Facet joint syndrome, also known as facet joint dysfunction, is a condition that affects the small joints located in pairs on the back of the spine.
Facet joints, called so, crucially provide stability and enable flexibility in the spine.
When these joints become irritated, inflamed, or injured, it can lead to facet joint dysfunction.
Anatomy of Facet Joint
Some important factors which leads to facet dysfunction are:
(1)anatomical variations that limit articular movement;
(2) anatomical variations that permit excessive movement;
(3) malaposition of the articular surfaces secondary to loss of disc height;
(4) The facet articular cartilage softens and undergoes fibrillation.
(5) loose bodies in the facet joint
(6) synovial thickening;
(7) classical changes of osteoarthritis, progressing from fibrillation to complete loss of articular cartilage and osteophytic thickening of the facets.
Facet Joint Dysfunction
In some cases, radiologically demonstrable vertebral shift is associated with some of these factors; in others, the abnormal movement is considered to be more subtle.
it is not surprising that this has given rise to semantic arguments about the concept (and indeed the very existence) of a condition called ‘segmental instability’,
which could give rise to otherwise inexplicable low-back pain.
in an attempt to explain the back pain on the basis of disordered biomechanics of the spine (or a spinal segment).
Many recognized that patients with chronic backache may develop intermittent episodes of severe pain with radiation into the buttock and thighs, even in the absence of any sign of intervertebral disc prolapse.
Fairly modest lifting strains usually trigger these attacks, but they can also occur ‘spontaneously’.
Kirkaldy-Willis suggested that the symptoms are due to abnormal movement and mechanical stress at the posterior facet joints
Emerging due to either a local injury or the non-specific ‘dysfunction’ of the lower lumbar vertebral segments.
he theory is controversial, partly because of differences about the meaning of the word ‘instability’
in this context and partly because some patients with demonstrably abnormal vertebral motion have no symptoms at all.
Radiological images indicating instability may or may not be deemed conclusive proof of mechanical instability by a bioengineer.
Symptoms of Facet Joint Dysfunction
the clinical appearances of this syndrome are easily recognizable.
The patient, usually a young adult engaged in bending and/or lifting activities, they can experiences mild backache from time to time.
This often leads to a specific episode of heightened back pain, potentially accompanied by discomfort in the buttock or the back of the thighs, yet without genuine neurological symptoms.
Rest, mobilization exercises, or chiropractic manipulation typically alleviate the pain, only for it to return a few weeks or months later following a comparable episode of physical strain.
The one with an established case reports intermittent backache associated with periods of strenuous work, prolonged standing, bending, or extensive walking, and occasionally following prolonged sitting during lengthy journeys.
Most patients find relief by lying down, or sitting and resting when backache appears during strenuous activity.
A suspicion of ‘instability’ is favoured in as much as the patient achieves relief through recumbency.
However, a large minority of patients describe a contrasting pattern: pain aggravated by rest and recumbency and partially relieved by movement
they usually manage full forward bending without discomfort but backward bending (which stresses the facet joints more) is dramatically halted by pain.
Interestingly, pathological features of OA have been described in specimens excised at surgery during operations for intractable back pain of this pattern (Eisenstein and Parry, 1987).
With time, pain becomes more constant and can sometimes be temporarily relieved only by manipulation, local warmth and anti-inflammatory drugs;
at that stage there are likely to be x-ray signs of osteoarthritis in the facet joints.
Examination during a painful episode may reveal muscle spasm, local tenderness and restriction of back movements, but little else.
Occasionally, skilled manipulation dramatically relieves the patient who presents with a ‘locked back’.
During intervals between acute attacks, physical signs are less apparent and frequently not persuasive.
While the range of movement might not be significantly restricted, the distinctive pattern of movement is often discernible.
characteristically the patient bends forward quite easily but when asked to return to the upright position
he or she does so with a noticeable ‘heave’ or ‘catch’, sometimes seeking support by pressing upon the thighs.
Straight-leg raising may be slightly restricted (in this case only because of back pain), but neurological examination is normal.
Treatment
Whatever pattern the back pain may present, the pain may be sufficiently distressing or disabling to justify treatment in increasing degrees of invasiveness.
Conservative measures:
General care and attention
Poor understanding has led to the neglect of the condition, and unless there is a very obvious abnormality amenable to surgery,
patients soon feel that the doctor has lost interest in their complaints. Little wonder that many of them turn to ‘alternative’ practitioners for help.
Healthcare providers should give them a clear explanation of the likely cause of their symptoms and an outline of the proposed treatment.
In more enlightened (and better-supported) centers, patients enroll in a ‘back school.’
Physical therapy
Conventional physiotherapy, including spinal ‘mobilization’, often relieves pain dramatically at least for a while.
In the longer term, weight control and strengthening of the vertebral and abdominal muscles will make for fewer recurrences.
There is also no reason why orthopaedic surgeons and chiropractors or osteopaths should not be able to collaborate in designing treatment programmes
drug therapy
one may need mild analgesics for pain control.
Healthcare providers still prefer long-term non-steroidal anti-inflammatory drug (NSAID) medication over the drastic remedy of spinal fusion surgery, but they should combine it with an appropriate gut protector such as omeprazole.
However, beware the one who becomes dependent on increasing doses of medication.
Spinal support
A soft lumbar support may give relief in some cases; Obese patients benefit from pulling their center of gravity in close to the spine.
Modification of activities
One of the most important aspects of treatment is modification of daily activities (bending, lifting, climbing, etc.) and specific activities relating to work.
The patient may need retraining for a different job. The co-operation of employers is essential.
Psychological support
Chronic back pain can be psychologically as well as physically debilitating.
he or she often welcome counseling and support.
Perhaps the most successful treatment is the reassurance that the surgeon can provide for the vast majority of patients, to the effect that the patient has no serious spinal disease.
Trigger point and facet joint injection
If clinical and x-ray signs point consistently to one or two facet levels, injection of local anaesthetic and corticosteroids may be carried out under fluoroscopic control.
Most patients can expect to gain short-term benefits, and some may experience relief from symptoms for periods exceeding a year.
Lumbosacral trigger points (Travell, 1983) in the midline or along the iliac crests, are a common finding in chronic low back pain.
If they are focal and consistent they may respond dramatically, if only temporarily, to deep soft tissue local infiltration without the need for fluoroscopic control