Facet Joint Osteoarthritis / Spondylosis

Facet-mediated joint pain typically presents with an insidious onset of central or biased unilateral lower back pain in patients over the age of 40. Referred pain is less common but can on occasion be referred into the buttock region; this would be in a non-specific dermatomal radiation pattern. Numbness and weakness of the lower extremities are not indicative of isolated facet joint arthropathy, but due to the degenerative changes, they may have concurrent lumbar radiculopathy via nerve root irritation.Source: Lumbar Facet Arthropathy – StatPearls – NCBI Bookshelf (opens in a new tab)

As a general rule, pain originating from the facet joints would typically manifest as back pain worse than leg pain, as opposed to pain originating from nerve root compression, which would give leg pain worse than back pain. This distinction is important, as it helps guide treatment pathways and highlight appropriate patients that would benefit from surgical intervention. Red flags (acute bowel and bladder changes, saddle anaesthesia, high-velocity trauma) should not be described and should point the practitioner away from the facet joint as the pain generator.Source: Cauda Equina and Conus Medullaris Syndromes – StatPearls – NCBI Bookshelf (opens in a new tab)

Despite its prevalence, many patients will remain asymptomatic, with a poor correlation between the severity of radiographic changes and severity of a patient’s symptoms.Sources: Lumbar Facet Arthropathy – StatPearls – NCBI Bookshelf (opens in a new tab); Facet joint disorders: from diagnosis to treatment – PubMed (opens in a new tab)

For these reasons, diagnosing facet joint disease as the sole cause of a patient’s lower back complaint is often challenging, let alone pinpointing a patient’s symptoms to a specific vertebral level. Physical examination may reveal localised para-lumbar tenderness; symptoms may be provoked by spinal extension and rotational movements and eased with spinal flexion; however, the sensitivity and specificity of such movements and physical findings in accurately diagnosing facet-mediated joint pain are poor.Sources: Facet Joint Disease – StatPearls – NCBI Bookshelf (opens in a new tab); The diagnostic accuracy of the Kemp’s test: a systematic review – PMC (opens in a new tab)

Imaging will still be used in the workup if symptoms persist, typically an MRI scan to exclude other potential causes of axial lower back pain and reduce the diagnostic window. Diagnostic medial branch blocks at two separate levels are the gold standard for diagnosing facet joint pain, with a significant reduction (80%) in axial symptoms following the procedure.Source: Facet Joint Injection – StatPearls – NCBI Bookshelf (opens in a new tab)

For the mainstay of isolated lower back pain, there are no surgical indications (excluding traumatic causes due to spinal instability, malignancies or infectious causes).

• Period of relative rest. For acute episodes of lower back pain +/- leg symptoms (without red flag symptoms), the vast majority will self-resolve within 12 weeks without any medical input.Source: Facet Joint Disease – StatPearls – NCBI Bookshelf (opens in a new tab)
• Physiotherapy and exercise. This is an important aspect of any lower back complaint to reduce the risk of chronic symptoms, improving spinal capacity, resilience and tolerance. The best exercises are the ones the patient will be compliant with. Evidence does not support one specific rehab/exercise programme over another.Source: Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis – PubMed (opens in a new tab)
• A short course of NSAIDs may be helpful at settling an acute flare in lower back pain. They are not intended for long-term use given the potential adverse effects on the gastrointestinal tract and renal function.Source: Non-steroidal anti-inflammatory drugs for acute low back pain – PubMed (opens in a new tab)
• For refractory cases, an ultrasound-guided facet joint injection of local anaesthetic and steroid can be helpful diagnostically and provide a therapeutic benefit. This is most commonly administered at the L4/L5 and L5/S1 levels either unilaterally or bilaterally. This intervention should be combined in a multipronged approach including compliance with appropriate rehab and exercise.Sources: Lumbar zygapophyseal joints injections under ultrasound guidance an alternative to fluoroscopy guidance in the management of low back pain – PMC (opens in a new tab); Efficacy of Ultrasonography-Guided Injections in Patients with Facet Syndrome of the Low Lumbar Spine – PMC (opens in a new tab)
• Other treatment options include medial branch denervation, which can provide additional longer-term benefit in certain patients but is not utilised in our clinics.Source: Radiofrequency Denervation on Lumbar Facet Joint Pain in the Elderly: A Randomised Controlled Prospective Trial – PubMed (opens in a new tab)

Surgical management

Surgery for facet joint osteoarthritis is rarely indicated, but if a patient experiences severe symptoms without benefit from conservative options, then a spinal fusion may be considered. Unfortunately, even with this arthrodesis procedure, residual symptoms are still common.Sources: Lumbar facet joint stabilisation for symptomatic spinal degenerative disease: A systematic review of the literature – PMC (opens in a new tab); Spinal Fusion for Chronic Low Back Pain: A ‘Magic Bullet’ or Wishful Thinking? – PMC (opens in a new tab)