Facet Joint: Everything You Need To Know
A facet joint is made of the top and bottom articular process of two adjacent vertebrae. Each spinal segment has two facet joints. Facet joints prevent the vertebra from slipping. They keep the spine in place. However, they are prone to degradation over time, which can lead to chronic back pain.
In this post, you can learn about facet joints, what they are, how they get injured, and what the treatment options are.
What Is A Facet Joint?
The bones that make up your spine are called vertebrae. Each vertebra has different components which include the body (front part) and posterior elements (back part). Each vertebrae is stacked on top of each other.
They are connected in the front part by the intervertebral disc and connected in the back by a pair of joints which are called facet joints. There is one facet joint on each side of the spine (right and left).
Its Functions For The Body
The facet joints limit the rotation of the spine and assist with the flexion and extension of the spine. This allows the spine to bend and twist. Due to the interconnection between the joints, movement is also restricted. The facet joints prevent over-flexion or overextension of the spine, thus protecting the spinal cord within.
Traumatic Injuries Affecting This Joint
The pars interarticularis, which is the lamina between the superior and inferior articular processes, is prone to stress fractures or spondylolysis due to stress and overuse. In other words, the bone that connects the back and front parts of the vertebrae are common fracture sites called pars fractures.
Here are some of the most common traumatic injuries affecting the facet joint.
- Acute Facet Injury: Acute injuries to the facet joints can occur due to accidents, falls, or sports-related trauma. Car accidents, even at speeds as low as 10mph, can cause havoc on spines. Force on your spine is comparable to a Mike Tyson (in his prime) full-force punch to the face!
- Recurrent Minor Traumas: Recurrent minor trauma due to occupations and sports which require frequent bending, twisting, or heavy lifting can cause stress on the processes, leading to trauma.
- Posture-Induced Injuries: Posture plays a very important role in balancing the forces acting on the spine. A spine that is not supported while sitting, standing or working places undue stress on the facet joints. The natural curvature of the spine distributes these stresses across the joints equally.
However, in an unsupported spine, certain parts of the spine experience more strain, which stresses the facet joints leading to fractures over time.
- Facet Dislocation: In facet dislocation, one of the vertebral bodies slips forward over the other. This anterior displacement causes the facet joint to dislocate and occurs due to forced flexion of the spine.
- Articular Process Fracture: If the spine is forced to flex and rotate beyond its normal physiological limit, the articular process of the facet joint can fracture. This can happen when falling from a great height, a motorcycle accident, or even a gunshot wound.
- Facet Capsule Strain: The facet joint is a synovial joint that is protected by a capsule. This capsule can be strained due to inflammation, which causes pain. If the joint is inflamed, the fibers of the capsule become stretched, leading to pain and swelling.
Degenerative Conditions Affecting This Joint
The facet joints are susceptible to degradation over time. Here are a few conditions that cause degeneration of the facet joints. The above mentions causes of facet injuries, also cause damage to the surrounding structures which creates instability in the spine. If left unchecked, the instability will eventually increase the stress on the spine causing degeneration!
Osteoarthritis of the facet joints is also known as facet arthropathy. Age-related degenerative changes occur over time. This includes degradation of the cartilage, which causes erosions and narrowing of the joint space. Part of this degenerative condition is facet joint syndrome.
The facet joints can break over time due to their mobility. As it breaks down, inflammatory mediators like prostaglandins and cytokines appear, which cause pain, activating the pain fibers of the nerves.
While degeneration happens over time, it does not equate to pain! The vast majority of people have degeneration but have zero pain.
Due to the degeneration of the synovium of the joint, cystic lesions of the synovial and ligamentous structures of the spine can occur. These are known as lumbar cysts when seen in the lumbar spine.
The synovial lining breaks down due to repetitive motion and stress, which leads to the formation of a cyst. Usually, the cyst is empty. However, in some cases, there may be calcifications in the cyst or it may have other fluid content.
Types Of Facet Joint Syndrome
Facet joint syndrome can affect the cervical, lumbar, or thoracic spine. These are explained in detail below.
Cervical facet joints are a common cause of nociceptive pain. Studies show that cervical facet joint syndrome has an estimated prevalence of about 25% to 66% in chronic neck pain (1). These can occur due to degeneration, or even acute whiplash injuries.
The lumbar facet joints play an additional role in not just balancing the spine and movement but also transmitting the weight to the legs. This additional stress on the lumbar facet joints makes them more susceptible to wear and tear, possibly leading to lumbar facet joint syndrome.
It is most often seen at the L4-L5 spinal level and constitutes about 15-45% of causes of lower back pain.
Thoracic facet joint pain is not as common as lumbar or cervical pain. However, the disability in thoracic facet joints is similar. It generally occurs between the 3rd to 6th thoracic vertebrae. This is mainly due to the anatomical positional change of thoracic facet joints. When it affects the thoracic facet joints, it can lead to chest and back pain.
It has been hypothesized that when external forces act on thoracic vertebrae, the facet joints dislocate incompletely. The synoviums of joints get drawn into the dislocated cavity due to the negative pressure which sucks it in. This leads to pain and dysfunction.
Common Causes Of Facet Joint Syndrome
Here are some common causes of facet joint syndrome. Facet Joint Syndrome is a basic way to say pain coming from your facet joints!
- Degeneration of discs due to age and pressure overload: Aging can cause loss of joint space, joint space narrowing, loss of synovial fluid, and loss of cartilage or bone growth. High-grade cartilage necrosis progresses rapidly in facet joints. Repetitive stress and overload can also cause wear and tear to the facet joints.
- Spondylolisthesis: This occurs when the vertebrae are displaced due to the subluxation of the facet joints. There is a progressive loss of cartilage and articular remodeling, leading to instability in the segment.
This stretches the capsule of the joint and is commonly seen at L4–5 level in older individuals. In younger people with acute fractures due to trauma or congenital abnormalities, it occurs at the L5-S1 level.
- Obesity: Obesity can put increased strain on the facet joints, especially in the lumbar region, as these joints are involved in weight distribution. This may also cause degeneration of the facet joints over time.
- Trauma: Accidents, falls, or sports injuries, where there is a twisting of the spine, can cause the facet joints to fracture.
- Abnormal Posture: The spine has a kyphotic curvature in the thoracic area. The natural curvature of the spine helps to distribute weight. With a bad posture, some parts of the spine are under greater duress than normal. Over time, this additional stress wears out the facet joints of the spine.
Symptoms Of Joint-Related Disorders
The symptoms of facet joint disorders can overlap with many other spinal conditions. They vary in intensity and time. These are listed below.
- Dull ache in the lower back that may radiate towards the buttocks in the case of lumbar facet joints
- Neck pain and headache if cervical facet joints are affected
- Sharp pain while bending or twisting the back
- Back discomfort due to prolonged standing or inactivity
- Back spasms that periodically flare up
- Back stiffness
- Sore muscles of the back or neck
- Pain radiating to the legs
Who Is At Risk Of Joint Degeneration?
Individuals who are at risk of facet joint degeneration have the following risk factors:
- Are overweight or obese
- Are between ages 40-70
- Have a previous history of spine injury or trauma to the spine
- Are sportsmen who bend or twist often
- Have occupations that involve frequent, heavy lifting
- Demonstrate postural abnormalities
- Have past history of torn ligaments
Are These Conditions Preventable?
You can prevent degeneration of the facet joints by doing the following:
- Practice good posture. Don’t slouch or bend too often while working.
- Take frequent breaks from heavy lifting or prolonged sitting.
- Maintain a healthy weight.
- Avoid smoking, as it can constrict your blood vessels and deprive the joints of oxygen and nutrients.
- Eat a balanced diet so that you don’t gain weight easily. Your diet should also contain the recommended dose of vitamins and minerals necessary for your joints.
- Try to avoid trauma by using safety gear like driving with your seat belt, using a harness if working at heights, and wearing the right gear for sports activities.
Examination And Diagnostics
The following tests are helpful in diagnosing facet joint conditions:
- Physical Examination: A physical examination can point to the facet joints as a source of back pain, but cannot confirm it. A thorough neurological exam is done to ensure there are no trapped nerve roots. While no single diagnostic test can show is a facet joint is a painful joint – mostly based on the physician examination and history of the issue
- X Rays: AP, lateral, and oblique views are usually ordered for facet joints. Oblique radiographs are the best to assess facet joints of the lumbar spine because of their oblique position. Lateral films are useful to look at pars interarticularis defects. If there is a very severe disease, X-rays can visualize the pathologic process.
- CT Scans: CT is the preferred imaging for facet joint disorders. It can reveal joint effusion, associated degenerative spondylolisthesis, or synovial and subchondral cysts.
- MRI: An MRI is useful for assessing soft tissues. It can show the consequences of facet joint degeneration, such as surrounding neural structure impingement.
- Single-Photon Emission Computed Tomography (SPECT): Radionuclide bone scintigraphy is a test done with Technetium-99m labeled bisphosphonates. The patient is given these labeled medications which reach the bones. Under the CT, the labeled medications light up on CT and can detect facet joint inflammation.
There is increased osteoblastic activity and synovial changes secondary to inflammation and remodeling of the bone.
The following alternatives for treating patients with facet joint-related conditions have been used successfully:
To treat facet joint syndrome, physical therapy that involves manual therapeutic techniques can improve the alignment and mobility of the spine. This treatment includes joint mobilization and stretching of the back muscles. This helps a person overcome restricted motion so they can carry out daily activities of living.
Self-care includes heat therapy or massage therapy. Heat can cause vasodilation and increase blood flow to the area. This can ease pain and inflammation temporarily. Massage therapy has also been employed to ease the discomfort associated with facet joint syndrome. There are limited studies to confirm its success (2). This also works by increasing circulation to the area.
Medications for facet joint syndrome usually target pain. They include acetaminophen, nonsteroidal anti-inflammatory drugs, muscle relaxants, and antidepressants.
Facet joint injections include long-acting corticosteroids. They work by suppressing the immune system and inhibiting nerve transmission within pain fibers. They can be given with local anesthetics into the facet joint, around the facet joint, and other branch injections.
Usually, patients experience temporary pain relief. Another alternative is the diagnostic blocks of nervous structures which cause pain. These blocks commonly include local anesthesia, like lidocaine or bupivacaine with or without steroids.
Platelet-rich plasma (PRP) is a regenerative medicine therapy that involves using a patient’s own blood to create a concentrated solution of platelets and growth factors. PRP is processed in a centrifuge to create a mixture of platelets and growth factors, which can be injected into the site of injury or tissue damage to stimulate tissue regeneration and healing, reduce inflammation and pain, and promote the formation of new blood vessels. We have been using PRP for facet joint syndromes for many years now!
Neurolysis (Radiofrequency Ablation – RFA)
There are many types of neurolysis. This can be via radiofrequency ablation chemicals or cryo-neurolysis. During neurolysis, the surgeon denervates the area of the facet joint. The ideal candidate for this treatment is someone who underwent medial branch infiltration with significant pain relief after conservative management failed.
Nerve fibers can be destroyed by physical heat via radiofrequency or cold via cryo-neurolysis, or by chemical means with alcohol or phenol. It provides pain relief, improves disability, and reduces the need for analgesic medications.
What is the best choice out of the above treatments:
- Kim et al. (2012) conducted a retrospective case series of 26 patients who received PRP injections for lumbar facet joint pain. The study found that the majority of patients reported significant improvement in pain and function scores, and that there were no major adverse events associated with the injections.
- Lee et al. (2018) conducted a randomized controlled trial to evaluate the effectiveness of intra-articular PRP injections in patients with chronic facet joint pain. The study found that the PRP group had significantly greater improvement in pain and function scores than the control group at 6 months after the injection.
- Patel et al. (2019) conducted a randomized, double-blind, placebo-controlled trial to evaluate the efficacy of PRP injections for the treatment of chronic low back pain originating from the facet joints. The study found that the PRP group had significantly greater improvement in pain and function scores than the control group at 12 weeks after the injection.
There is no evidence to support the use of surgery for facet joint conditions, especially facet joint syndrome. Nonoperative treatment is the treatment of choice and when that fails, surgical intervention is considered. Optimal surgical management includes decompressive lumbar laminectomy and non-instrumented or instrumented lumbar fusions.
When Does Surgery Become Necessary?
Surgery is a last resort for facet joint disorders, but may be necessary for the following conditions:
- When conservative treatment with medications, physical therapy, acupuncture, or nerve blocks fails.
- Those with a displaced vertebra or a condition involving the foramina of vertebrae.
- Individuals with grade I or II lumbar spondylolisthesis.
Don’t Take Spinal Disorders or Injuries Lightly
Injuries to the facet joints can affect your spinal cord if they are ignored over time. If you have a spinal injury or back pain, it must be treated right away. Facet joint disease can become chronic and progressive if it is not treated. Various lifestyle changes have to be made to reduce the stress on the facet joints.
At CSC, we use various treatments, including regenerative medicine, to treat injuries or conditions associated with facet joints. Find out if you are eligible for regenerative therapy if you have injured your facet joint. Schedule an appointment with one of our board-certified physicians.
Christopher J. Centeno, MD
Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…Read more
John Schultz, MD
John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training in both. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Dr. Schultz trained at George Washington School of…Read more
John Pitts, M.D.
Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.Read more
Jason Markle, D.O.
Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.Read more
Brandon T. Money, D.O., M.S.
Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…Read more
Am I a Candidate?
- Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review. Arch Phys Med Rehabil. 2008;89(4):770-774. doi:10.1016/j.apmr.2007.11.028
- Zhou KL, Dong S, Ji W, et al. Effects of massage therapy for patients with thoracic facet joint disorders: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020;99(49):e23480. doi:10.1097/MD.0000000000023480