Facet joint syndrome, facet osteoarthritis cause of chronic back pain?

Facet syndrome refers to pain originating from the joints joining the vertebrae, i.e. the facet joints.

The problem is reported to affect approximately 15  to 45% of people with chronic back pain .

Pain is not the only problem. It is associated with various unpleasant sensations, such as tingling or armor. They are technically referred to as paraesthesias.

These difficulties can radiate to other parts of the body and, in the long run, reduce the quality of life and, to some extent, also disability.

Facet syndrome occurs most often in the lumbar and at the passage of the lumbar spine to the rump. The pain shifts to the buttocks and lower limbs. In a lower proportion, it also affects the neck area.

The causes of the difficulties are diverse. At a young age after overloading the spine, to degenerative changes due to the aging of the body.

The pain recurs in the attacks but may persist over time.

What are facet joints? 

First, we present brief information about the spine, which will lead the issue to facet joints.

The spine is made up of small bones - vertebrae. We have 33 to 34 vertebrae. According to the place of storage, we divide them into vertebrae of the neck, chest, stem, croup, and coccyx. 

Spine = vertebral column, 
vertebrae = vertebrae. 

Vertebrae, their number, and sections of the spine:

1. cervical vertebrae - vertebrae C ervicales = 7  - C1 , C2 , C3 , C4 , C5 , C6 and C7
2. thoracic vertebrae - vertebrae Th oracicae = 12 - Th1 to Th12
3. lumbar vertebrae L umbales = 5 - L1 to L5
4. sacral vertebrae - vertebrae S acrales = 5 (or 6) S1 to S5 (S6),
   form sacrum , sacrum axis
5. coccyx - vertebrae Co coccygeal = 4 or 5 = Co1 - Co4 (Co5)

The vertebrae have their specific shape, which gives them a special functionality across the entire spine. The individual sections differ in their static and dynamic properties.

The cervical spine is the most mobile, the ribs are fed by the ribs, the lumbar spine is the most loaded, the sacrum is connected to the pelvis. And the coccyx also has its significance, from the point of view of movement and posture.

In addition to carrying the body's weight, creating support for the body and the locomotor component, the spine has the important function of protecting the spinal cord.

The spinal cord connects the brain, ie the central nervous system (CNS), to the periphery, that is, to the body. Its function is both transferable and reflective.

The fact that the spinal cord is hidden in the spine allows the typical shape of the vertebrae.

The composition of the vertebrae is as follows:

1. vertebral body - corpus vertebrae
2. vertebral arch - arcus vertebrae
3. vertebral processes - vertebrae process

1. Vertebral body

The body of the vertebra is the anterior part, which is formed by the bone. In the upper and lower part, there is a flat surface on which intervertebral discs - discs (disc intervertebral) are fed. 

The first two cervical vertebrae have their own shape, thus adapting them to the function of connection to the head and to movement, more precisely to rotation and rocking.

The first cervical vertebra - C1, which is connected to the skull, and is also referred to as the atlas -  carrier. 
The second cervical vertebra - C2, named capicle - axis, which contains the census tooth - dens axis. This allows rocking movements of the head up and down.

There are no intervertebral discs between the first two vertebrae.
They are located from C2 - C3 to the vertebrae L5 and S1. And their number is 23 pieces.

Like the vertebrae, the discs also have different sizes. Smaller in the neck and wider in the lumbar region. As it is in the stem that the highest static and dynamic overload of the spine occurs.

2. Vertebral arch

The arch of the vertebra is formed by two plates. They recede from the body of the vertebra - with their feet. The feet are technically referred to as pedicles. 

Thus, after withdrawing from the body of the vertebra, two plates pass along the sides. They form a vertebral opening - foramen vertebral and together with other vertebrae a  spinal canal - canalis vertebralis .

The spinal cord runs through the spinal canal.

This is by withdrawing from the brain from the C1 vertebra to approximately the second lumbar vertebra. In the L2  region, a tangle of nerves separates from the spinal cord, which is referred to as kauda equina , ie the horse's tail.

3. Vertebral projections 

The protrusions protrude from the arch of the vertebra. They connect the vertebrae and participate in the movement, just like the intervertebral disc.

We know several types of protrusions, namely:

1. trnov projection 
   • spinosus process
   • it extends from the arch of the vertebra directly backward
   • there is only one
   • can be felt on the back under the skin
   • connection of muscle and tendon attachments
2. transverse protrusion 
   • the transfer process
   • pair of protrusions
   • muscle strengthening 
   • in the section of the thoracic spine, the attachment of the ribs
3. articular process 
   • articulatory process
   • pair of protrusions
   • in place behind the foot of the vertebral arch
   • articulated joints of vertebrae - facet joints
   • contain cartilage

Intervertebral joints - facet joints

Intervertebral joints, in Latin articulatio intervertebrales form a movable connection between individual vertebrae. They allow movement, but also restrict it in order to maintain a certain range of mobility of the spine.

Facet joints (FK), also Latin articulations zygapophysial = articulations intervertebral.

Thus, the facet joints allow movement + determine the given range of mobility of the individual segments and thus also form a stabilizing component. Restriction of movement and stabilization of the spine prevents excessive bending of the spine.

Two facet joints + intervertebral disc =  three-joint complex .

Intervertebral disc at the front and a pair of facet joints at the rear in one segment.
This connection is movable, but at the same time firm and allows the spine to bend and rotate. 

Facet joints contain cartilage, synovial fluid, and an articular capsule. The inter-articular space represents the size of approximately 1 to 2 milliliters of synovial fluid.

They are located from vertebrate level C2 to S1.

Disease changes in one place - they affect the other place, ie they interact with each other, and thus transmit mechanical changes to the entire segment.

Damage to the intervertebral disc has a negative effect on the facet joint and vice versa.

The area of ​​the facet joint is richly innervated. Nerve fibers are a source of pain in various difficulties. 

The nerve supply of the facet joints: 
The rear branch (ramus dorsalis) nerve root (exiting the spinal cord that - spinal nerve), of which the withdrawing arm medial (medial branch).
One branch of the nerve arm sensitively innervates the upper and lower joint.

Anatomical knowledge of the location of this nerve supply is of important diagnostic therapeutic (therapeutic) importance. 

And that's why facet syndrome is ...

For this reason, facet syndrome is a set of symptoms that are based on irritation of nerve endings near these small intervertebral joint surfaces.

The pain may come from one or more facet joints.

It stems from an articular capsule, fibrous cartilage, or nearby soft structures. Causes and manifestations can be diverse and individually variable.

However, facet syndrome can be confused with other diseases. Therefore, a professional examination is important for long-term back pain.

The cause of facet syndrome is mechanical or inflammatory stimulation of nerve endings in a given intervertebral joint.

Inflammatory irritation =
biochemical and immune changes due to damage, cell injury -
not due to infection. 

Facet syndrome also occurs in the young population.
It is mainly an overload of the intervertebral joints due to excessive load. The source can be physical or sports activity  (sports requiring high or impact performance, in the event of sudden changes in movement and position).

Excessive load = microtraumatization of joints.

It is more common due to degenerative changes that are the cause of aging. Thus, this syndrome is also present in the elderly.

In this context, a degenerative process involving the intervertebral joints is known -  spondylarthrosis. The problem arises from the disruption of the connection between the joint surface, the narrowing of the joint space, the reduction of the fluid content, the damage to the cartilage, it is also related to the diseased growth of bone growths - osteophytes.

Degenerative processes begin at a young age and are present in everyone after the age of 60.

The degenerative process, inflammatory changes, or injury to the facet joints are associated with damage to the intervertebral disc, ie osteochondrosis. Alternatively, the difficulties stem from synovitis, which is inflammation of the joint capsule.

Risk factors are:

• age
• gender, more in men
• orientation of facet joints
• degenerative disk changes
• physical overload
• obesity
• incorrect posture
• long-term unilateral load (working environment)
• spinal injury
• malnutrition
• smoking

In the case of facet syndrome, it is necessary to think about the initial stage of rheumatic and autoimmune diseases, such as axial spondylarthritis, ankylosing spondylitis, rheumatic or psoriatic arthritis.

Other causes include spondylolisthesis and spondylolysis with interruption of the isthmus. A disease state caused by the displacement of two vertebrae. It occurs mainly at the level of L4 - L5, in young people.

An uncommon cause is a synovial cyst or septic infection.

Cysts are described in spondyloarthritis and can also cause nerve oppression and associated radiculopathy. The infectious disease is rather secondary, in addition to spondylodiscitis (inflammation of the vertebra and disc) in the spread of bacteria through the bloodstream, more rarely in TB of the spine.

Summary of causes :

1. degenerative process
   • osteochondrosis
   • spondyloarthritis
2. spondylolisthesis and spondylolysis
3. excessive overload of the spine, sport, physical activity
4. spondyloarthritis (autoimmune diseases)
5. injury
6. less often
   • synovial cyst
   • infection

Facet syndrome is manifested by pain that is resting, early, starting (after prolonged inactivity at the beginning after agitation). The pain intensifies, especially in the caster body.

The highest load on the facet joints is with the extension of the spine - with the bend
and with the lateral tilting of the spine.

Pain radiation may also be present.

And in lumbar facet syndrome to the sciatic muscles - buttocks, hips, groin, lower limbs, thigh (outer part and back) to the level of the knee. Abdominal and pelvic pain are also reported.

These problems are reminiscent of sciatica .

When afflicted with cervical segment (cervical facet syndrome - cervical facet syndrome) -
it is to move from the neck in arms, blades, and upwards into the head.

Unpleasant sensations (paraesthesia) such as tingling or tingling may be associated. However, the nature of the spread is pseudoradicular , ie it is not sharply limited and is not accompanied by sensory disorders or muscle weakness.

Plus.

There is increased muscle tension, spasms of the paravertebral (spinal) muscles, and limited mobility in a given section of the spine, similar to an acute lumbag.

Alleviate the difficulties delivers the position of leaning forward. Relief also occurs during physical activity. The pain can be one-sided, but also on both sides.

Facet syndrome - typical symptomatology :

• long-term back pain, more than months to many years
• the pain is dull to burning
• gradual onset of difficulties
  • with repeated attacks of pain
  • later persistent pain
• morning stiffness of the spine
  • morning pain
  • pain during inactivity, during inactivity
• muscle spasms increased tension
• starting pain to stir
• increase in pain intensity
  • when tilting the hull
    • the associated slower erasure of the bend
  • when rotating the hull
  • when palpating, palpating at the site of the problem
• improvement in forward bending
  • improvement in physical activity
    • beware of overwork, increases the intensity of difficulties
• painful walking up the stairs
• nocturnal pain when changing position
  • waking up from sleep
• the pain worsens the cold
  • similarly, meteosensitism is present - the influence of weather
• the pain is dampened by dry heat
• spread of pain to the limbs
• the psycho-social burden for the disabled

The diagnosis is based on anamnesis. The doctor takes detailed information about the pain, its onset, spread, relief mechanisms, and more.

Followed by a physical examination, this includes an examination by sight (from each side and in different positions), palpation, evaluation of the condition of the spine, posture, gait, forward bend, leaning. 

X-rays, CT, and magnetic resonance imaging are important. These imaging methods can detect the structural changes present and also serve for differential diagnosis (revealing the true cause of difficulties).

However, none of these methods will determine the diagnosis 100%. Therefore, the intervention method follows. 

The diagnostic-therapeutic method is facet block - selective blockade of the medial arm innervating the facet joint.

It involves injecting a locally acting anesthetic into the nerve area near the joint. The examination, procedure, takes place under USG or CT control.

The injection of the medicine has a relief effect.

The pain condition is then monitored on the second day and then for another 14 days. The person in question writes down the course in a diary, which is then evaluated by a doctor.

When the difficulties subside by more than 75%, it is a facet syndrome. If the blockade did not have an effect, another disease must be sought. The application of facet blockade is performed during several sessions, one procedure has no diagnostic level.

The course of the disease is individual and also depends on the cause and extent of the damage.

First, repeated attacks of difficulty may occur. These are repeated for months. Over the years, difficulties can occur permanently. 

Deteriorating their position in the bend and rotation of the torso, longer periods of inactivity - inactivity. Typical are the morning and start- pain - pain in camera shake.

Similarly, the sufferer may wake up from sleep as a result of an increase in intensity when changing position. Walking up the stairs is problematic and there is a risk of excessive strain on the spine during certain activities and sports.

Pseudoradicular propagation present, which is not precisely limited. From the neck to the head, shoulders, or shoulders. In the case of the stalk to the buttocks, groin, thighs to the knees, not lower. Pain can radiate to the abdomen and pelvis.

The muscles of the back are tense, stiff, and thus the mobility of the affected area of ​​the spine is reduced.

Relief is brought by a change of position, from sitting to standing, physical activity. Similarly, the position in the forward bend.