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Facet Syndrome Symptoms and Treatments
Treatments for Facet Syndrome are very often unnecessary. Facet syndrome is a typical result of the standard aging process. Usually pain does not result in the majority of people, however there are those that can experience severe pain symptoms that may find benefits by experimenting with various treatments.
Ongoing treatment of conditions such as facet joint syndrome, is the main perpetuator of the chronic back pain epidemic. The only thing worse than convincing people that a relatively symptom-free condition requires ongoing treatment, is the flip side of the coin. Treatments for facet joint pain offer mostly symptomatic relief.
Options for Facet Syndrome Treatments follow:
Physical Therapy: (Increases the comfortable range of motion and increases circulation and oxygenation.)
Surgery: Last resort Laminectomy and / or spinal fusion, for severe unresolved pain.
Medicine: Use of drugs for back pain.
Heat: Unusual treatment for a skeletal disorder. If heat therapy works, the diagnosis of facet syndrome is most likely incorrect. Heat works best for pain due to oxygen deprivation or muscle injuries.
Acupuncture: (all natural symptom relief.)
Posture: Patient learns how to move more comfortably.
Chiropractic: Manipulation of bones that are in pain from movement… Makes sense? Not really. Relief from chiropractic might indicate another real cause of the pain.
Newer more modern treatments include one procedure that terminates the nerve endings of the facet joint. While an invasive outpatient procedure, facet rhizotomy also offers a good alternative to traditional surgery for chronic back pain.
Recommendation for Facet Syndrome Treatments
Remember that facet syndrome is normal. We will all get it as we age. You can not expect to have gray hair, wrinkles and be far sighted, but still have the facet joints of an 18 year old…
If you suffer from chronic treatment-resistant facet syndrome, I would recommend knowledge therapy as an alternative approach to a real cure. It worked for me…
It is unlikely that severe pain is caused by facet syndrome. If you have minor symptoms, relax. Try some conservative treatments. I would recommend holistic and natural treatments over pharmaceutical pain relief. If surgery becomes your only option, make sure to be confident in the diagnosis and the surgeon, to improve your chances of a positive result.
Evolving Understanding of Facet Syndrome
For nearly 100 years, spinal experts have discussed and studied the facet joint and the role it might play in the thousands of cases of back pain whose origins can't be traced to disc disorders or other types of mechanical conditions. In 1911, J.E. Goldthwait first described the lumbar facet joint as a potential source of back and leg pain. Some 20 years later, the term "facet joint syndrome" first appeared in the medical literature.
"In the vast majority of low-back pain cases, the etiology is unknown, and that's where facet joint syndrome comes in," says Partap Khalsa, DC, PhD, DABCO, an associate professor of biomedical engineering, orthopaedics, and neurobiology at the State University of New York at Stony Brook, and also the vice chairman and graduate program director for the department of biomedical engineering. That's also where, over the years, some controversy has arisen. At times, questions have been raised as to whether facet syndrome is a legitimate cause of back pain. But recent research bears out long-standing biomechanical theories as to what's behind facet syndrome and what role it may play in certain cases.
Once facet syndrome as a clinical entity began to receive increasing attention from practitioners, it was distinguished by its pain pattern. "The pain typically followed a scleratogenous, rather than a radicular, distribution," says Dr. Khalsa. "This was a different type of referred pain that didn't follow the classic, well-mapped-out, radicular distribution associated with disc problems." Clinical studies using injections-some involving anesthetic to stop pain referral and others involving injection of isotonic saline to recreate the pain in healthy volunteers - seemed to bear out the idea that at least some cases of back pain with specific scleratogenous distribution could be traced to facet syndrome.
But what was really going on in the facet joint? "What had never really been done previously, and what my lab has done in recent studies, is to go in and measure the biomechanics of the ligamentous capsule during physiological motions," explains Dr. Khalsa. "We then showed that the stretch-or what biomechanically is called the strain-that develops in the capsules is substantial, even in physiological motion."
Using a human cadaveric spine model specimen, Dr. Khalsa and his colleagues also simulated a hypomobile subluxation, and measured how that affected the strain distribution patterns in the facet joint capsule. "There were significant changes, confirming, or at least validating, some of the biomechanical theories that have previously been proposed," he says.
After documenting the biomechanical effects of hypomobility on the facet joint capsule, the logical next step was to assess what happens in the capsule during chiropractic manipulation. Using the same cadaveric model, in a study presented at RAC in spring 2004 and submitted to the Spine Journal, Dr. Khalsa and his colleagues simulated standard high-velocity, low-amplitude manipulations to the lumbar spine to measure how the manipulation itself affected the strains on the facet joint capsule. "As far as the capsule is concerned, our model shows that manipulation is biomechanically safe," Dr. Khalsa says. "The strains produced were on the same order of magnitude as those produced by full physiological motions, but did not exceed them. They also showed a profound effect on the facet joint capsule as an innervated structure."
Next on the agenda is work with computational models of the lumbar spine that include realistic geometry and material properties of the facet joint and its capsules. "These are real phenomena going on, and we've clearly established that," says Dr. Khalsa. "The next step, from a bioengineering perspective, is to develop models that allow us to do the kind of exploration on the computer that's difficult to do in the laboratory."
Limitations of Imaging
One category of radiographic findings that may prove helpful is spinographic findings-relationships shown on postural x-ray. "There are some moderately significant correlations there," says Dr. Banks, who published research in this area in the early 1980s."If you do weight-bearing x-rays and analyze the position of the segments, they are much more in extension in symptomatic patients, as opposed to asymptomatic patients. With patients who have back pain attributable to the disc, the spinographic findings tend to be the opposite-fairly lordotic and moderately in flexion."
Imaging may be useful, but it has its limitations. "There are some standard pathological findings, like facet arthrosis. But the difficulty with that finding is that like any other degenerative changes in the spine, it has a fairly high rate of appearance in asymptomatic populations," Dr. Banks says. "Anything you see commonly in asymptomatic patients, you must be careful about drawing an association in pain patients. The great majority of people with clinical facet syndrome have negative pathological findings."
Dr. Wyatt agrees. "Occasionally on plain film radiography in an older person, you may find facet arthritis, but the evidence is equivocal about radiographie findings showing the facets as pain generators," he says. "On an MRI, sometimes you'll see fluid in the facet joint and sometimes that fluid suggests inflammation of the synovium in the facet joint, indicating facet synovitis or capsulitis. But you don't need to do an MRI with these patients, because they are neurologically intact."
How Many Cases?
The overall prevalence of facet joint syndrome as a cause of back pain remains unknown.
"Is it involved in 5% of cases? 10%? 30%? 80%?" asks Dr. Khalsa. "We don't know that yet. We haven't developed precise diagnostic measures, from a clinical perspective, that can allow us to unambiguously say, 'Aha! This person's pain is due to facet joint syndrome.' But I think it's been clearly identified that there is facet joint syndrome. It's a real syndrome, and it happens to real people."
He adds that facet joint pain tends to be induced by spinal motion, particularly during the extension of the neck or back. "There's also general tenderness when palpating over the facet joint. And one of the major indicators is the absence of neurologic findings. Your patient has this radiating pain, but nothing neurological to suggest that it's coming from nerve root compression."
"If neurologic symptoms are present, it takes you well out of the category of facet syndrome," agrees Dr. Banks. "But if they're not present, it doesn't automatically put you in that category. You can, for example, have disc lesion without neurological findings."
The physical exam, Dr. Banks notes, either adds to the evidence for facet syndrome or points toward something like a disc problem, which may easily be confused with facet syndrome. "For example, the facets are more loaded in extension, and the disc is more loaded in flexion," he explains, "so something as simple as finding out whether the patient has a primary block of ability to flex or extend can help draw you toward disc problems and away from facet syndrome, or vice versa."
Another differentiating factor is the patient's radiographie posture. Both groups of patients-those with disc disorders and those with facet syndrome-have a decreased sacral base angle compared to the asymptomatic population, Dr. Banks says, but there the similarity ends. "Disc patients lose their lumbar lordosis, so that they stand in a very rigid, alordotic posture. Facet patients, on the other hand, have normal lordosis, so the thoracolumbar junction tends to be displaced posteriorly compared to an asymptomatic patient."
Indeed, says Dr. Banks, it's thought that posture may be a predisposing developmental factor for facet syndrome. "That may be why there is this small, but significant, subgroup of people whose mechanical back pain tends to be facet pain. Other people can do the exact same activities and precipitate sacroiliac or disc-based back pain, instead."
Tom Bergmann, DC, a professor in the methods department and faculty clinician at Northwestern Health Sciences University, says distinguishing between back pain that's associated with the facets and pain that's associated with the discs may be difficult and not always necessary. "Certainly, the facets are a well-documented source of pain; however, it's an elusive diagnosis in that it's very difficult at best to be certain that this is the source of someone's back pain," he says. "I really believe that we should consider the functional units of the spine as 3-joint complexes when we treat back pain. When there are problems in the facets, there are probably going to be problems in the disc, and vice versa, and it's difficult to say with a degree of diagnostic certainty that the facets are involved and the discs aren't, or vice versa. I don't think you can separate them."
"Consider what might happen in a car accident, for example, in which someone sustains a significant flexion-extension injury," Dr. Bergmann explains. "The facets are going to take the brunt of that, there's no doubt. There will be injury to the capsular ligaments, but the disc also takes a load with those movements. The acute injury may be to the facet joints, but if something isn't done to help provide proper function, the disc is going to start undergoing internal derangement. The more involvement you have, the more extensive treatment will be and the longer it will take."
Studies on the prevalence of facet joint involvement in cases of chronic low-back pain vary widely-stating that it's involved anywhere from 8% to 75% of the time, according to Carl H. Shin, MD, a member of the consulting staff of the department of physical medicine and rehabilitation at the University of Pennsylvania. "Reported incidence seems to be a function of the size of the sample studied and the conviction of the authors," he observes wryly.
"In some patients, spinal facet syndrome is a cause of back pain, but of course, there are many more possible causes," says Scott Banks, DC, who maintains a private practice in Virginia Beach, Virginia, and is a long-standing postgraduate faculty member at Logan College of Chiropractic. "Classification and treatment of spinal facet syndrome has often involved invasive approaches, such as 'blocking' injections into the facet joint to anesthetize the nerve, and then ablation of the nerve, should the injection prove successful." If that sounds like a fairly extreme solution, Dr. Banks says, it is. "When you take that kind of approach out of frustration, you have a frustrating outcome. Diagnostic blocking injections, when they lead to temporary relief, are certainly more indicative that there is facet syndrome involved. But if invasive treatment is done without appropriate preceding diagnostic testing, you can have a bad outcome."
While it is not completely determinative, a physical exam plus the patient's history can help the DC draw a profile that leads either toward or away from spinal facet syndrome, Dr. Banks explains. "Facet syndrome tends to involve pain that localizes to the lumbosacral region. Contrast that, for example, with sacroiliac pain; although it has some symptom overlap, it tends to localize more to the sacroiliac joint below the lumbosacral margin. If a person with facet joint involvement has leg pain, it tends to be proximal, in the upper leg only." Patients with facet joint syndrome also report a very deep, aching pain, rather than a distal leg pain or specific paresthesia that would point more toward disc involvement.
"Interestingly, facet joint-related neck pain may radiate into the arm or shoulder, but it won't radiate past the elbow," adds Larry Wyatt, DC, DACBR, a professor in the division of clinical sciences at Texas Chiropractic College. "If it's localized low-back pain, the pain won't radiate past the knee. Now, if the pain doesn't radiate past the knee or elbow, it doesn't automatically mean patients have facet joint syndrome, but if it does radiate past those landmarks, they probably don't."
To be continued...
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