Lumbar Facet Arthropathy

The lumbar zygapophysial joint, also known as the facet joint, is often the source of lower back pain. This particular joint connects the bottom of one vertebra (a bone in the spine) with the top part of the vertebra underneath it. The facet joint works like any other joint in your body – it has a protective layer of synovial membrane, cartilage, and is surrounded by a fibrous joint capsule. It also has a meniscoid structure, which is a little fold in the joint space.

What’s interesting about this joint is that it receives signals from two separate branches of nerves, originating from the backbone at the same level and one level above the joint. This dual innervation plays a huge role in determining its functioning and our perception of pain.

These facet joints carry out important tasks, like carrying loads, helping in supporting the back, stabilizing the spine when you bend or stretch, and preventing your spine from rotating excessively. In fact, studies suggest that the facet joint may support up to 25% of axial compressive forces (the downward force your spine experiences when you stand or sit) and 40% to 65% of rotational and shear forces (forces experienced by the spine when you twist or turn).

Facet joint arthrosis is a medical condition where the facet joints begin to fail. This starts with the breakdown of the cartilage in the joints, which then leads to the creation of erosions and a decrease in joint space, and eventually the hardening of the bone just beneath the cartilage. Factors that can increase the likelihood of getting this condition include being older, having a facet joint that is more vertically oriented, and also having degeneration in the intervertebral disk (the cushiony material between your spine’s vertebra).

Facet joint arthrosis is a condition where the facet joints in the spine wear down. This typically happens due to factors like age, obesity, poor body movements, overuse, and small, repetitive injuries. Many studies have shown that the wearing down of the discs between the vertebrae (intervertebral disk degeneration) often happens before facet joint arthrosis develops.

This could be because once these discs start to wear down, the facet joints have to bear more load, leading to their degeneration. Some studies have also pointed out that facet joints that are more vertically positioned are more prone to this condition.

The process of degeneration starts with the breakdown of hyaline cartilage, a rubbery tissue that covers the ends of the bones and reduces friction in joints. This leads to the formation of small breaks and the narrowing of the joint space, leading to sclerosis, or hardening of the subchondral bone (the layer of bone just beneath the cartilage).

Over time, the back part of the joint capsule (a protective sac) changes due to wear and tear, thickening and leading to the growth of fibrocartilage (a tough, resilient type of cartilage) and even possibly forming a synovial cyst (a fluid-filled sac or cavity). Bony outgrowths, known as osteophytes, are also likely to form where the fibrocartilage extends beyond the original joint space.

Pain in the facet joints happens due to these degenerative changes, since the whole joint is rich in nerve endings. Other possible causes for this pain include entrapment of the meniscoid (a crescent-shaped intraarticular lip) within the facet joint and impingement or pressure in the synovial fluid (a lubricating fluid within the joints).

The prevalence of lumbar facet-mediated pain, which is pain in the lower back, can vary greatly according to different studies. Some reports suggest less than 5% while others suggest over 90% of patients with back pain have this condition. These studies often use a mix of patient history, physical exams, and radiology, which can be unreliable in diagnosing this type of pain accurately. However, studies that follow the International Association for the Study of Pain’s criteria implicate the lumbar facet joint as the source of chronic lower back pain in 15% to 45% of patients.

Different factors are associated with the prevalence of lumbar facet arthropathy, a form of degenerative joint disease specific to the lower back. Age is a significant factor. Moderate to severe lumbar facet arthropathy was found in:

36% of adults under 45 years old
67% of adults from 45 to 64 years old
89% of adults 65 years old and over

Further, the condition is more likely in women over 50, and Caucasians are more likely to have it than African Americans. High body mass index (BMI) also contributes to the risk – a BMI of 25 to 30 triples the risk, whereas a BMI of 30 to 35 multiplies the risk by five.

Other risk factors include disc height narrowing, a sagittal orientation of the facet joint, and poor spinal extensors. The condition is most often found in the L4-5 and L5-S1 levels of the spine, compared to the L3-L4, L1-2 and L2-3 levels.

Lumbar facet joint pain is often indicated by chronic lower back pain that occurs without a clear reason. The specific characteristics of this pain can vary significantly from person to person, making it quite difficult to diagnose without some form of additional testing. However, some signs that might suggest the source of the pain is the facet joint are:

Localized pain in the back, which radiates in a non-specific pattern
Referred pain around the buttock and thigh, usually not below the knee
No numbness or weakness in the legs unless other related conditions, such as bony growths (osteophytes), large fluid-filled sacs (synovial cysts), or joint enlargement (facet hypertrophy) are present, which can interfere with the nerves
No bowel or bladder dysfunction, which would suggest other diagnoses

Upon examination, a patient with facet joint pain may have tenderness in the lower back area over the small bony protrusions on either side of the vertebrae (transverse processes) as well as the muscles alongside the spine (paraspinal muscles). Their pain may become worse when they extend or turn their spine. For standard neurological tests, such as those for sensation, muscle strength, and reflexes in the lower limbs, the results will normally be within average parameters. However, their lower limb strength might be less due to the pain.

One potential diagnostic test is the Kemp test (also known as the quadrant test and extension-rotation test). For this test, the patient performs a combined back extension and rotation, and if the test is positive, their pain will reoccur. However, this test has been found to lack precision as it’s only sensitive less than 50% of the time and specific less than 67% of the time.

Current research doesn’t advocate for the use of medical imaging as a routine way to identify facet-mediated pain, a common source of lower back discomfort. The most reliable method for diagnosing this type of pain is a procedure called an anesthetic block of the facet joint, which numbs this region to test if it’s the source of the pain.

However, medical imaging can still be valuable for ruling out other potential causes of lower back pain. These might include a herniated disk, spinal narrowing (stenosis), a slipped vertebra (spondylolisthesis), spinal joint inflammation (ankylosing spondylitis), overgrowth of skeletal tissue, infection, or cancer. It’s also common to find facet joint wear-and-tear alongside these other causes of lower back pain.

There are certain visible signs of facet joint arthrosis, or joint wear and tear, which can be detected through imaging. These may include narrowing of the space in the facet joint, erosion of the bone underneath the joint, cysts near the joint, bone spurs, and thickening of the joint process. Despite this, regular x-rays of the lower back have limited value as they should involve oblique views because facet joints are positioned at an angle. However, oblique x-rays can only positively identify facet joint disease with 55% accuracy and rule it out with 69% accuracy.

Although some studies suggest that MRI scans have over 90% accuracy in detecting facet joint degradation, others propose that MRIs are less accurate than CT scans in revealing the margin of the bony cortex. Therefore, CT scans are often the preferred imaging method to assess facet joint wear and tear due to their ability to show precise bony details and relatively lower cost than MRI. However, to rule out pain originating from non-facet sources, MRI is the superior diagnostic tool. Other imaging techniques, such as bone scintigraphy with SPECT, may be used to show bone areas of synovial changes and degenerative remodeling.

The most reliable diagnostic procedure for facet-mediated pain is the facet joint block, which has been recognized as a high-evidence method by the United States Preventive Services Task Force. Both injections into the facet joint and shots into the medial branch blocks have shown to be effective. However, both have their downsides. Studies have shown similar accuracy between fluoroscopy-guided and ultrasound-guided injections, although ultrasound is less accurate for overweight patients.

Facet joint injections involve injecting a local anesthetic directly into the tiny facet joint capsule. However, if more than 1 to 2 milliliters are injected, the capsule could rupture, spreading the anesthetic to other nearby structures that could be causing pain. On the other hand, the medial branch block involves applying local anesthetic to areas of the dorsal branches at the level of, and one level above, a given facet joint. A block is considered successful if it results in 80% or more pain relief. However, because the medial branch nerve affects many other local pain-causing structures, there’s a high rate of false-positive results, meaning the pain relief might not be due to the anesthetic block of the region which was assumed to be causing pain. To improve the accuracy, some suggest doing a double diagnostic block. However, this is rarely done due to risks such as patient drop-out, costs, and increased chances of complications.

Treatment for long-term lower back pain usually starts with simple remedies. This is also the case for back pain that comes from the small joints in your spine (facet joints), even when a diagnostic block (an anesthetic injection to confirm the source of the pain) hasn’t been carried out.

Physical therapy is key in treating long-term, lower back pain. It will typically include learning how to maintain a good posture, stretching, and exercises to strengthen your core muscles. Pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, are commonly recommended as the initial treatment for lower back pain. Additional medications – like antidepressants for long-term pain, or muscle relaxants for short term pain – have been shown to be effective, too.

If this initial treatment doesn’t work, patients may be given a diagnostic block. If this block is successful, more invasive treatment may be an option. Injections into the joint with steroids are an option; however this treatment is debatable, and some support their use. Other treatments that use heat or cold to interrupt nerve conduction to the joint are available too; although, these methods haven’t been thoroughly evaluated and often need to be repeated every 6 months to a year as the nerves can grow back.

Surgery is rarely an option for facet joint pain. Studies have shown that surgical intervention is only really considered in cases of serious injury. That being said, sometimes, the facet joints can cause bone growths, or large fluid-filled sacs, which can press on other structures around the spine leading to narrowing of the spinal canal (stenosis), pinched nerves (nerve root impingement), or shooting nerve pain (radiculopathy). In these cases, a surgical procedure that removes the facet joint (lumbar facetectomy) may be performed. This procedure is usually done in combination with another procedure that removes part of the vertebra to relieve pressure on the nerves (laminectomy). In some cases, a complete removal of the facet joint is required during a spinal fusion procedure, which joins two vertebrae together to restrict movement and reduce pain.

When a doctor is trying to diagnose lumbar facet arthropathy, they will consider a range of possible conditions that could be causing the symptoms. These can include, but are not limited to:

A herniated disc in the lower back (lumbar herniated disc)
Chronic pain resulting from a damaged disc (discogenic pain syndrome)
Nerve root irritation in the lower spine (lumbosacral radiculopathy)
Muscle spasm in the buttock area (piriformis syndrome)
Straining or spraining the muscles or ligaments in your back (paraspinal muscle/ligament sprain/strain)
Degenerative changes, fracture, or displacement of the spine bones (lumbar spondylosis/spondylolysis/spondylolisthesis)
Arthritis of the spine (rheumatoid arthritis and seronegative spondyloarthritis like ankylosing spondylitis or psoriatic arthritis)
Gout or pseudogout, which are types of arthritis caused by crystal deposits in the joints
Excessive bone growth throughout the skeleton (diffuse idiopathic skeletal hyperostosis)
Pain or dysfunction in the joint connecting the spine and the pelvis (sacroiliac joint dysfunction)
Pain in the connective tissue between the spine and the ribs (thoracolumbar fascia dysfunction)
Conditions like infections, cancer (neoplasm), or fibromyalgia

The occurrence of facet arthropathy, a condition that affects the joints in your spine, typically increases as you age. The first step in managing this condition is usually conservative treatments, such as physical therapy. If physical therapy doesn’t bring about improvement, a diagnostic block – a procedure where a local anaesthetic is injected into the affected joint – may be recommended.

A treatment known as radiofrequency neurotomy, which uses heat to help relieve pain, has been shown to be effective. This can reduce pain for 6 months to a year. If pain returns after this period, the procedure could be repeated.

Complications from facet interventions, which consist of treatments for joint pain, are typically few and far between. When patients receive steroid injections directly into the joint, there were no reports of any metabolic or endocrine side effects. However, it’s still possible for patients to experience disruptions to their body’s glucose levels and hormonal balance; but, there haven’t been any studies that confirm this yet.

In some rare instances, after receiving a joint steroid injection, a patient may develop an infection, illustrated by things like septic arthritis, an abscess near the spine, or meningitis. Moreover, there are additional complications such as spinal anesthesia and unintentional puncture of the outer layer of the spinal cord.

Meanwhile, with the radiofrequency neurotomy procedure- used to reduce nerve pain- the most frequently reported complication is neuritis- a form of nerve inflammation- which happens to roughly 5% of patients. There are other cases of patients experiencing temporary numbness or tingling sensations. In more unique situations, there have been reports of burns occurring as a result of electrical malfunctions during the procedure.

Common complications:

Disruptions in glucose levels and hormonal balance
Infections, such as septic arthritis, spinal abscess, or meningitis
Spinal anesthesia
Unintentional puncture of the outer layer of the spinal cord
Transient numbness or tingling sensations
Neuritis or nerve inflammation
Burns from potential electrical faults during treatment

Keeping away from facet arthropathy, a condition that involves wear and tear to the joints in the spine, can involve learning how to maintain proper posture. If your spine is aligned in the right way, it may help avoid this issue. Furthermore, if a person maintains a healthy weight, it may also reduce the chances of developing this health problem as obesity often leads to it. It’s a good idea to consider weight loss if you’re overweight. If you have been experiencing persistent back pain, seeking a professional opinion is recommended. This is because the reasons for chronic back pain can be many, and it’s imperative to get an exact diagnosis.

Frequently asked questions

Lumbar Facet Arthropathy is a medical condition where the facet joints in the lumbar spine begin to fail. It is characterized by the breakdown of cartilage in the joints, erosions, a decrease in joint space, and eventually the hardening of the bone beneath the cartilage.

Moderate to severe lumbar facet arthropathy was found in 36% of adults under 45 years old, 67% of adults from 45 to 64 years old, and 89% of adults 65 years old and over.

Some signs and symptoms of Lumbar Facet Arthropathy include: - Chronic lower back pain without a clear reason - Localized pain in the back that radiates in a non-specific pattern - Referred pain around the buttock and thigh, usually not below the knee - Absence of numbness or weakness in the legs, unless other related conditions are present - No bowel or bladder dysfunction, which would suggest other diagnoses Upon examination, a patient with Lumbar Facet Arthropathy may also exhibit the following: - Tenderness in the lower back area over the small bony protrusions on either side of the vertebrae (transverse processes) - Tenderness in the muscles alongside the spine (paraspinal muscles) - Worsening of pain when extending or turning the spine - Normal results for standard neurological tests, such as sensation, muscle strength, and reflexes in the lower limbs, although lower limb strength might be reduced due to pain One potential diagnostic test for Lumbar Facet Arthropathy is the Kemp test (also known as the quadrant test and extension-rotation test). However, this test has limited precision, being sensitive less than 50% of the time and specific less than 67% of the time.

Age, gender (more likely in women over 50), race (more likely in Caucasians than African Americans), high body mass index (BMI), disc height narrowing, sagittal orientation of the facet joint, and poor spinal extensors are all factors associated with the prevalence of Lumbar Facet Arthropathy.

A doctor needs to rule out the following conditions when diagnosing Lumbar Facet Arthropathy: - A herniated disc in the lower back (lumbar herniated disc) - Chronic pain resulting from a damaged disc (discogenic pain syndrome) - Nerve root irritation in the lower spine (lumbosacral radiculopathy) - Muscle spasm in the buttock area (piriformis syndrome) - Straining or spraining the muscles or ligaments in your back (paraspinal muscle/ligament sprain/strain) - Degenerative changes, fracture, or displacement of the spine bones (lumbar spondylosis/spondylolysis/spondylolisthesis) - Arthritis of the spine (rheumatoid arthritis and seronegative spondyloarthritis like ankylosing spondylitis or psoriatic arthritis) - Gout or pseudogout, which are types of arthritis caused by crystal deposits in the joints - Excessive bone growth throughout the skeleton (diffuse idiopathic skeletal hyperostosis) - Pain or dysfunction in the joint connecting the spine and the pelvis (sacroiliac joint dysfunction) - Pain in the connective tissue between the spine and the ribs (thoracolumbar fascia dysfunction) - Conditions like infections, cancer (neoplasm), or fibromyalgia

The types of tests that are needed for Lumbar Facet Arthropathy include: 1. Anesthetic block of the facet joint: This procedure numbs the facet joint to test if it is the source of the pain. 2. Medical imaging: Although not routine, medical imaging can be valuable for ruling out other potential causes of lower back pain. This may include X-rays, CT scans, and MRI scans. 3. Bone scintigraphy with SPECT: This imaging technique can show bone areas of synovial changes and degenerative remodeling. 4. Diagnostic blocks: Facet joint injections and medial branch blocks can be used to confirm the source of the pain. 5. Physical examination: A physical examination by a doctor can help assess the range of motion, muscle strength, and any signs of inflammation or joint abnormalities. It's important to note that the most reliable diagnostic procedure for facet-mediated pain is the facet joint block, which has been recognized as a high-evidence method.

Lumbar Facet Arthropathy is typically treated with a combination of non-surgical methods. The initial treatment usually involves physical therapy, including exercises to strengthen core muscles and improve posture. Pain medications, such as NSAIDs and acetaminophen, may also be recommended. If these treatments are not effective, a diagnostic block may be performed, followed by more invasive treatments such as injections into the joint with steroids or treatments that use heat or cold to interrupt nerve conduction. In rare cases, surgery may be considered, which may involve removing the facet joint (lumbar facetectomy) or performing a spinal fusion procedure.

The side effects when treating Lumbar Facet Arthropathy may include disruptions in glucose levels and hormonal balance, infections such as septic arthritis, spinal abscess, or meningitis, spinal anesthesia, unintentional puncture of the outer layer of the spinal cord, transient numbness or tingling sensations, neuritis or nerve inflammation, and burns from potential electrical faults during treatment.

The prognosis for Lumbar Facet Arthropathy can vary depending on the individual and the severity of the condition. However, conservative treatments such as physical therapy are usually the first step in managing this condition. If physical therapy does not bring about improvement, a diagnostic block or radiofrequency neurotomy may be recommended, which have been shown to be effective in reducing pain for 6 months to a year.

You should see a doctor specializing in pain management or a spine specialist for Lumbar Facet Arthropathy.

Back Pain Degenerative Disc Disease Joint Muscle and Bone Normal Aging Process Obesity