facet arthropathy
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TRANSCRIPT
Facet Syndrome
Paul S. Jones, D.O.PM&RHarry 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
symptomsFacets
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!
• 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
History
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 painThe 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 LBPRandom 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
L3-4
Z-joint cyst of one of my patients
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
• 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
Bibliography