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:
- As you may have been told by your doctor, surgeon, or neurologist your Facet Syndrome diagnosis and the cause of your spinal pain is a degenerative disease, spondylosis, with its cause in wear and tear osteoarthritis. Facet syndrome describes pain from the facet joints.
- Some of you may have had old injuries, from sports, car accidents, etc, that caused post-traumatic osteoarthritis.
- Some of you may have had a prior spinal surgery that is now causing pain and pressure at points above and below and fusion surgery.
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.
- “Several reports indicate that total lumbar disk replacement revision surgery carries a major risk and that it should not be recommended.”
- Comment, if the disc replacement fails, surgery to fix the problem carries more risk
- This study followed 48 patients who continued to have low back pain following their total lumbar disk replacement. The average age of the patient was 39. The youngest being 24, the oldest being 61. The patients of this study were followed between two and ten years.
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?
- “Facet joint osteoarthritis was associated with total lumbar disk replacement failure in 85%.
- In 68% the position of the prosthesis was suboptimal. (The disk was not put in right).
- Range of motion was preserved in 25%, limited in extension in 65%, and limited in flexion in 40%. Limited range of motion and facet joint osteoarthritis were significantly related.
- The complication rate in the seven patients who had disk removal and frontal and rear fusion procedure was 43%
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:
- The intertransverse ligament helps limit sideward or lateral extension.
- The interspinous ligament connects the spinous process or back of the vertebrae to the spine. It helps limit bending over too far.
- The capsular ligament. The capsular ligament draws special attention from us as not only does it provide overall stability to the spine, it is also thought to be a prime pain generator because of its rich supply of nerves.
- The ligament flavum, highlighted in green. As mentioned above, when the spine is unstable, this ligament will try to hold the spine together by thickening and stiffening. Seeing the placement of the ligament flavum deep in the spine gives a good understanding of why this ligament would try to turn itself into a supportive fusion-type rod.
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?
- They wanted to clarify for other doctors the influence of facet joint osteoarthritis on the development and advancement of degenerative spondylolisthesis.
- This they suggested would help their fellow doctors develop a treatment to prevent the progression of degenerative spondylolisthesis in patients with lumbar spinal canal stenosis associated with degenerative spondylolisthesis.
What did the doctors find?
- Progressive, worsening facet joint osteoarthritis was found in the degenerative spondylolisthesis.
What did this mean?
- The doctors were able to pinpoint that degenerative spondylolisthesis, the unnatural movement, and rotation of the vertebrae were caused by the degenerative condition of the facet joint.
- The degenerative condition of the facet joint was also caused by unnatural movement and unnatural position of the vertebrae.
- This unnatural, degenerative motion and the related pressure and pain it caused, was in fact caused by “ligament laxity” due to facet joint osteoarthritis that affects spinal segmental motion.
The conclusion? Treat the spinal ligaments before the situation gets worse.
- To quote the research: “We consider that a treatment method based on facet joint osteoarthritis would be useful for treating patients with degenerative spondylolisthesis.”
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.
- Thirteen male and 21 female patients with facet-joint degeneration at the L3-S1 spinal region were included in the study.
- The L3-S1 lumbar segments of all the patients were divided into 3 groups according to the degree of facet-joint degeneration (mild, moderate, or severe).
- The ranges of motion (ROM) of the vertebrae were analyzed, during functional postures, the ROMs were compared between the 3 groups at each spinal level (L3-L4, L4-L5, and L5-S1).
- Degeneration of the facet joint alters the ROMs of the lumbar spine. As the degree of facet-joint degeneration increased, the ROMs of the lumbar vertebra that had initially increased declined. (Spinal instability replaced by the fusion effect of the bone spurs).
- However, when there was severe facet-joint degeneration, the ROMs of the lumbar spine declined to levels comparable to the moderate group. (In other words, the bone spurs could only do so much. They were failing to hold the spine together.)
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.
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:
- Along with the intervertebral disc, the facet joint (zygapophyseal joint) supports spinal motion and aids in spinal stability. Highly susceptible to the early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current non-invasive treatments cannot offer long-term pain relief, while invasive treatments (surgery) can relieve pain but fail to preserve joint functionality.
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:
- Pain medication in the form of anti-inflammatories and/or muscle relaxants.
- Physical exercise and therapy. Why these treatments may not have been effective for you is covered in our article: Why physical therapy and yoga did not help your low back pain.
- Eventually, epidural and steroid injections come into play.
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.
- Some think facet joint treatment is an injection of steroids injected directly into the facet joint.
- A Medial branch block facet injection is given around the facet joint so it can reach the nerves that are sending pain signals and thereby “block” the message.
- In fact, some patients are routinely given the choice of facet joint injections or Radiofrequency neurotomy. This is where heat generated by radio waves is targeted to damage specific nerves and interfere with their ability to send pain signals to the brain.
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.”
- In this study 66 patients (33 Medial branch nerve block patients, 17 facet joint injections, and 16 patients who got both.)
- All the patient groups showed significant post-treatment improvements.
- There was no added benefit of combining the treatment.
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.
- One purpose is diagnostic in that it confirms or denies that the facet joint is the cause of back pain or neck pain.
- The second purpose is therapeutic in treating the facet joints.
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.
- At one week after treatment, low back pain reduced significantly
- The outcomes were assessed as “good” or “excellent” for 9 patients (47.37%) immediately after treatment,
- 14 patients (73.68%) at one week,
- 15 patients (78.95%) at one month
- 15 patients (78.95%) at 2 months,
- and 15 patients (78.95%) at 3 months.
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.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This page was updated April 14, 2021