Facet Arthropathy


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Facet Arthropathy

  1. 1. Facet Syndrome<br />Paul S. Jones, D.O.<br />PM&R<br />Harry S. Truman, VA<br />
  2. 2. Facet Syndrome<br />What would be the presenting history?<br />What are the physical findings?<br />What Imaging studies are used to make the diagnosis of Facet Syndrome?<br />
  3. 3. Criteria for Pain Generator<br />Bogduk: 2002<br />Identified 4 factors necessary for any structure to be deemed a cause of back pain:<br />Nerve supply to the structure<br />Ability of structure to cause pain similar to that seen clinically in normal volunteers<br />Structure’s susceptibility to painful diseases or injuries<br />Demonstration that structure can be a source of pain in patients using diagnostic techniques of known reliability and validity<br />
  4. 4. Historical <br />1911, Goldthwait <br />Identified the lumbar facet joints as cause of low back pain<br />“The peculiarities of the facet joints” were responsible for LBP and instability<br />1933, Ghormely described the facet syndrome<br />1934, Mixter and Bar<br />Intervertebral disc as source of pathology<br />1963, Hirsch injected hypertonic NS in facet joints with production of LBP<br />1979, Mooney and Robert, Fluoroscopic intra-articular injection of hypertonic NS to facet in asymptomatic patients<br />Caused back and leg pain<br />Injection of local anesthetic in provoked facet relief of back and Lower extremity pain<br />Demonstrated root tension signs and EMG changes when the facet joints were injected<br />
  5. 5. Historical<br />Schmorl and Junghanns<br />Introduced concept “motor segment”,functional spinal segment or motion segment<br />Adjacent lumbar vertebral disc, intervertebral disc, and facet joints.<br />
  6. 6. Anatomy<br />
  9. 9. NEUROLOGICAL RELATIONSHIPS<br />Osteophytic spurs or Anterior herniated disc<br />Symptoms related to SNS of levels involved<br />Facet Exostosis<br />Nerve root symptoms<br />Facets<br />
  10. 10. Vertebral Innervation<br />Zygophophyseal joint:<br /> Nociceptive fibers<br /> Nociceptive Mediatiors<br />
  11. 11. Anatomy<br />
  12. 12. Zygapophyseal joint<br />True synovial joint<br />Joint space<br />Hyaline cartilage<br />Synovial membrane<br />Fibrous capsule<br />Mechanosensitive fibers<br />Nociceptive fibers.<br />Nociceptive mediators<br />Plane progresses from sagittal plane at L1-2 to approximately 45 degrees coronally at L5-S1<br />Volume 1-2 cc’s<br />Facets take 3%-25% of compressive load in normal joints<br />Up to 47% if facets are arthritic<br />
  13. 13. Degenerative Cascade<br />
  14. 14. Degenerative Cascade Model<br />Based upon work of Kirkaldy-Willis<br />Stage I: Dysfunction<br />Stage II: Instability<br />Stage III: Stabilization<br />
  15. 15. Dysfunction<br />Trauma and cumulative stress lead to changes in<br />Facets<br />Joint synovitis<br />Subluxation<br />Cartilage Distruction<br />Discs<br />Annular tears, release of inflammatory chemicals<br />Local ischemia<br />Sustained segmental muscle hypertonicity<br />Ligamentous strain <br />
  16. 16. Instability<br />Facets<br />Increasing cartilaginous deterioration<br />Capsular laxity<br />Increased rotational movement in physiologic range<br />Discs<br />Increasing frequency of tear with coalescense<br />Nuclear and annular disruption<br />Increased translational forces<br />Changes in disc and facet increase ligamentous stress and dysfunction<br />
  17. 17. Stabilization<br />Facets<br />Loss of joint surface-cartilage<br />Intra- and extrarticular fibrosis<br />Hypertrophy and spurring<br />Joint space narrowing<br />Osteophyte formation according to Wolff’s law<br />Discs<br />Nuclear deterioration<br />Changes in collagen types<br />Endplate irregularities<br />Osteophytes and spurring<br />Disc resorption and fibrosis<br />Progressive loss of disc space height<br />Central and/or lateral canal stenosis<br />Ligamentus flavum hypertrophy and calcification<br />Nerve root scarring.<br />
  18. 18. Development Abnormal weight bearing status<br />Bogduk: Posterior elements only hold 15-20% of posterior column weight<br />(Adams-16% with relatively unloading with sitting)<br />Disc degeneration and hyperlordosis causes z-joint participating more in loading.<br />
  19. 19. Diagnosis<br />
  20. 20. Zygapohyseal Joint Pain Causes:<br />Meniscoid entrapment and extrapment<br />Synovial impingement<br />Chondromalacia Facetae<br />Capsular and synovial inflammation<br />Mechanical injury to the joint capsule<br />Inflammatory changes<br />RA, Ankylosing Spondylitis<br />Metabolic disorders—Gout<br />Villonodullar synovitis, synovial cysts, infection<br />
  21. 21. Facet (zygapophyseal)Joint pain<br />15-40% of chronic pain is due to facet joints<br />Acute injury usually starts from injury in extension and rotation, torsion injuries to the lumbar spine<br />Has referral patterns.<br />Pain often reproduced with extension and rotation<br />Clinical diagnosis of exclusion<br />Precise instillation of local anesthetic into joint or its nerve eliminates all or part of the patient’s pain<br />
  22. 22. History with Chronic LBP<br />Pain worse with extension and rotation<br />Helbig and Lee—22 patient with response to facet diagnostic injection, reported positive predictive value of 67%<br />Groin or thigh pain<br />Well-localized paraspinal tenderness<br />Pain reproduced by extension and rotation, usually toward symptomatic side.<br />Revel—Increase of pain during hyperextension and extension and rotation—Less frequent in those responding to Facet Joint injection<br />Schwarzer—Double block technique showed extension and rotation poor discriminator (26 patients/176 underwent double block)<br />Facet Capsular ligament strained most with rotation<br />
  23. 23. History<br />Fairbanks, 1983 25 patients with positive dx block<br />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.<br />Little, 2004—Cadaveric lumbar spine<br />Restriction of vertebral motion segment could cause capsular strain and stimulate capsule nociceptors.<br />
  24. 24. History<br />Revel 7 clinical features of which 5 items found together distinguishes 92% of patient responding to lidocaine injection and 80% not responding lidocaine injection:<br />Age>65<br />Pain no exacerbated by coughing<br />Hyperextension<br />Forward flexion<br />Rising from flexion<br />Extension-rotation<br />Pain relieved with recumbency<br />Unfortunately no reliable historical data!<br />
  25. 25. History<br />Manchikanti, et al: 2000<br />6 features with 4 present at one time that provided negative correlation with facet double block in 93% of patients<br />Pain not relieved in supine position<br />History of surgery<br />Occupational Onset<br />Abnormal gait<br />Positive neurological examination<br />No evidence of osteoporosis<br />Manchikanti, Laxmaiah: “The inability of the clinical picture to characterize pain from facet joints; Pain Physician, Vol3, #2, pp 158-166<br />
  26. 26. Exacerbation of Pain<br />Aggravated <br />Extension<br />Standing<br />Arching backwards<br />Rest<br />Prolonged sitting<br />Relieved<br />Flexion<br />Standing<br />Walking<br />Rest<br />Repeated movements or activities.<br />Pain is generally a deep, dull ache<br />Morning pain and stiffness, not aggravated by valsalva<br />
  27. 27. CT Usefulness<br />Schwarzer, Anthony: 1995<br />63 patient with low back pain >3 months<br />No demonstrable relationship between the degree of OA changes seen on CT scan and the presence or absence of Zygapophyeal joint pain<br />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<br />“No correlation between clinical picture, MRI, CT scan, Dynamic bending fields, SPECT scan, and radionuclide bone scanning”<br />Manchikanti: Pain Physician, Vol 3, #2 2000<br />
  28. 28. Suspected Clinical Findings Z-Joint Pain<br />Site of maximal segmental or direct articular tenderness<br />Concordant pain on provocative segmental testing<br />“Articular restriction” and local soft tissue changes such as increased muscle tone<br />Pain in recognized Z-joint referral zones<br />Injection with reproduction of pain is “not diagnostic” for Z-joint pain<br />
  29. 29. Facet Referral Pattern<br />
  30. 30. Treatment<br />
  31. 31. Treatment<br />Need to address problem based upon presumptive diagnosis<br />Injections are indicated after a minimum of 4 weeks of appropriate, directed conservative care has failed to bring relief<br />
  32. 32. Treatment<br />Relative rest<br />Medications<br />Physical Therapy<br />Avoid prone positions<br />Modalities<br />Traction<br />90/90 traction to unload facet joints(not sustained)<br />Corsets-neutral or slight flexion<br />Flexibility training in a neutral to slightly flexed position<br />Strength training<br />Flexion and lumbar neutral mechanics<br />Posterior pelvic tilt<br />
  33. 33. Treatment<br />Alan Bani: 2002<br />715 Facet joint injections in 230 patient<br />Duration of symptoms 1 week to many years<br />Follow up period of 10 months<br />1cc bupivacaine 1% followed by betamethasone if 1st effective<br />10% long lasting relief of leg and back pain<br />15.2% General improvement of pain<br />11.7% relief of back but not leg pain<br />3.9% suffered no back pain but still leg pain<br />50.4% no improvement of pain<br />Conclusion<br />“Facet joint block is minimally invasive procedure used to differentiate between facet joint pain and other causes of LBP<br />Useful to distinguish Facet pain from postoperative pain due to inappropriate neural decompression after lumbar surgery<br />Can be recommended as midterm intervention for chronic LBP”<br />Neurosurg. Focus, Vol 13, August, 2002<br />
  34. 34. Radiofrequency Denervation<br />Kleef, M: 1999<br />31 patients with 1 year chronic back pain<br />Use patients with + response to lidocaine<br />Double blind, random study<br />+ effect of VAS, Global Perceived Effect, Ostwestry Disability Scale<br />RF may be beneficial in chronic LBP<br />Random trial of radiofrequency lumbar facet Denervation fro chronic low back pain: Kleep, M Spine, Vol 24, #18, pp 1937-1942. 1999<br />
  35. 35. Medial Branch Block<br />Kaplan, Michael: 1998<br />14 Asymptomatic Individuals randomly injecting L4-5,L5-S1 Zygopophyseal joint<br />Capsular distention of Z-joint with contrast without extracapsular spread<br />Randomize saline or 2% lidocaine-medial branch injection<br />30 minutes later-repeat capsular distention with saline<br />89% inhibition pain associated with capsular distention (CI 95%-69%-100%)<br />11% False-negative rate due to venous uptake<br />If vascular uptake 50% chance of false-negative<br />Fails to block targeted joint (CI95% 11%-31%)<br />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<br />
  36. 36. Medial Branch Block<br />Manchikanti, L: 2004<br />500 patients with pain 6 months, ages 18-90 yo<br />1% lidocaine block then repeat with 0.25% Buprivacaine 3-4 weeks after 1st block<br />31% of patients with lumbar spine pain or 63% of lidocaine-positive group reported response to Buprivacaine (95% CI 27%-36%)<br />79%(313) had 2 joints involved<br />20% (80) had 3 Joints involved<br />1% (4) had >3 joints involved<br />False-positive rate 27% lumbar spine for single block<br />Facet joints are clinically important spinal pain generators with chronic spine pain<br />If failed conservative treatment: PT, Chiropractic, analgesic then benefit specific interventions designed to manage facet joint pain<br />Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions; Manchikanti,L, BMC musculoskeletal Disorders 2004, 5:15<br />http://www.biomedcentral.com/1471-2474/5/15<br />
  37. 37. Medial Branch Block<br />Dreyfuss, Paul, 1997<br />Fluoroscopic guidance effective in 85% of injection with False-negative rate of 8%<br />The targeted nerve was selectively and exclusively infiltrated<br />Injection superior border of transverse process may cause epidural/foraminal spread<br />0.5 cc of contrast adequately bathes site of the target nerve<br />No reason to use larger volumes<br />Recommended use of contrast to insure positioning over target nerve with less venous uptake.<br />Specificity of lumbar medial brance and L5 dorsal ramus blocks: A computed tomography study, Paul Dreyfuss, Spine, Vol 22, # 8, pp 895-902, 1997<br />
  38. 38. Recommendation Medial Branch Block<br />Double-block paradigm<br />Avoids false positive diagnostic injection<br />False-positive rate for facet or MBB is 38%<br />Criteria of 80% relief of pain<br />With just baseline pain<br />Also with provocative procedures <br />Loading the joint<br />MBB vs Facet injection<br />Controversial <br />Schwarzer, The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygophophaseal joint. Pain 1995:58,195-200<br />
  39. 39. Facet Injection<br />C-arm rotation<br /> 45° L4-5,L5-S1<br />30° upper lumbar facet<br />
  40. 40. Medial Branch Block<br />0.3 cc of 2% Lidocaine<br />0.3 cc of 0.5% Marcaine<br />
  41. 41. CT Guided Facet Injection<br />CT guided facet block<br />Addresses the biochemical and mechanical aspects of this problem<br />No need for contrast dye<br />Limited exposure to radiation<br />Ease of performing the procedure<br />May actually find entrance to facet<br />Has image guide to help direct needle<br />
  42. 42. CT Guidance<br />
  43. 43. Post Procedure MRI<br />Z-joint cyst of one of my patients<br />L3-4<br />
  44. 44. Summary Facet Injection<br />No physical examination correlation<br />No imaging studies valuable<br />Double injection with “concordance” supports the diagnosis<br />If young try a facet injection<br />If older and multiple disease, may want to try Medial Branch Block with follow up of RF ablation<br />
  45. 45. Epidural Injections<br />
  46. 46. Neuroaxial Anesthesia<br />
  47. 47. Precautions<br />Absolute <br />**Anticoagulation (coumadin, heparin, LMWH, ASA, Plavix, Ticlid) or coagulation disorder** <br />INR > 1.5<br />Platelets <50,000/mm3<br /><ul><li>Stop 7-10 days prior to the procedure</li></ul>Sepsis <br />Patient refusal <br />
  48. 48. Side Effects of Epidurals<br />STEROIDS <br />Generalized erythema / facial flush <br />Hyperglycemia <br />Elevated BP <br />Fluid retention <br />Weight gain <br />Bone demineralization <br />HPA suppression <br />Cushing syndrome <br />Steroid myopathy<br />Anaphalctoid reaction <br />Succinate salts: rare <br />Acetate or phosphate salts: absent <br />LOCAL ANESTHETIC <br />Paresthesia<br />Weakness <br />Hypotension <br />Cardiac arrhythmia <br />Seizure <br />Allergic reaction <br />CONTRAST <br />Allergic reaction <br />Other options<br />
  49. 49. Risks with Epidurals<br />MORE COMMON <br />Increased pain: <br />usual pain <br />Injection site<br />Bruising <br />LESS COMMON <br />Bleeding/Hematoma <br />Infection <br />Dural puncture: spinal HA <br />Extremity weakness <br />Spinal cord injury <br /><ul><li>Esp with sedation</li></ul>Intravascular injection <br />Hypotension <br />Seizure <br />CVA<br />
  50. 50. Epidurogram<br />AP<br />Lateral<br />
  51. 51. Paramedian With Good Flow<br />
  52. 52. Epidural Flow<br />
  53. 53. Caudal Approach<br />L5<br />
  54. 54. Bibliography<br />1. Dennis M. Lox, Anatomic and biomechanical principles of the lumbar spine, PM&R: STAR; Vol.13, No.#, Oct. 1999<br />2. Andrew Cole,Stanley Herring: The low back pain Handbook: A guide for the practicing Clinician, 2nd Edition, Hanley & Belfus, 2003<br />3. Carl H Shin MD; Lumbar Facet Arthropathy: e-medicine;Dec 26, 2001<br />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<br />
  55. 55. Bibliography<br />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<br />6. Douglas Fenton: Image-Guided Spine Intervention, WB Saunders, 2003<br />
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