Facet joint disorders: from diagnosis to treatment

Abstract

One of the most common sources of spinal pain syndromes is the facet joints. Cervical, thoracic, and lumbar facet joint pain syndromes comprise 55%, 42%, and 31% of chronic spinal pain syndromes, respectively. Common facet joint disorders are degenerative disorders, such as osteoarthritis, hypertrophied superior articular process, and facet joint cysts; septic arthritis; systemic and metabolic disorders, such as ankylosing spondylitis or gout; and traumatic dislocations. The facet pain syndrome from osteoarthritis is suspected from a patient's history (referred pain pattern) and physical examination (tenderness). Other facet joint disorders may cause radicular pain if mass effect from a facet joint cyst, hypertrophied superior articular process, or tumors compress the dorsal root ganglion. However, a high degree of morphological change does not always provoke pain. The superiority of innervating nerve block or direct joint injection for diagnosis and treatment is still a controversy. Treatment includes facet joint injection in facet joint osteoarthritis or whiplash injury provoking referred pain or decompression in mass effect in cases of hypertrophied superior articular process or facet joint cyst eliciting radicular pain. In addition, septic arthritis is treated using a proper antibiotic, based on infected tissue or blood culture. This review describes the diagnosis and treatment of common facet joint disorders.

Keywords: Arthritis; Ganglia; Hypertrophy; Infectious; Intervertebral Disc; Osteoarthritis; Pain; Physical Examination; Referred; Spinal; Synovial Cyst; Weight-Bearing; Zygapophyseal Joint.

Fig. 1

Referred pain pattern from the facet joints. (A) Cervical facet joint syndrome. It is quite difficult to differentiate referral patterns to the greater occipital protuberance from the atlanto-occipital joints and atlanto-axial joints. One of the most common referral pain patterns to the supraspinatus and infraspinatus area with interscapular area originates from the C5-C6 and C6-C7 facet joints, respectively. These facet joints become the common targets of neck straightening. (B) Thoracic facet joint syndrome. Mid-back pain with referred pain to the chest and abdomen arises from senile kyphosis, a long-term sleeping with a semi-Fowler position with the head of the bed at 30°–45° due to respiratory difficulty or intractable abdominal pain, or osteoporotic or osteolytic compression vertebral fractures. (C) Lumbar facet joint syndrome. Referral pain patterns from the upper and lower lumbar facet joints are shown to the groins and buttocks, respectively. It occurs commonly after fusion surgery as junctional pain syndrome.

Fig. 2

Three staged minimally invasive interventional procedures for the facet joint cysts. (A) The first step is placement of a needle into the targeted facet joint and injection of the contrast medium for bursting the facet joint cyst. However, half of ruptured cysts can grow again and elicit radiculopathy within 3 years. (B) Enucleation of the root of the cyst with using a bipolar radiofrequency after injection of mixture of contrast medium and indigo carmine into the targeted facet joint is the second step after bursting. However, half of the cases of cystic enucleation have recurrence. (C) Endoscopic removal of involved superior articular process after recurrence of cystic enucleation is the third step before open surgery with fusion for preventing recurrence of facet joint cyst. The hypertrophied superior articular process which compresses dorsal root ganglion is removed. Adapted from the article of Kim et al. (Pain Physician 2019; 22: E451-6) [39].