Facet Arthropathy
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Facet Arthropathy

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Facet Arthropathy Facet Arthropathy Presentation Transcript

  • 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.
  • Anatomy
  • ANATOMY
    Bone Relationships
    LIGAMENTS
    ANTERIOR LONGITUDINAL LIGAMENT
    POSTERIOR LONGITUDINAL LIGAMENT
    LIGAMENTUM FLAVUM
  • TYPICAL LUMBAR VERTEBRAL BODY
  • NEUROLOGICAL RELATIONSHIPS
    Osteophytic spurs or Anterior herniated disc
    Symptoms related to SNS of levels involved
    Facet Exostosis
    Nerve root symptoms
    Facets
  • Vertebral Innervation
    Zygophophyseal joint:
    Nociceptive fibers
    Nociceptive Mediatiors
  • Anatomy
  • 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
  • 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.
  • Diagnosis
  • 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
  • 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
  • Facet Injection
    C-arm rotation
    45° L4-5,L5-S1
    30° upper lumbar facet
  • 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
  • CT Guidance
  • 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
  • Epidural Injections
  • Neuroaxial Anesthesia
  • Precautions
    Absolute
    **Anticoagulation (coumadin, heparin, LMWH, ASA, Plavix, Ticlid) or coagulation disorder**
    INR > 1.5
    Platelets <50,000/mm3
    • Stop 7-10 days prior to the procedure
    Sepsis
    Patient refusal
  • 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
  • Epidural 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