facet arthropathy

55
Facet Syndrome Paul S. Jones, D.O. PM&R Harry S. Truman, VA

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Page 1: Facet Arthropathy

Facet Syndrome

Paul S. Jones, D.O.PM&RHarry S. Truman, VA

Page 2: Facet Arthropathy

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?

Page 3: Facet Arthropathy

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

Page 4: Facet Arthropathy

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

Page 5: Facet Arthropathy

Historical• Schmorl and Junghanns

– Introduced concept “motor segment”,functional spinal segment or motion segment

– Adjacent lumbar vertebral disc, intervertebral disc, and facet joints.

Page 6: Facet Arthropathy

Anatomy

Page 7: Facet Arthropathy

ANATOMY• Bone

Relationships• LIGAMENTS

– ANTERIOR LONGITUDINAL LIGAMENT

– POSTERIOR LONGITUDINAL LIGAMENT

– LIGAMENTUM FLAVUM

Page 8: Facet Arthropathy

TYPICAL LUMBAR VERTEBRAL BODY

Page 9: Facet Arthropathy

NEUROLOGICAL RELATIONSHIPS

• Osteophytic spurs or Anterior herniated disc– Symptoms related

to SNS of levels involved

• Facet Exostosis– Nerve root

symptomsFacets

Page 10: Facet Arthropathy

Vertebral Innervation

Zygophophyseal joint:

Nociceptive fibers

Nociceptive Mediatiors

Page 11: Facet Arthropathy

Anatomy

Page 12: Facet Arthropathy

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

Page 13: Facet Arthropathy

Degenerative Cascade

Page 14: Facet Arthropathy

Degenerative Cascade Model

• Based upon work of Kirkaldy-Willis– Stage I: Dysfunction– Stage II: Instability– Stage III: Stabilization

Page 15: Facet Arthropathy

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

Page 16: Facet Arthropathy

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

Page 17: Facet Arthropathy

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.

Page 18: Facet Arthropathy

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.

Page 19: Facet Arthropathy

Diagnosis

Page 20: Facet Arthropathy

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

Page 21: Facet Arthropathy

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

Page 22: Facet Arthropathy

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

Page 23: Facet Arthropathy

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.

Page 24: Facet Arthropathy

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!

Page 25: Facet Arthropathy

• 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

Page 26: Facet Arthropathy

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

Page 27: Facet Arthropathy

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

Page 28: Facet Arthropathy

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

Page 29: Facet Arthropathy

Facet Referral Pattern

Page 30: Facet Arthropathy

Treatment

Page 31: Facet Arthropathy

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

Page 32: Facet Arthropathy

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

Page 33: Facet Arthropathy

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

Page 34: Facet Arthropathy

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

Page 35: Facet Arthropathy

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

Page 36: Facet Arthropathy

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

Page 37: Facet Arthropathy

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

Page 38: Facet Arthropathy

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

Page 39: Facet Arthropathy

Facet Injection

C-arm rotation

45° L4-5,L5-S1

30° upper lumbar facet

Page 40: Facet Arthropathy

Medial Branch Block

0.3 cc of 2% Lidocaine

0.3 cc of 0.5% Marcaine

Page 41: Facet Arthropathy

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

Page 42: Facet Arthropathy

CT Guidance

Page 43: Facet Arthropathy

Post Procedure MRI

L3-4

Z-joint cyst of one of my patients

Page 44: Facet Arthropathy

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

Page 45: Facet Arthropathy

Epidural Injections

Page 46: Facet Arthropathy

Neuroaxial Anesthesia

Page 47: Facet Arthropathy

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

Page 48: Facet Arthropathy

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

Page 49: Facet Arthropathy

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

Page 50: Facet Arthropathy

Epidurogram

AP Lateral

Page 51: Facet Arthropathy

Paramedian With Good Flow

Page 52: Facet Arthropathy

Epidural Flow

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Caudal Approach

L5

Page 54: Facet Arthropathy

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

Page 55: Facet Arthropathy

• 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