Facet Joint Disease

Etiology

The most common cause of facet joint disease is degeneration of the spine, also known as spondylosis. When the degeneration of the joint is due to natural wear and abnormal body mechanics, the condition is termed osteoarthritis (OA). Previously, lumbar facet joint degeneration was viewed as secondary to lumbar disc degeneration. However, recent studies have shown that lumbar facet joint degeneration may precede lumbar disc degeneration instead of being solely a consequence.

The pathophysiology of OA is complex and not fully understood, involving various cytokines, proteolytic enzymes, and individual risk factors. This complexity encourages healthcare professionals to understand the disease better, fostering engagement. Other causes of facet joint disease include trauma from injuries or sports activities. Inflammatory conditions like rheumatoid arthritis and ankylosing spondylitis may also contribute to synovial inflammation.

Additionally, subluxation of the facet joints due to spondylolisthesis can contribute to the development of facet joint disease. Individuals with facet joint disease often exhibit signs of cartilage erosion and inflammation, which can lead to pain. The body also undergoes various physical changes in response to this process. Ligaments, eg, the ligamentum flavum, may thicken and become hypertrophic. New bone formation around the joint can develop osteophytes, commonly known as “bone spurs.” Hypomineralization may also increase subchondral bone volume.

Epidemiology

The lifetime adult prevalence of low back pain in the United States is 65% to 80%.[2] This prevalence is consistent with the idea that degeneration is the leading contributory cause of facet joint disease, as the elderly population is more often affected. No studies have confirmed that males are affected more often than females. However, having a history of doing heavy work younger than 20 increases the likelihood of developing facet joint osteoarthritis.[3]

Obesity also largely contributes to osteoarthritis and is likely a contributing factor in the development of facet joint disease. Spondylolisthesis caused by degeneration is often caused by facet joint osteoarthritis and typically occurs at the L4-L5 level. Spondylolisthesis in a younger population, approximately 30 to 40 years, is due to congenital abnormalities, stress, or acute fractures.[3] Cervical facet disease and pain have a prevalence rate of 29% to 60% following whiplash injuries, although overall trauma is still a rare cause.[4]

History and Physical

Facet joint disease is often diagnosed clinically, making the patient history and physical examination essential. Patients presenting with chronic back pain often show symptoms that overlap with other conditions. Facet-mediated pain is typically non-radiating. Patients commonly report that the pain is worse in the mornings, upon waking, or during periods of inactivity. Symptoms associated with facet joint disease may also intensify with spine extension, facet joint palpation, and rotary trunk motion. Pain can be triggered by facet joint palpation and axial loading. Reproducing the patient’s pain with Kemp’s maneuver, lateral rotation, lateral bending, and back extension indicates facet joint disease and arthropathy.

In the lumbar region, this pain can be unilateral but is usually axial, with occasional radiation into the buttocks, groin, and thighs, extending down to the knee.[5] Reports of pain radiating to the abdominal and pelvic areas have been noted; however, this occurs less frequently. This “pseudo-radicular” pain does not present any associated neurological deficits. When this radiating pain is experienced, it can resemble sciatic pain, but this type of radiation primarily occurs in cases of osteophytes or synovial cysts.[3] Additionally, excluding other causes of lower back pain, including disc herniations, vertebral body fractures, and neoplastic causes of the patient’s pain, is essential.

Evaluation

Identifying facet joint disease as the sole cause of a patient’s neck or back pain is often challenging. Imaging has not been proven to possess much, if any, diagnostic validity. X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) may reveal degeneration, joint space narrowing, facet joint hypertrophy, joint space calcification, and osteophytes; however, these findings may be present in symptomatic and asymptomatic patients. The extent of the facet joint degeneration does not always correlate with the severity of pain.[6] Data shows that 89% of patients aged 60 to 69 have facet joint osteoarthritis. However, not all are symptomatic.[7] Diagnostic medial branch blocks are the gold standard for diagnosing facet joint pain. A positive response to a series of 2 diagnostic blocks performed on 2 separate occasions at 2 or more levels can confirm the source of pain. High false-positive responses are more likely if only 1 level is blocked.[8]

Treatment / Management

Conservative Management

Conservative management is the first-line approach for treating facet-mediated pain, emphasizing a patient-centered and holistic approach. This multimodal strategy includes anti-inflammatory medications, weight management, muscle relaxants, physical therapy, and manual therapies such as massage. Medications typically include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen to reduce inflammation and alleviate pain.

Weight loss is recommended to minimize mechanical stress on spinal structures, while muscle relaxants help mitigate muscle spasms commonly associated with back pain. Physical therapy is crucial in tailoring exercise programs to enhance flexibility, strength, and posture. Manual therapies, such as massages, can provide subjective symptomatic relief for some individuals.[9](A1)

Stepwise Management

A methodical approach is the foundation for managing facet disease before progressing to more invasive interventions. When conservative treatments prove insufficient, interventional procedures may be considered to reduce pain, enhance functionality, and minimize reliance on medications.[10] The management of facet disease follows a structured, stepwise approach that prioritizes conservative treatments, including medications, physical therapy, weight management, and manual therapies. When these measures fail to provide adequate relief, interventional procedures, eg, diagnostic medial branch blocks, radiofrequency ablation, and alternative injections—including platelet-rich plasma, hyaluronic acid, and mesenchymal stem cells—may be explored to alleviate pain and improve function. While RFA offers temporary pain relief by disrupting pain transmission, emerging regenerative therapies promise longer-term benefits, though further research is required.

Medial branch block

One such procedure is the diagnostic medial branch block (MBB), which confirms that the pain originates from the facet joints. These blocks are diagnostic and therapeutic as the procedure uses anesthetics with or without steroids to decrease nociceptor transmission of pain signals and directly decrease inflammation.[11] Due to the reported 30% to 45% false-positive rate associated with a single MBB, 2 diagnostic blocks are often recommended to ensure accuracy.[12](B2)

Alternative injection therapies

Research has also explored alternative injection therapies either as adjuncts to or replacements for corticosteroids. A promising option is platelet-rich plasma (PRP), which is derived from the patient’s blood and contains high concentrations of growth factors believed to have anti-inflammatory properties and potential for tissue regeneration. Evidence from one study suggests that PRP may provide more sustained pain relief at 6 months than corticosteroids and radiofrequency ablation.[13] 

Another alternative is hyaluronic acid, a substance naturally present within joint spaces that contributes to joint health by providing lubrication and reducing friction. Another study found that hyaluronic acid injections demonstrated comparable efficacy to corticosteroids and highlighted their potential as an alternative treatment.[14] Mesenchymal stem cell (MSC) therapy is an emerging treatment recognized for its regenerative and anti-inflammatory properties. Although the precise mechanisms underlying MSC-induced pain relief remain unclear, preliminary research indicates promising results, with ongoing studies evaluating its application in human subjects.[15](A1)

Radiofrequency ablation

If MBB injections or alternative therapies provide significant pain relief, radiofrequency ablation (RFA) may be performed to target the medial branch nerves. RFA utilizes heat to destroy these sensory nerves, thereby reducing pain temporarily. The relief typically lasts between 6 and 12 months following lumbar medial branch RFA.[7] Both MBB and RFA are performed under local anesthesia with fluoroscopic guidance to ensure accurate placement of medications or electrodes and minimize the risk of inadvertently affecting motor neurons. This provides adequate placement of drugs or electrodes and a decreased likelihood of blocking or ablating more distal structures, including motor neurons.

Surgical fusion 

At present, no established guidelines support surgical fusion (arthrodesis) as a treatment for patients who experience minimal or no relief from interventional procedures. Surgery may be warranted for specific conditions, eg, grade I or grade II spondylolisthesis; however, surgery is not considered a first-line treatment and may not necessarily lead to significant pain reduction.[3] Surgical intervention, eg, spinal fusion, remains a last resort and is generally reserved for specific cases like spondylolisthesis. This individualized approach ensures that treatment is tailored to symptom severity while prioritizing minimally invasive options before considering surgical intervention.

Differential Diagnosis

The differential diagnosis for facet joint disease includes the following:

• Sciatica
• Hip osteoarthritis
• Sacroiliac impingement
• Lumbar radiculopathy
• Myofascial pain
• Compression fractures
• Disc herniation
• Osteophytes
• Rheumatoid arthritis

Prognosis

Facet joint disease is a chronic process that can cause pain for the remainder of an individual’s lifetime. Facet joint disease is a progressive disease. The spinal and joint degeneration typically progresses as the patient ages. Maintaining a healthy weight and active lifestyle is essential to prevent the degeneration from progressing. Physical therapy and core strengthening exercises can strengthen the spine and reduce the stress on the facet joints. Interventional procedures such as medial branch blocks and radiofrequency ablations do not treat the underlying cause of the patient’s pain but allow the patient’s pain to be more manageable. Patients can have a reduction in their pain for months at a time, but some studies have shown an even longer-term decrease in pain of up to 2 years after radiofrequency ablations.[16]

Complications

Complications of treating facet joint pain with medial branch blocks or radiofrequency ablation are rare. Due to heat denervation and needle entry, patients may experience a transient increase in pain following radiofrequency ablations and medial branch blocks. Postdural headaches, transient numbness or weakness, bleeding, infection, and increased post-procedural pain are all potential but rare complications of facet interventions.