Facet Joint Syndrome Complicates Neck And Back Pain
The facets are parts of the bones in the neck and back which form joints that guide motion. Facet joint pain, also known as facet syndrome is common among patients with chronic back and neck pain. In the neck, injuries to the facet joints are a common cause of pain after whiplash and is a major source of clinical importance.
As you can see from this graphic, the facet joints produce pain when arching back. Irritated facets approximate and cause inflammation. This limits backward motion of the neck and back and the typical posture of those in pain is one of being bent forward to move the joints away from eachother.
Facet joints are implicated as a major source of neck and lower back pain. Both neck and back facet syndromes have been described in the medical literature and biomechanical studies have shown that these facet joint capsules undergo significant strain during spinal loading (lifting or sitting), especially when they have degenerated..
Studies have demonstrated pain sensitive nerve endings in facet joints mechanically sensitive receptors which become activated with inflammation. A 2015 study in the journal Osteoarthritis and Cartilage indicates facet joint degenerated tissues contain inflammatory chemicals, ingrowth of blood vessels and chemicals that activate pain nerve fibers. These factors cause pain and progression of the condition, similar to the process involved with disc degeneration. Biomechanical studies indicate that rear end motor vehicle impacts give rise to excessive deformation of the capsules of facet joints, often a cause for persistent pain after whiplash trauma, and injury to the facets in the lower back may be produced by lifting and twisting to one side.
Facet syndrome is often associated with chronic pain. Illustrated here is the degenerative process often associated with arthritis. The front part of the bone with the disc is usually the first to begin this process of degeneration. Soon after, the decreased height of the bones places undue stress on the facet joints which start to degenerate. This causes additional inflammation and allows a smaller window for pain free motion.
There are many reasons for this degenerative process, often associated with arthritis. Many have wrongly suggested that this process is normal with aging. It is normal for degeneration to occur with aging, however, it is not associated with pain. Degenerative disc disease is painful and often disabling. Radiographic signs of significant decreases in disc space are most often associated with pain and the disease process, not normal aging! Genetics have been found to be of major importance in addition to loading history (heavy lifting or prolonged sitting). Unfortunately, with this type of condition in the lower back, typical back supports used in seats may be of no help and may even aggravate the condition.
In the lower back, facet joint syndrome is characterised by: low back pain; pressure soreness at the level of the facet joints involved; leg pain, but not following a radicular pattern of a pinched nerve; pain increase during rotation movements; greater pain during extension with respect to flexion; pain in the transition from the seated position to the standing one; reduced range of movement with greater stiffness in the morning.
If the back pain exercises do not help or make pain worse, then you may have facet joint problems and must avoid extension. Your problem may be degeneration and chronic or long standing back pain or it may be from an injury to the facet joints usually from lifting and twisting to one side. This recently happened to me as I was lifting a vacuum cleaner. I jammed the facet joints on the right side and immediately experienced pain along the distribution as pictured below. The pain radiating from the back, around the buttock and into the groin was quite disturbing. I have severe degeneration of the L5-S1 disc and, as a consequence, have developed degeneration of the lumbar facets. I first noticed the facets were becoming a problem when using a back support that extends the lower back region which increased the pain. The best solution I have found for seating support is the Backtivator, which also helps with reducing spasm of the Quadratus Lumborum muscle when seated for long periods, especially when driving.
With facet syndrome, you should do back exercises (1, 2, 3, 6, 7, and 9). Additionally, specific chiropractic adjustments can help. The adjustments must be done on the correct side. In my case, a right L5-S1 facet compression injury, I used a Medrol Dose Pack (1 of 5 I have taken in about 9 years) to reduce inflammation, hot packs, massage and while I was backing into a parking space, I twisted to the right with my right arm around the back of the car seat and kept my torso straight at which point a loud release of the joints were noted and the pain subsided for the first time. I do not suggest you try this, a chiropractor would test the joints and perform a right side posture lumbar adjustment to the same effect. Painful, but effective. A concentrated massage along the pain referral areas and application of herbal liniment to the affected areas finally got rid of the pain – for now.
Another area of concern is safe lifting and the discussion regarding While lifting, you must retain the normal curve or arch in the back under back posture. When you have damage to the facet joints resulting in a pain syndrome, you should not arch your lower back when lifting. It is also important to use a stool when standing for long periods as when using an ironing board and to flatten the lower back when raising your arms above your head. Pain in the lower back that is relieved by sitting is a sign of lumbar facet syndrome.
Facet joint syndrome in the neck follows a similar course. Injuries to the facets are common in whiplash accidents and for those whose job demand looking up or holding the head and neck in extension. Think of painting a ceiling, so Painters, Electricians, Carpenters, Sheet Rockers, Ceiling Installers, HVAC Workers, Automotive, Aircraft, All Overhead Assembly Personnel Electricians, Carpenters, Sheet Rockers, Ceiling Installers, HVAC Workers, even Recreational activities like: Rock Climbers (Belayers Neck), Birdwatchers (Warblers Neck), Sailors (Trimmers Neck) and Astronomers can develop irritation of the facet joints over time. I have found that use of the neckaid neck support or the neck guard can have a significant impact to help with the development of facet syndrome of the neck.
If all else fails, the medical community has facet joint injections and nerve disruption techniques that you may wish to consult with. A surgical procedure called radiofrequency rhizotomy might be necessary to relieve pain and improve mobility. Radiofrequency rhizotomy, also called radiofrequency neurotomy, is the surgical “de-nerving” of the facet joint.
When home measures or conservative care like chiropractic, physical therapy and medications fail to provide satifactory relief, injections can be a good alternative prior to considering surgery. Injections for facet joint pain can serve 3 purposes: 1) For pain relief. 2) As a diagnostic tool. 3) Both.
By injecting either a analgesic like lidocaine, an anti-inflammatory like cortisone, or both, relief of pain can indicate that the diagnosis of facet joint pain is valid. This may be done with an anesthetic to “block” the nerve, confirming the source of pain. By including an anti-inflammatory, longer term pain relief can be the objective.
Getting a facet joint injection is a minimally invasive procedure, usually lasting about 15 minutes. Lying down on a table, the skin over the joint is numbed and a needle is guided into the joint using a type of live x-ray called fluoroscopy. With this procedure, a contrast dye is used to confirm excatly where the medications will go. The injection slowly releases the medications.
The results can provide immediate relief from the anesthetic, and longer lasting relief in a couple of days or perhaps a week from the anti-inflammatory. Results may be about 50%. With no relief of pain after a week, additional testing may be done to determine if a nerve that supplies pain sensations (medial branch) would respond to similar injection. With pain relief on injection of the medial branch nerve, further consideration for radiofrequency neurotomy/ablation, which is a type of injection using a radiofrequency energy heat probe to destroy the nerve function. A 2014 study in the Pain Physician Joiurnal observed 55 patients who underwent cervical radiofrequency neurotomy for chronic whiplash symptoms. There were improvements in disability, pain and psychological distress 3 months following the procedure. The lateral branch nerve is the focus of pain from the sacroiliac joint.
Injections may be repeated a few times a year if necessary. The neurotomy may provide relief for up to a year or more. Typically, the relief may be shorter and the nerve usually regenerates. Success is better for the neck than the lower back, however some will not respond at all.
Adverse Reactions To Facet Injections
According to a 2014 study in Pain Physician Journal, the adverse reactions are minimal. Vasovagal reaction occurred as the most common immediate adverse reaction and injection site soreness was the most common delayed reaction. Vasovagal reaction can be a number of things: dizziness, lightheadedness, weakness, nausea, palpitations, blurred vision, feeling cold or warm, sweating and possibly fainting.
More serious events are rare
There are some very rare but potential complications. Those on medications for blood thinning, have an infection or are allergic to any medications or contrast agent used should not have facet injections. Consult with your doctor regarding any potential complications from infection, nerve or spinal cord damage from the needle, bleeding or artery damage from facet joint injections.