. While we do not utilize this therapy we do understand that many people have derived benefits from ozone. Why do we not use this treatment? In nearly thirty years of providing regenerative injection injections, we have had the opportunity to assess many treatments. Clinical observation and patient outcomes indicate for many treatments that their effectiveness was no better than treatments that we were already providing and the treatments themselves did not fill a need some of our patients may have had in their difficulty to treat joint pain.

A December 2021 paper from the University of Rome published in the journal Medical Gas Research (5) suggested: “oxygen-ozone (O2–O3) therapy is becoming an effective treatment option for musculoskeletal disorders and it could be an (effective) and valid alternative to traditional facet joint interventional treatments. Unlike traditional fluoroscopic or computed-tomography-guided procedures that are associated with radiation exposure, scarce availability, and high costs, the ultrasound-guided oxygen-ozone (O2–O3) is not expensive and easily available, without radiation exposure. The oxygen-ozone (O2–O3) mechanism of action has not been fully understood; however it would seem to attenuate inflammatory responses . . .  (In other words, it acts as an anti-inflammatory).

What are we seeing in this image? The concept that the ligaments are the spine is important in spinal instability.

Later in this article, we will discuss treatments for the spinal ligaments. In this image let’s focus on what is happening to the right of the image for now as this article deals with facet osteoarthritis. However, this is not to minimalize the importance of the anterior or front of the spinal ligaments. All the ligaments of the spinal complex work in harmony together.

In this image we see:

A Eureka moment by Japanese and American researchers linking spinal ligament weakness to degenerative spinal conditions

A team of researchers from Kyoto Chubu Medical Center and Rush University in Chicago wrote of the problems in treating lumbar stenosis and spondylolisthesis (the vertebrae has slipped forward out of place and is causing pain and pressure in your spine), in the medical journal Clinical Spine Surgery (6).

They took 50 patients with lumbar spinal canal stenosis involving the L4/5 segment and divided them into 2 groups: with degenerative spondylolisthesis; 12 male, 14 female; average age 74 years old; and without degenerative spondylolisthesis; 15 male, 9 female; average age 70 years old.).

What were the doctors trying to do?

What did the doctors find?

What did this mean?

The conclusion? Treat the spinal ligaments before the situation gets worse. 

Spinal Instability leads to Bone Spurs

An August 2020 study in the Journal of Orthopaedic Surgery and Research (7) cited this paper and explained further that facet joint instability leads to a degenerative condition that causes spinal instability. eventual the body responds to this spinal instability by creating bone spurs to hold the spine in place. The person suffering from facet joint osteoarthritis then goes from hypermobility to hypomobility in the spine. The bone spurs have fused the spine together and are now causing their own issues. Here are the learning points of this paper.

Results:

What are we seeing in this image? Bone spurs

Bone spurs form when the body tries to naturally fuse weak areas or where there is instability and ligament laxity.

What are we seeing in this image? Bone spurs

How do you treat the spinal ligaments before the situation deteriorates to surgery? “Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments (surgery) can relieve pain but fail to preserve joint functionality.”

June 2018, published in the Annual Review of Biomedical Engineering, (8) listen to what researchers from University of California, Davis, Boston Children’s Hospital, Harvard Medical School, and the University of California, Irvine suggest:

What are non-invasive treatments for facet joint instability and pain?

The usual treatments you as a sufferer have likely been prescribed are the same ones usually discussed in research:

Facet joint treatment

There is often a great amount of confusion when it comes to facet joint treatment as a non-surgical treatment option for spinal pain.

To get these treatments to a higher degree of effectiveness, doctors may recommend the treatments in combination.

A January 2021 study in the journal Pain Research & Management (9) discussed what patients may expect with the steroid and medial branch block facet injections combination treatment.

“Medial branch nerve block and facet joint injections can be used to manage axial low back pain. Although there have been studies comparing the Medial branch nerve block and facet joint injections effects, a few studies have compared the therapeutic effects of both interventions combined with each separate intervention. This study aimed to compare the pain relief effect of Medial branch nerve block, facet joint injections, and combined treatment with Medial branch nerve block and facet joint injections in patients with axial low back pain.”

These injections and treatments can help some. Typically the patients we see at our center have had some degree of success with these treatments but the benefit was not long-lasting and a more permanent solution is being recommended.

A facet joint injection can be performed for one of two purposes.

Diagnostically, a small amount of anesthetic is injected into the facet joint near the area of pain. If pain relief results then the facet joint has been deemed the culprit of pain. Once the facet joint is pinpointed as the problem area, further injections of anesthetics and anti-inflammatory agents are injected to try to achieve more permanent pain relief.

A facet joint injection usually involves a patient lying on an X-ray table so that the physician can guide the needle placement using a fluoroscopic X-ray. A contrast dye is first injected so that the physician can confirm that the medication will go to the proper spot. Once proper placement is determined, the physician will inject the medication, usually an anesthetic and corticosteroid, into the facet joint.

Therapeutic injections into the ligaments supporting the facet joints

The facet joint or apophyseal joint helps to connect one vertebra to another vertebra. This joint connects the superior articular process of one vertebra with the inferior articular process of the other.  Capsular ligaments are part of the joint capsule that surrounds the facet joint.  The capsular ligaments join together with surrounding ligaments to provide stability to the joint. The capsular ligament is a very important structure and is key in the treatment of spinal pain and spinal instability, as these tiny ligaments hold the facet joint in place.  They also have nerve fibers that are associated with pain.

The facet joint and capsule have been demonstrated in various studies as the site of pain following injury to the spine.  Abnormal movement in the facet joint during such forceful conditions as that which occurs in whiplash plays a role in the production of pain. It is not unusual in these cases, for the capsular ligaments to exceed their physiologic range during these events, causing stretching and damage to these ligaments.

At Caring Medical, we have successfully treated the facet joints and the capsular ligaments with Prolotherapy.

Generally, an injury to the spine will cause damage to the facet joints and capsular ligaments at various levels of the spine. For this reason, Comprehensive Prolotherapy would be required in order to treat all injured areas. Prolotherapy to the facet joints and capsular ligaments will help the body to stimulate the repair of the damaged ligaments. When the capsular ligaments are strengthened, the joint will become stable, and the pain will go away.

In one research study, doctors showed a 63% improvement in patients receiving Prolotherapy following diagnostic block injection for sacroiliac joint pain had improved at six months, compared to 33% who had intra-articular corticosteroid. Further,  sacroiliac prolotherapy showed good long-term outcomes at one year. (10)

At one week after treatment, low back pain reduced significantly

Patients were followed up immediately, at one week, one month, 2 months, and 3 months following treatment, and progress was measured with a series of standardized scoring systems.

In the short-term period of 3 months, the new technique of lumbar facet joint injection with autologous PRP is effective and safe for patients with lumbar facet joint syndrome.

Our December 2021 paper – Prolotherapy and PRP for facet joint pain

In December 2021 we published a review study (an examination of previously published studies) in the Journal of Back and Musculoskeletal Rehabilitation. (11) Below are a few of the research papers we commented on:

2005 single-blind, randomized, crossover study was published in the journal Pain Physician (12) which evaluated the effectiveness of Prolotherapy in 35 patients diagnosed with enthesopathy (these are painful conditions caused by the ligament or tendon attachment to the bone).

In this study, 86% of patients had already had spinal surgery and were considered failed back surgery patients.

After Prolotherapy Treatment

Sustained pain reduction

A 2006 study published in the journal Pain Medicine (13) cited in our 2021 paper demonstrated Prolotherapy injections sustained pain reduction in patients who suffered from chronic advanced degenerative discogenic leg pain, with or without low back pain, including those with moderate to severe disc degeneration. Patients underwent bi-weekly disc space injections of a solution consisting of 50% dextrose and 0.25% bupivacaine in the affected disc(s). Each patient was injected an average of 3.5 times. Overall, 43.4% of patients achieved sustained improvement as shown by average changes in numeric pain scores of 71% between pretreatment and 18-month measurements. The authors concluded that intradiscal injection of hypertonic dextrose has promise as a treatment for managing the pain of advanced lumbar disc degeneration.

In a 2016 retrospective case (14) series of 21 patients with MRI-confirmed lumbar disc degeneration and non-responding to treating low back pain/non-radicular low back pain, 18 (86%) of patients experienced 70% or greater improvements in pain and function at 1-year follow up. Patients underwent 3 Prolotherapy treatment sessions at 1–3 weeks apart, which included injections at the ligamento-periosteal junctions at the origin and insertion of the posterior sacroiliac ligaments, iliolumbar ligaments, facet joint capsules, and supraspinous and interspinous ligaments (all bilaterally). Injections were done under fluoroscopic guidance.

A small case series of 4 patients (15) with low back pain also proved successful in treating those with disc herniations with prolotherapy. Patients underwent 3–9 prolotherapy sessions to the ligaments of the low back (almost all 1 month apart) with all patients experiencing 95–100% pain relief and increase in function, including the ability to return to work.

PRP treatments

In the medical journal Pain Physician, doctors wrote of “A New Technique for the Treatment of Lumbar Facet Joint Syndrome Using Intra-articular Injection with Autologous Platelet Rich Plasma.”(16) In this research, they looked at 19 patients with lumbar facet joint syndrome (8 men, 11 women between the ages of 38 and 62) who received lumbar facet joint injections with autologous PRP under x-ray fluoroscopic guidance.

In a follow-up study led by the same lead author, a group of 46 patients (17) were treated with facet joint injections using either PRP or anesthetic and corticosteroid. At the 1-month mark, 80% of subjects in the corticosteroid group were satisfied with the results of the procedure, but this declined to between 20% and 50% after 6 months. Conversely, the subjects in the PRP group had an increase in satisfaction over time, leading the authors to conclude that PRP was the superior treatment. As the facet joint capsular ligaments loosen, the spinal segments begin to flex (bend forward) more, though imperceptibly to us, when a person leans forward, sits, or lifts. Over time, this results in several possible adaptations, the first of which is disc degeneration.

In a 2017 paper in the journal Pain Practice (18) one randomized, controlled trial of PRP versus corticosteroid injection, 90% of subjects treated with PRP to the sacroiliac joint were satisfied at the 3-month follow-up compared with only 25% of those who were treated with the steroid. The researchers concluded “Despite the widespread use of steroids to treat sacroiliac joint pain, their duration of pain reduction is short. Platelet-Rich Plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.”

A January 2022 study published in the journal Regenerative Medicine (19) evaluated the use of a multitarget (similar to our approach as demonstrated in the video) platelet-rich plasma (PRP) injection approach for the treatment of chronic low back pain.

A 2019 study (20) from the Irkutsk State Medical University found that among forty-nine patients, average age 39.5 who were diagnosed with isolated facet syndrome and received PRP therapy that “PRP therapy is a highly effective method for treatment of patients with isolated facet syndrome caused by degenerative diseases of the facet joints. Clinical efficacy is confirmed by the persistent significant reduction of pain symptoms and restoration of functional status in the early and late postoperative periods with low risks of adverse outcomes.”

Summary

Typically people with chronic low back pain show degenerative changes in their vertebrae on x-rays. When the pain is primarily located at a specific attachment of two vertebrae, which is the facet joint, the person is said to have facet syndrome. The person with such a condition will typically have localized pain over the facet with bending to that side.

In our experience, Prolotherapy injections may provide a better option for carefully selected patients with Facet Syndrome. Prolotherapy to the facet joints, their surrounding ligaments, vertebral segments, and other structures of the lower back causes these areas to strengthen. Once the ligaments are repaired and strong, the pressure on the facets decreases. Once this happens the pain of facet syndrome is typically eliminated. Because Prolotherapy stimulates the repair of the structures that led to facet syndrome it may make the most amount of sense to have it as a first line treatment for facet syndrome.

Questions about our treatments?

If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

 

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References

1 Curtis L, Shah N, Padalia D. Facet Joint Disease. StatPearls [Internet]. 2020 Apr 20. [Google Scholar]
2 Schmitz A, Collinet A, Ntilikina Y, Tigan L, Charles YP, Steib JP. Revision Surgery of Total Lumbar Disk Replacement: Review of 48 Cases. Clinical Spine Surgery. 2021 Apr 1. [Google Scholar]
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9 Seo JH, Baik SW, Ko MH, Won YH, Park SH, Oh SW, Kim GW. Comparing the Efficacy of Combined Treatment with Medial Branch Block and Facet Joint Injection in Axial Low Back Pain. Pain Research and Management. 2021 Jan 7;2021.
10 Chakraverty R, Dias R. Audit of conservative management of chronic low back pain in a secondary care setting–part I: facet joint and sacroiliac joint interventions. Acupunct Med. 2004 Dec;22(4):207-13. [Google Scholar]
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20 Byvaltsev VA, Kalinin AA, Okoneshnikova AK, Satardinova EE. Analysis of the clinical efficacy of platelet-rich plasma therapy in the treatment of patients with isolated facet-syndrome of the lumbar spine. Zhurnal nevrologii i psikhiatrii imeni SS Korsakova. 2019 Jan 1;119(11):27-31. [Google Scholar]
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This page was updated January 1, 2022

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