Facet Joint Syndrome: Symptoms, Causes & Treatment

Facet syndrome is an articular disorder related to the lumbar facet joints and their innervations, and produces both local and radiating pain.

Ghormley was the first who characterized the ‘facet syndrome’ by back and/or leg pain, as a result from mechanical irritation of a lower lumbar zygapophysial joints. This is more then 20 years ago, but the facet joint has been increasingly recognized as an important cause of low back pain.

Excessive rotation, extension, or flexion of the spine (repeated overuse) can result in degenerative changes to the cartilage of the joint and may involve degenerative changes to other structures including the intervertebral disc.

Facet Joint Syndrome

Strain of the lumbar facet joint is highest at end-range extension. Additionally, with a reduction of disc height, Lumbar facet mechanical loads will increase, which can also leads to degeneration of the facet joints.

55% of facet syndrome cases occur in cervical vertebrae, and 31% in lumbar. This includes all the structures that are a part of the facet joint such as the fibrous capsule, synovial membrane, hyaline cartilage and bone.

Neck pain due to cervical facet joint involvement is known as cervical facet syndrome and low back pain due to lumbar facet joint involvement is known as lumbar facet syndrome.

Clinically Relevant Anatomy

The facet joints are joints in the posterior aspect of the spine. In each spinal motion segment there are two facet joints.

Although these joints are most commonly called facet joints, they are more properly termed zygapophyseal joints (abbreviated as Z-joints; also commonly spelled as "zygapophysial joints"), a term derived from the Greek roots zygos, meaning yoke or bridge, and physis, meaning outgrowth.

This “bridging of outgrowths” is most easily seen from a lateral view, where the Z-joint bridges adjoin the vertebrae.

The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint or the posterior intervertebral joint.

Facet Joint Syndrome

Characteristics/Clinical Presentation

Zygapophyseal joint pain is felt locally as a unilateral back pain, which when severe can spread down the entire limb.

Cervical facet syndrome includes following symptoms:

• Axial neck pain (rarely radiating past the shoulders), most common unilaterally
• Pain with and/or limitation of extension and rotation
• Tenderness upon palpation
• Radiating pain locally or into the shoulders or upper back, and rarely radiate in the front or down an arm or into the fingers as a herniated disc might.

Lumbar facet syndrome can be characterised by following symptoms:

• Pain or tenderness in lower back.
• Local tenderness/stiffness alongside the spine in the lower back.
• Pain, stiffness or difficulty with certain movements (such as standing up straight or getting up from a chair.
• Pain upon hyperextension
• Referred pain from upper lumbar facet joints can extend into the flank, hip and upper lateral thigh
• Referred pain from lower lumbar facet joints can penetrate deep into the thigh, laterally and/or posteriorly
• L4-L5 and L5-S1 facet joints can refer pain extending into the distal lateral leg, and in rare instances to the foot

Additionally, facet joint syndrome is more common in the elderly since changes at the joints develop with aging.

Acute episodes of lumbar and cervical facet joint pain are typically intermittent, generally unpredictable, and occur a few times per month or per year.

Typically, there will be greater aggravation of symptoms with lumbar extension than lumbar flexion. In lumbar cases, standing may be somewhat limited but sitting and riding in a car are most provocative.

Recurrent painful episodes can be frequent and quite unpredictable in both timing and extent. Improper diagnosis can result in patients that are left with the notion that this is a psychosomatic problem.

Osteoarthritis is only one of many inflammatory processes that affect the facet joint. Other inflammatory conditions include rheumatoid arthritis, ankylosing spondylitis, reactive arthritis, synovial impingement, meniscoid entrapment, chondromalacia facetae, pseudogout, synovial inflammation, villonodular synovitis, and acute chronic infection.

Intrafacetal synovial cysts can be a source of pain because of distension and pressure on adjacent pain-generating structures, calcification, and asymmetrical facet hypertrophy.

Facet Joint Syndrome

Differential Diagnosis

Cervical spine:

• Cervical disc injuries
• Cervical discogenic pain syndrome
• Cervical radiculopathy
• Cervical spine sprain/strain injuries

Lumbar spine:

• Lumbosacral Disc Injuries
• Lumbosacral Discogenic Pain Syndrome
• Lumbosacral Radiculopathy
• Lumbosacral Spine Acute Bony Injuries
• Lumbosacral Spine Sprain/Strain Injuries
• Lumbosacral Spondylolisthesis
• Lumbosacral Spondylolysis
• Piriformis Syndrome
• Sacroiliac Joint Injury
• Inflammatory arthritis (rheumatoid arthritis)
• Spondylarthropathies (osteoarthrosis, synovitis)

Diagnostic Procedures

X-ray, computed tomography (CT) scan of the spine or a magnetic resonance imaging (MRI) scan are commonly used to diagnose this syndrome. Plain radiography does not provide information in establishing the diagnosis of facet joint syndrome, but it may help with the evaluation of the degree of degeneration. Once degeneration is visible on plain radiography it has already reached an advanced stage.

The working diagnosis of facet pain, based on history and clinical examination, may be confirmed by performing a diagnostic block.

A positive indication is when the patient experiences a 50% pain reduction after a block has been performed. It involves injecting a medicine into or near the nerves that supply the facet joint.

If the pain is not relieved by the injection, it is unlikely that the facet joint is the source of the pain. If these injections help to reduce the pain, we can suggest that the pain comes from the facet joint.

Although no single sign or symptom is diagnostic, Jackson et al demonstrated that the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular facet joint injection:

• Older age
• Previous history of low back pain
• Normal gait
• Maximal pain with extension from a fully flexed position
• The absence of leg pain
• The absence of muscle spasm
• The absence of exacerbation with a Valsalva manoeuvre
• Outcome Measures
• Finger-floor test
• Lumbar spine rotation
• Schober's index
• Visual analog scale

Examination

Inspection

Inspection should include an evaluation of paraspinal muscle fullness or asymmetry, increase or decrease in lumbar lordosis, muscle atrophy, or posture asymmetry.

Patients with chronic facet syndrome may have flattening of the lumbar lordotic curves and rotation or lateral bending at the sacroiliac joint or thoracolumbar area.

Palpation

The examiner should palpate along the paravertebral regions and directly over the transverse processes because the facet joints are not truly palpable.

This is performed in an attempt to localize and reproduce any point tenderness, which is usually present with facet joint–mediated pain. In some cases, facet joint–mediated pain may radiate to the gluteal or posterior thigh regions.

Range of motion

Range of motion should be assessed through flexion, extension, lateral bending, and rotation. With facet joint–mediated low back pain, pain is often increased with hyperextension or rotation of the lumbar spine, and it might be either focal or radiating.

Flexibility

Inflexibility of the pelvic musculature can directly impact the mechanics of the lumbosacral spine.

With facet joint pathology, the clinician may find an abnormal pelvic tilt and rotation of the hip secondary to tight hamstrings, hip rotators, and the quadratus, but these findings are nonspecific and can be found in patients with other causes of low back pain.

Sensory examination

Sensory examination (light touch and pinprick in a dermatomal distribution) findings are usually normal in persons with facet joint pathology.

Muscle stretch reflexes

Patients with facet joint–mediated LBP usually have normal muscle stretch reflexes.

Radicular findings are usually absent unless the patient has nerve root impingement from bony overgrowth or a synovial cyst. Side-to-side asymmetry should lead one to consider possible nerve root impingement.

Muscle strength

Manual muscle testing is important to determine whether weakness is present and whether the distribution of weakness corresponds to a single root, multiple roots, or a peripheral nerve or plexus.

Typically, manual muscle testing results are normal in persons with facet joint pathology; however, subtle weakness of the muscles of the pelvic girdle may contribute to pelvic tilt abnormalities.

This subtle weakness may be appreciated with trunk, pelvic, and lower-extremity extension asymmetry.

Medical Management

Pharmacological therapy commonly consists of the prescription of muscle relaxants prescribed by a physician to treat acute back pains secondary to facet joint syndrome.

Over the counter pharmacological therapy includes: nonsteroidal anti-inflammatory drugs (NSAIDS) and acetaminophen as a first line intervention to help decrease of LBP. Little evidence supports one particular drug over another

Standard treatment for facet joint syndrome pain include intra-articular steroid injections and radiofrequency ablation of the medial branches innervating the joints. Yet there is much controversy in scientific articles related to this standard treatment.

Physical Therapy Management

Although numerous studies have examined conservative management for low back pain, at the present time, we couldn’t find published investigations of conservative management specifically targeted to facet joint pain.

However, most experts would agree that the general principles for treatment of nonspecific benign low back pain may be applied.

The initial treatment for acute facet joint pain is focused on:

Education

Patient education includes explaining the problem or their associated impairment to the patient, without making them anxious.

It includes pain education mostly therefore a diplomatic approach is recommended in order to prevent the patient from catastrophizing.

During the therapy, it’s also important that the therapist gives advice/instructions or cues about the patient’s posture and placement of his body to make corrections during everyday activities. The patient must learn to take postures that will not provoke or exacerbate the symptoms.

Relative rest

Bed rest beyond 2 days isn’t recommended as it can have undesirable effects on bones, connective tissues, muscles and the cardiovascular system.

The patient is encouraged to limit activity on days when the symptoms are not tolerable, but should never be completely inactive. Therapist must strive to influence the patient to be as active as possible.

Reducing lumbar lordosis

Therefore it is important to reduce excessive lumbar lordosis with exercise because excessive lordosis increases loading on the posterior aspect of the spine, including the z-joints.

To achieve this, the patient should be taught pelvic manoeuvres to reduce the degree of lumbar lordosis. These pelvic tilt exercises can be performed in multiple positions such as sitting, standing with knees bent or straight legs.

Pain relief

Bronfort G. et al studied the relative efficacy of three different treatments for chronic low back pain.

They comprised followed combinations: spinal manipulative therapy (SMT) combined with trunk strengthening exercises (TSE) vs. SMT combined with trunk stretching exercises and SMT combined with TSE vs. non-steroidal anti-inflammatory drug (NSAID) therapy combined with TSE.

During 11 weeks (5 weeks under supervising and 6 weeks alone) they examined: patient-rated low back pain, disability and functional health status.

Their conclusion was that each of the three therapeutic regimens was associated with similar and clinically important improvements. For the management of facet joint syndrome, trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile.

Spinal manipulation is being used for both short- and long-term pain relief.

Exercises

Other scientific sources recommend treating facet joint syndrome with heat, cryotherapy and mobilizations.

These techniques appear to have a relaxing effect on the muscles. As the muscles relax, the nociceptive information will decrease. While these techniques have clear advantages, they generally only attain a temporary pain relief as they are often not a final solution to treat facet joint syndrome.

In the final phase of the rehabilitation, eccentric muscle strengthening exercises and dynamic exercises are added to the program.

These are to be performed in a functional manner and in functional planes. All exercises were performed in the treatment room under the supervision of a physical therapist with technical knowledge.