What is facet joint pain
Facet joints, also known as zygapophysial joints, are paired joints that lie more to the back of the spinal column, providing the rear connection between adjacent vertebrae. Although small, they are typical of most other joints of the body, in that they are lined with cartilage and are coated with a lining of joint fluid (called synovial fluid), which is contained within a joint capsule.
These joints are supplied by a nerve supply, and thus, when the joint is damaged or inflamed, it can produce pain. Whilst the stability of an inter -vertebral joint is provided mainly by the disc, the facet joints are also essential for stability, particularly if the disc has degenerated.
Cervical spine
The cervical spine consists of seven cervical vertebrae, called C1 to C7. The C1 vertebra is also called the atlas, as it supports the head. The skull is composed of many different bones, and the occiput is the bone at the base of the skull that connects to the vertebral column. The first joint in the spine is therefore called the occipito -atlantal joint. Using easier terminology, the occiput is notated by its first letter (‘O’), and the atlas is known as C1. The joint can be called the O/C1 joint. The second intervertebral joint in the spine is the C1/C2 joint. Both the O/C1 and C1/2 facet joints are very different from the other joints in the spine; they are less accessible, and have quite different nerve supplies to all the other facet joints. Pain from the cervical spine facet joints most commonly comes from the C2/3 level (neck pain with headaches) and the C5/6 joints (lower neck pain spreading to the shoulder and scapula).
Thoracic spine
The thoracic spine consists of 12 thoracic vertebrae, called T1 to T12, the lowest of which lies above the first lumbar vertebra, forming the T12/L1 intervertebral joint. Thus, the disc at that level is called the T12/L1 disc, and the paired facet joints are known as the T12/L1 facet joints. The most superior vertebra (the highest) is called T1. It forms a joint above with the lowest cervical vertebra, forming the C7/T1 intervertebral joint.
Lumbar spine
The lumbar spine is composed of five lumbar vertebrae, called L1 to L5, the lowest of which (L5) lies upon the sacrum, called S1. Each vertebra body is joined at either side by a disc, and the arches of the vertebrae are joined by facet joints on each side. The lowest two facet joints, the L4/5 and L5/S1 facet joints are the most common source of facet joint pain. They can produce back pain with or without leg pain that is typically felt in the buttock, and down the leg as far as the foot.
How can a facet joint cause pain?
As mentioned above, the facet joint has articular cartilage, which can be damaged by injury and other processes, and a nerve supply. Thus, it can be painful. Facet joint injuries most commonly occur in association with trauma, particularly direct falls. In these events the articular cartilage can be damaged. As articular cartilage does not heal at all well, the joint can remain painful. The most common mechanisms of facet joint pain are trauma, including motor vehicle accidents and falls, and ‘degenerative’, where the onset tends to be later in life and more insidious.
In the cervical spine the most common cause of facet joint pain is trauma.
Typical mechanisms include:
- whiplash mechanisms in motor vehicle accidents and;
- blunt trauma to the head (such as a person hitting his/her head on an overhead object). Anatomical studies have shown that these mechanisms do cause facet joint damage, as well as damage to other structures including discs and nerves.
Sometimes facet joint injuries occur over time. In these presentations the onset is typically slow and perhaps progressive.
When will I recover?
Facet joint pain can present as an acute attack of pain, or, in a more chronic and insidious fashion. In many cases, the pain associated with the acute attacks disappears. However, those with more chronic facet joint pain may continue to experience pain and may not fully recover. It is not possible for a practitioner to confidently predict what will happen in the long term. However, in general pain does improve with time, and total recovery is also possible.
How is facet joint pain diagnosed?
Can the diagnosis be made by a clinician without recourse to special tests? The answer is no. However, there are certain factors that suggest facet joint pain.
Studies have shown that facet joint pain refers typically into the head, shoulder, upper back and chest. The pain is well localised into these areas. Pain spreading into the head, even into the eyes, can come form the upper neck, especially form the C2/3 joint. Pain spreading into the upper back tends to come from lower down, typically the C5/6 joint. Facet joint origin pain spreading to the shoulder can mimic shoulder injuries; thus, care needs to be made in assessment in determining whether a pain in this region is referred from the shoulder or neck structures.
The diagnosis is further complicated because x -rays, CT scan, bone scan and MRI cannot establish whether or not a facet joint is the source of pain. How then is the diagnosis made? The only methods involve the use of x -ray controlled injection of anaesthetic either into the joint itself or onto the nerve supply of the joint. This is referred to as a medial branch block. The question that needs to be asked concerning the injection is: “does the anaesthetic eradicate the pain”? If it does, then the pain is likely to derive from the joint. This is a simple process when the patient has persistent pattern of pain. Then the patient is in a position to adjudicate the extent to which the anaesthetic injection relieves the pain, and the duration of the response.
A problem arises when the pain is not always present, as the pain may change spontaneously after the injection, and not be the result of the anaesthetic injection. This would be a false positive response. In such instances, a diagnostic anaesthetic injection would not be worth performing. As an alternative, a facet joint injection might be performed with cortisone, and temporary recovery suggests but does not prove facet joint pain.
What should I be doing with my facet joint injury?
There are no proven preventative measures that are specific for facet joint pain. However, evidence and common sense suggest the following to be good practice:
- During an acute attack, try to start exercising and stretching as early as possible
- Excess rest leads to prolonged disability
- Assess and change your ergonomics (work and home life)
- Keep active – find activities that do not exacerbate your pain following the exercise
- Pool exercise can be beneficial if the pain is severe.
The pain sometimes goes down my arm – how does that come from the neck?
Arm pain can occur because of referred pain. In facet joint problems the pain tends to be worse in the neck than in the arm. However, pain from facet joints can travel all the way to the hand. The other type of pain, which is nerve pain, tends to concentrate more in the scapula region and the arm, and is thinner and shooting in quality. This problem is often associated with numbness or tingling into the hand and a number of fingers.
Will I need surgery for my facet joint injury?
Chronic facet joint pain can usually be treated with either an intra -articular injection or with radiofrequency neurotomy (RFN). There is good evidence that RFN is the superior option. Rarely is surgery required.
[For related information see also: Radiofrequency Neurotomy Case Study .]
Once I have had a facet joint injury - will it always be a problem?
Not necessarily. The facet joint pain can fully resolve and heal. However, if it does not, repeat radiofrequency neurotomy treatments may be relevant. Exercise systems to prevent recurrence have been devised and may help.
Do I need to get a scan to show my facet joint injury?
X -rays and CT Scans may be useful for facet joint pain especially to ascertain if there is local bone pathology such as a fracture. In the acute situation, the diagnosis is made purely on clinical presentation. However, in the chronic situation, medial branch blocks or facet joint injections are required to make the diagnosis. The decision to have scans is one that you and your primary care physician and/or specialist will make depending upon circumstance. Such tests are generally required to exclude other pathology, and thus, do not aid in the diagnosis of the source of neck pain.
Should I use medication? Isn’t that just masking the problem?
In acute pain presentations, your doctor may wish to organise some medication to alleviate the pain, inflammation and muscle spasm. These may be required for 24 hours up to a week. If pain persists past that time a review of the diagnosis and medication may be required. Your doctor should be involved in any decision regarding the use of medication as this will vary depending upon individual circumstances.
If the facet joint is out – can it be “clicked back in”?
In acute presentations it is possible that joint manipulation will help. In more acute pain presentations, it is considered that the facet joint may be a “stuck” joint that doesn’t move freely. Manipulative techniques (popping the joints) as well as simple mobilising techniques might be helpful to loosen up the motion of the joint. However, if there are complicating issues (such as acute pars defect – a spinal fracture around the facet joints) then manipulation could be dangerous. Additionally, neck manipulation has been associated with injuries to vascular structures. Physical therapists should discuss risks of neck manipulation with patients.
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