Facet Syndrome Paul S. Jones, D.O. PM&R Harry S. Truman, VA
Facet Syndrome What would be the presenting history? What are the physical findings? What Imaging studies are used to make the diagnosis of Facet Syndrome?
Criteria for Pain Generator Bogduk: 2002 Identified 4 factors necessary for any structure to be deemed a cause of back pain: Nerve supply to the structure Ability of structure to cause pain similar to that seen clinically in normal volunteers Structure’s susceptibility to painful diseases or injuries Demonstration that structure can be a source of pain in patients using diagnostic techniques of known reliability and validity
Historical 1911, Goldthwait Identified the lumbar facet joints as cause of low back pain “The peculiarities of the facet joints” were responsible for LBP and instability 1933, Ghormely described the facet syndrome 1934, Mixter and Bar Intervertebral disc as source of pathology 1963, Hirsch injected hypertonic NS in facet joints with production of LBP 1979, Mooney and Robert, Fluoroscopic intra-articular injection of hypertonic NS to facet in asymptomatic patients Caused back and leg pain Injection of local anesthetic in provoked facet relief of back and Lower extremity pain Demonstrated root tension signs and EMG changes when the facet joints were injected
Historical Schmorl and Junghanns Introduced concept “motor segment”,functional spinal segment or motion segment Adjacent lumbar vertebral disc, intervertebral disc, and facet joints.
Zygapophyseal joint True synovial joint Joint space Hyaline cartilage Synovial membrane Fibrous capsule Mechanosensitive fibers Nociceptive fibers. Nociceptive mediators Plane progresses from sagittal plane at L1-2 to approximately 45 degrees coronally at L5-S1 Volume 1-2 cc’s Facets take 3%-25% of compressive load in normal joints Up to 47% if facets are arthritic
Degenerative Cascade Model Based upon work of Kirkaldy-Willis Stage I: Dysfunction Stage II: Instability Stage III: Stabilization
Dysfunction Trauma and cumulative stress lead to changes in Facets Joint synovitis Subluxation Cartilage Distruction Discs Annular tears, release of inflammatory chemicals Local ischemia Sustained segmental muscle hypertonicity Ligamentous strain
Instability Facets Increasing cartilaginous deterioration Capsular laxity Increased rotational movement in physiologic range Discs Increasing frequency of tear with coalescense Nuclear and annular disruption Increased translational forces Changes in disc and facet increase ligamentous stress and dysfunction
Stabilization Facets Loss of joint surface-cartilage Intra- and extrarticular fibrosis Hypertrophy and spurring Joint space narrowing Osteophyte formation according to Wolff’s law Discs Nuclear deterioration Changes in collagen types Endplate irregularities Osteophytes and spurring Disc resorption and fibrosis Progressive loss of disc space height Central and/or lateral canal stenosis Ligamentus flavum hypertrophy and calcification Nerve root scarring.
Development Abnormal weight bearing status Bogduk: Posterior elements only hold 15-20% of posterior column weight (Adams-16% with relatively unloading with sitting) Disc degeneration and hyperlordosis causes z-joint participating more in loading.
Zygapohyseal Joint Pain Causes: Meniscoid entrapment and extrapment Synovial impingement Chondromalacia Facetae Capsular and synovial inflammation Mechanical injury to the joint capsule Inflammatory changes RA, Ankylosing Spondylitis Metabolic disorders—Gout Villonodullar synovitis, synovial cysts, infection
Facet (zygapophyseal)Joint pain 15-40% of chronic pain is due to facet joints Acute injury usually starts from injury in extension and rotation, torsion injuries to the lumbar spine Has referral patterns. Pain often reproduced with extension and rotation Clinical diagnosis of exclusion Precise instillation of local anesthetic into joint or its nerve eliminates all or part of the patient’s pain
History with Chronic LBP Pain worse with extension and rotation Helbig and Lee—22 patient with response to facet diagnostic injection, reported positive predictive value of 67% Groin or thigh pain Well-localized paraspinal tenderness Pain reproduced by extension and rotation, usually toward symptomatic side. Revel—Increase of pain during hyperextension and extension and rotation—Less frequent in those responding to Facet Joint injection Schwarzer—Double block technique showed extension and rotation poor discriminator (26 patients/176 underwent double block) Facet Capsular ligament strained most with rotation
History Fairbanks, 1983 25 patients with positive dx block Acute onset of pain associated with movement (Bending or twisting); pain increased by sitting and forward flexion; pain relieved by walking; pain occurring more proximally in the leg; pain in the back with straight leg raising. Little, 2004—Cadaveric lumbar spine Restriction of vertebral motion segment could cause capsular strain and stimulate capsule nociceptors.
History Revel 7 clinical features of which 5 items found together distinguishes 92% of patient responding to lidocaine injection and 80% not responding lidocaine injection: Age>65 Pain no exacerbated by coughing Hyperextension Forward flexion Rising from flexion Extension-rotation Pain relieved with recumbency Unfortunately no reliable historical data!
History Manchikanti, et al: 2000 6 features with 4 present at one time that provided negative correlation with facet double block in 93% of patients Pain not relieved in supine position History of surgery Occupational Onset Abnormal gait Positive neurological examination No evidence of osteoporosis Manchikanti, Laxmaiah: “The inability of the clinical picture to characterize pain from facet joints; Pain Physician, Vol3, #2, pp 158-166
Exacerbation of Pain Aggravated Extension Standing Arching backwards Rest Prolonged sitting Relieved Flexion Standing Walking Rest Repeated movements or activities. Pain is generally a deep, dull ache Morning pain and stiffness, not aggravated by valsalva
CT Usefulness Schwarzer, Anthony: 1995 63 patient with low back pain >3 months No demonstrable relationship between the degree of OA changes seen on CT scan and the presence or absence of Zygapophyeal joint pain The ability of computer tomography to identify a painful zygapophyeal joint in patients with chronic low back pain; Schwarzer, Anthony, Spine, Vol 20, #8, pp 907-912, 1995 “No correlation between clinical picture, MRI, CT scan, Dynamic bending fields, SPECT scan, and radionuclide bone scanning” Manchikanti: Pain Physician, Vol 3, #2 2000
Suspected Clinical Findings Z-Joint Pain Site of maximal segmental or direct articular tenderness Concordant pain on provocative segmental testing “Articular restriction” and local soft tissue changes such as increased muscle tone Pain in recognized Z-joint referral zones Injection with reproduction of pain is “not diagnostic” for Z-joint pain
Facet Referral Pattern
Treatment Need to address problem based upon presumptive diagnosis Injections are indicated after a minimum of 4 weeks of appropriate, directed conservative care has failed to bring relief
Treatment Relative rest Medications Physical Therapy Avoid prone positions Modalities Traction 90/90 traction to unload facet joints(not sustained) Corsets-neutral or slight flexion Flexibility training in a neutral to slightly flexed position Strength training Flexion and lumbar neutral mechanics Posterior pelvic tilt
Treatment Alan Bani: 2002 715 Facet joint injections in 230 patient Duration of symptoms 1 week to many years Follow up period of 10 months 1cc bupivacaine 1% followed by betamethasone if 1st effective 10% long lasting relief of leg and back pain 15.2% General improvement of pain 11.7% relief of back but not leg pain 3.9% suffered no back pain but still leg pain 50.4% no improvement of pain Conclusion “Facet joint block is minimally invasive procedure used to differentiate between facet joint pain and other causes of LBP Useful to distinguish Facet pain from postoperative pain due to inappropriate neural decompression after lumbar surgery Can be recommended as midterm intervention for chronic LBP” Neurosurg. Focus, Vol 13, August, 2002
Radiofrequency Denervation Kleef, M: 1999 31 patients with 1 year chronic back pain Use patients with + response to lidocaine Double blind, random study + effect of VAS, Global Perceived Effect, Ostwestry Disability Scale RF may be beneficial in chronic LBP Random trial of radiofrequency lumbar facet Denervation fro chronic low back pain: Kleep, M Spine, Vol 24, #18, pp 1937-1942. 1999
Medial Branch Block Kaplan, Michael: 1998 14 Asymptomatic Individuals randomly injecting L4-5,L5-S1 Zygopophyseal joint Capsular distention of Z-joint with contrast without extracapsular spread Randomize saline or 2% lidocaine-medial branch injection 30 minutes later-repeat capsular distention with saline 89% inhibition pain associated with capsular distention (CI 95%-69%-100%) 11% False-negative rate due to venous uptake If vascular uptake 50% chance of false-negative Fails to block targeted joint (CI95% 11%-31%) The ability of the lumbar medial branch blocks to anesthetize the zygapophyseal joint: A physiologic Challenge; Kaplan, Michael; Spine, Vol 23, #17, pp 1847-1852; 1998
Medial Branch Block Manchikanti, L: 2004 500 patients with pain 6 months, ages 18-90 yo 1% lidocaine block then repeat with 0.25% Buprivacaine 3-4 weeks after 1st block 31% of patients with lumbar spine pain or 63% of lidocaine-positive group reported response to Buprivacaine (95% CI 27%-36%) 79%(313) had 2 joints involved 20% (80) had 3 Joints involved 1% (4) had >3 joints involved False-positive rate 27% lumbar spine for single block Facet joints are clinically important spinal pain generators with chronic spine pain If failed conservative treatment: PT, Chiropractic, analgesic then benefit specific interventions designed to manage facet joint pain Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions; Manchikanti,L, BMC musculoskeletal Disorders 2004, 5:15 http://www.biomedcentral.com/1471-2474/5/15
Medial Branch Block Dreyfuss, Paul, 1997 Fluoroscopic guidance effective in 85% of injection with False-negative rate of 8% The targeted nerve was selectively and exclusively infiltrated Injection superior border of transverse process may cause epidural/foraminal spread 0.5 cc of contrast adequately bathes site of the target nerve No reason to use larger volumes Recommended use of contrast to insure positioning over target nerve with less venous uptake. Specificity of lumbar medial brance and L5 dorsal ramus blocks: A computed tomography study, Paul Dreyfuss, Spine, Vol 22, # 8, pp 895-902, 1997
Recommendation Medial Branch Block Double-block paradigm Avoids false positive diagnostic injection False-positive rate for facet or MBB is 38% Criteria of 80% relief of pain With just baseline pain Also with provocative procedures Loading the joint MBB vs Facet injection Controversial Schwarzer, The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygophophaseal joint. Pain 1995:58,195-200
Medial Branch Block 0.3 cc of 2% Lidocaine 0.3 cc of 0.5% Marcaine
CT Guided Facet Injection CT guided facet block Addresses the biochemical and mechanical aspects of this problem No need for contrast dye Limited exposure to radiation Ease of performing the procedure May actually find entrance to facet Has image guide to help direct needle
Post Procedure MRI Z-joint cyst of one of my patients L3-4
Summary Facet Injection No physical examination correlation No imaging studies valuable Double injection with “concordance” supports the diagnosis If young try a facet injection If older and multiple disease, may want to try Medial Branch Block with follow up of RF ablation
Side Effects of Epidurals STEROIDS Generalized erythema / facial flush Hyperglycemia Elevated BP Fluid retention Weight gain Bone demineralization HPA suppression Cushing syndrome Steroid myopathy Anaphalctoid reaction Succinate salts: rare Acetate or phosphate salts: absent LOCAL ANESTHETIC Paresthesia Weakness Hypotension Cardiac arrhythmia Seizure Allergic reaction CONTRAST Allergic reaction Other options
Risks with Epidurals MORE COMMON Increased pain: usual pain Injection site Bruising LESS COMMON Bleeding/Hematoma Infection Dural puncture: spinal HA Extremity weakness Spinal cord injury
Esp with sedation
Intravascular injection Hypotension Seizure CVA
Epidurogram AP Lateral
Paramedian With Good Flow
Caudal Approach L5
Bibliography 1. Dennis M. Lox, Anatomic and biomechanical principles of the lumbar spine, PM&R: STAR; Vol.13, No.#, Oct. 1999 2. Andrew Cole,Stanley Herring: The low back pain Handbook: A guide for the practicing Clinician, 2nd Edition, Hanley & Belfus, 2003 3. Carl H Shin MD; Lumbar Facet Arthropathy: e-medicine;Dec 26, 2001 4. Jesse S. Little; Human lumbar facet joint capsule strains: II. Alteration of strains subsequent to anterior interbody fixation; The Spine, Journal 4 (2004) 153-162
Bibliography 5.Nikolai Bogduk, MD: International spinal injection society guidelines for the performance of spinal injection Procedures. Part 1: Zygapophysial Joint Blocks. The Clinical Journal of pain13: pp285-302, 1997 6. Douglas Fenton: Image-Guided Spine Intervention, WB Saunders, 2003