Facet Joint Osteoarthritis and Facet Arthropathy Treatments

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

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.

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 and 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.

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.

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.

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 (3).

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 (4) 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, (5) 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 (6) 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 is 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 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. (7)

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

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.”(8)

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.

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. (9)

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.

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections. Offices are located in Oak Park, Illinois and Fort Myers, Florida.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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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]
3 Kitanaka S, Takatori R, Arai Y, Nagae M, Tonomura H, Mikami Y, Inoue N, Ogura T, Fujiwara H, Kubo T. Facet Joint Osteoarthritis Affects Spinal Segmental Motion in Degenerative Spondylolisthesis. Clinical spine surgery. 2018 Jun. [Google Scholar]
4 Yin J, Liu Z, Li C, Luo S, Lai Q, Wang S, Zhang B, Wan Z. Effect of facet-joint degeneration on the in vivo motion of the lower lumbar spine. Journal of Orthopaedic Surgery and Research. 2020 Dec;15(1):1-9. [Google Scholar]
5 O’Leary SA, Paschos NK, Link JM, Klineberg EO, Hu JC, Athanasiou KA. Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration. Annual review of biomedical engineering. 2018 Mar 1(0). [Google Scholar]
6 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.
7 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]
8 Wu J, Du Z, Lv Y, Zhang J, Xiong W, Wang R, Liu R, Zhang G, Liu Q. A new technique for the treatment of lumbar facet joint syndrome using intra-articular injection with autologous platelet rich plasma. Pain physician. 2016 Nov 1;19(8):617-25. [Google Scholar]

This page was updated April 14, 2021

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