Lumber Facet Arthopathy

Thaneshwar Pahari

 

Introduction

Lumber backpain is the most common pain symptom experienced by adults. Low back pain defined as pain and discomfort, localized below the costal margin and above the inferior gluteal folds with or without leg pain.

Degeneration inflammation and injury can lead to pain with joint motion these disorders are some of the most common of all the recurrent, disability low back and can cause serious symptom and disability for the patients. Facet joint pain is typically in the paravertebral region. Pain from the upper lumber facets tend to extend into the flank hip and upper lateral thigh. Where as pain from the lower lumber levels is likely to penetrate deeper into the thigh usually into the lateral and posterior aspects.

There are many structures into the lumber spine that can serve as pain generators and often the etiology of the low back pain is multifactorial.

A facet joint is located at the junction of the inferior articular process of a more cephalad vertebra and the superior articular process of a more caudal vertebra. It has been estimated that facet joint pathology is a contributory factor in 15 – 45% of patients with chronic low back pain.

Causes :

        Aging is often the indirect cause of facet arthropathy other conditions that affect the facet joints and result in facet arthropathy include

  1. a) Osteoarthritis – degeneration of joint cartilage and under lying bone often occurring in middle age.
  2. b) facet degeneration – wear and tear on the facet joint caused by aging.
  3. c) facet joint injury – trauma to the facet joints caused by impact, such as a car accident or fall.
  4. d) Synovial cyst – a fluid-filled sac that develops in the spine, usually as a result of aging.

 

Symptoms

As the facet joint cartilage wears down over time, the surfaces of the facet joints become inflamed and uncomfortable as they rub against each other. Inflammation may stimulate bone spur (osteophyte) development near the joints, which can increase the risk of a pinched nerve in the spinal canal. The resulting symptoms can include

  • Lower back pain
  • Tenderness
  • Stiffness
  • Radiating pain down the buttocks or back of the thigh.
  • Pain when twisting or arching the lower back.
  • Limited mobility and range of motion.

Diagnosis :

        Facet pain can be similar to other spine conditions. An accurate diagnosis is important to determine whether the facet joint is the source of pain. Evaluation includes a medical history and physical examination. It is important to evaluate the Red Flag conditions which requires immediate further investigations and multidisciplinary approach for it management. As delay in immediate decision making may proved to be fatal to the patients these clinical  features should be taken care during history taking and physical examinations.

  • Trauma
  • Tumor
  • Neurological deficit
  • Infection

Other physical examination include,

  • Palpation over lumber facet joint may be painful
  • through neurological examination
  • special test to be performed to rule out other possible causes of low back pain like,
  • Stoop test for spinal stenosis.
  • Tests to exclude sacroiliac joint paint eg. distraction test, thigh thrust, Gaenslen’s test, compression.
  • Straight leg raising test for lumber root irritation.

Radiography

In oblique degeneration is characterised by joint space narrowing, sclerosis, bone hypertrophy and osteophytes.

Intra-articular gas (vacuum phenomenon)may be present.

CT

In CT Scan we can see articular joint space narrowing with subchondral Sclerosis and erosion, osseous overgrowth and hypertrophy of ligamentum flavum causing impingement of the foramina.

MRI

The role is less clear.

Facet Joint Diagnostic infections can be given into the intraarticular joint space or along the medical branches (junction between the transverse process and the superior articular processes under fluoroscopic guidance if diagnostic test is positive, radiofrequency ablation of medial branch is the definitive treatment modality.

 

Treatment :

  1. Conservative Management.
  2. Pharmacological management

The choice of analgesic depends on the type of pain & underlying etiology, if the pain is nociceptive in nature (aching, pressing, no tingling or burning).

  1. simple analgesic like paracetamol at the dose of 3g/day can be started and the dose reduced after 10 days. Although less effective than NSAIDS, it has less adverse effect and is safe they are useful in mild to moderate pain.
  2. Non-steroidal anti-inflammatory drugs (NSAIDS) are highly effective in acute low back pain but are limited by their serious adverse effects. Hence NSAIDs should be restricted to only a short duration (5 -7 days).
  3. Opioids – weak opioids like tramadol can be given in acute low back pain both as monotherapy and in combination with NSAIDs and paracetamol.

 

If the pain has neuropathic component (tingling, numbness, burning, shooting, (electric shock like) then it is wise to start antineuropathic drugs.

 

  1. Pregabalin started with 75 mg. once or twice a day and dose gradually increased depending at the patient tolerance.
  2. Gabapentin started with 100mg. thrice a day and the dose if gradually increased. Maximum dose is 3600 mg/day.

Pain which is of burning quality better responds to antidepressants like :

  1. Amitrptyline 5-10 mg. and increased up to a maximum dose of 100mg. per day.
  2. Nortriptilyne 5 – 10 mg. /day.
  3. Psychological interventions

chronic pain is associated with psychological disturbances and hence need proper counseling and treatment of associated depression, anxiety.

  1. Non pharmacological treatment.
  2. Reassurance and patient education
  3. Back school
  4. Strengthening and flexibility exercises and correction of deficits in kinetic chain.
  5. Flexon, extension and specific exercise treatment for low back pain.

 

  1. II) Interventional pain management for Facet Joint Pain, C-arm/USG/CT-guided intraarticular facet joint block or medial branch blocks are definitive diagnostic for facet joint arthropathy and are usually followed by steroid injection or radio-frequency ablation of medial branches for long term results.

III.        Surgical Management

It is a general rule that presence of red flags warrants surgical management in most situations. Failure of conservative management and interventional management may also need surgical management if pain is moderate to severe.

 

 

 Reference

1.Basic of pain management, 36-43,Gautam Das

2.Journal of recent advances in pain. 2017,3,142-144.

3.spine-health.com

4.clinical methods in pain medicine, Gautam Das, 2nd edition.