By Jonathan Chu, MD
Interventional Pain Medicine
PM&R

Facet joints are an extremely common source of spine pain…yet most people have never heard of these joints or know what they are.

The mainstream media talk about sciatica and disc pain all the time.

However, they rarely mention facet joint pain. As a result, many of my patients are surprised and little confused when I diagnose the facet joints as the source of their pain.

“You mean that my pain isn’t coming from my discs?”

Though many people suffer from disc pain and pinched nerves—these aren’t the only structures of the spine that can cause problems.

I go on to explain that facet joint pain is actually the second most common issue I see in my practice.

Officially, it is estimated that 15 to 45 percent of all back pain originates from the facet joints!

This means that right now at this moment, there are millions of Americans who suffer from facet joint syndrome.

Thus, in a lot of ways, the facet joints are probably the most overlooked source of low back and neck pain.

In this article I’ll teach you everything you need to know about your facet joints and why they can hurt.

To start, let’s take a closer look at the structure of the joints themselves.

The facet joints are located throughout the neck (cervical spine), upper back (thoracic spine), and lower back (lumbar spine).

Many professionals also refer to them as zygopophyseal joints, or Z-joints.

They exist in pairs (one on each side) at every level of the spine.

These joints are located in the back of the spine, behind the vertebrae and discs. From a more technical standpoint, the facet joints are considered part of the posterior column of the spine. This means that they are a key part of the rear support structure of the spine.

The facet joints are synovial joints, which makes them very similar to the joints of your knuckles or knees. This means that they are surrounded by a fibrous capsule on the outside, and are lined with cartilage inside. It also means that they are filled synovial fluid, which serves as a natural lubricant.

The facet joints are classified as plane joints, which means that the two cartilage surfaces are flat and slide over one another. This unique shape is how the facet joints got their name.

Sensations and pain signals from the joints are carried by small nerves known as the medial branch nerves. These nerves are very fine, about the size of floss, and branch off from the main spinal nerve to wrap around the facet joints.

The medial branch nerves are very important because they are often targeted by physicians with nerve blocks and radiofrequency ablation procedures.

The facet joints are surrounded by multiple layers of important muscles, both small and large. These muscles help to stabilize and protect these joints, as well as the rest of the spine.

The facet joints have several important functions:

-They help to absorb loading.

-Stabilize the spine while bending forward (flexion) and backward (extension).

-They help limit the rotation of the spine.

These facet joints work closely together with the discs in the front of the spine. The discs are flexible cartilage pads between the vertebral bones on the spine. At every level of the spine, there is a disc in the front, along with the two facet joints in the back, and together these three joints form what is called a motion segment.

The motion segment is the fundamental functional unit of the spine.

The facet joints and the disc work together all through the day to support tremendous amounts of stress and loading, and are what allow you to bend and rotate in so many different ways.

As you can see, the facet joints are absolutely key and have a multitude of important jobs, and often take quite a bit of abuse as you go through your daily activities.

Unfortunately, this is why the facet joints are a very common source of pain in the neck and low back.

Several types of injuries and abnormalities can occur with facet joints.

Degenerative and arthritic changes of the facet joints are the most common I see in my office.

Dislocation and fracture can also occur at these joints, causing a great deal of pain.

Additionally, it’s important to keep in mind that the discs and facet joints work very closely together.

Hence, problems with the facet joints tend to affect the discs, and vice versa. This why degeneration is often seen in all 3 joints at the same time, and it is common for doctors to diagnose both disc and facet issues simultaneously.

Arthritis and Degeneration of the Facet Joints

Let’s focus on degenerative changes of the facet joints, since this is by far most common cause of facet joint pain.

Over time, after years and years of various stresses on these joints, they will often begin to wear out.

Your doctor may be able to see these changes on your X-rays or MRI, and will often refer to them as arthritic or osteoarthritic changes.

Let’s take a step closer and see what this really means.

As the facet joints age and degenerate, a number of changes can take place.

First, the cartilage inside the joint begins to thin and erode. Microscopic fissuring and flaking can often take place.

The capsule around the joint becomes thicker and more fibrous. The joint can also become more swollen and become surrounded by increased blood vessels.

The bone of the facet joint can also thicken, deform, and develop cysts and spurs.

All these changes can sound somewhat scary and make many patients very nervous.

But it’s important to keep in mind that degenerative changes of the facet joints are exceedingly common, and degeneration does not directly correlate with pain.

In fact, it has been shown that:

Almost 60% percent of adults over the age of 65 have some degree of arthritic changes in the neck.

And

Nearly 90% of adults over the age of 65 have arthritic changes of the facet joints in the low back.

As I often tell my patients, no human being on planet Earth can escape developing some degree of degeneration of the spine if they live long enough.

Of course, arthritic facet joints are often more prone to developing painful inflammation compared to young and healthy facets.

However, there are many people who live pain-free in spite of having facet arthritis.

Furthermore, pain flare-ups due to facet arthritis are very treatable.

Later in the article I’ll go further in depth into exercises and lifestyle changes you can do to actively manage your facet issues. I’m also going to delve further into interventional treatments that can be tremendously effective for flare-ups of facet pain. 

How Does Facet Joint Pain Present?

People with facet joint pain usually experience pain well-localized to the neck or the low back.

Cervical (neck) facet pain can often radiate into the shoulders and back of the head, often triggering headaches. Additionally, it can frequently cause aching and soreness in the area right between the shoulder blades.

Lumbar (low back) facet pain can commonly radiate into the buttocks and thighs. Once in a while it can radiate as far as the calves, though this is rare.

In general, facet pain tends to worsen with both back bending (extension) and rotating. It also tends to improve with bending forward (flexion).

My patients typically describe the pain as dull and aching in character. It can also be sharp in quality and is usually associated with muscle spasms.

Often, the facet joints will be tender when I palpate them.

Lastly, pain originating from the facets tends to worsen with standing and walking for long periods of time, and improves with sitting.

Treatments for Facet Joint Pain

Here’s the good news: facet joint pain is very treatable.

There are several very effective interventional procedures that exist for this condition.

In fact, facet joint procedures are some of my favorite to do, since they tend to work very well in patients who are accurately diagnosed.

Facet joint injections:

With this procedure, your physician will directly inject your painful facet joints with help of X-Ray guidance (fluoroscopy). During procedure, your physician will introduce a mixture of corticosteroid and numbing medication right into the joint itself.

The goal of this procedure is to decrease inflammation of the joint, quelling your flare-up for a few months. This gives you a great opportunity to rebuild your strength and mobility in physical therapy and your home exercise program.

Medial branch blocks:

This procedure is intended to be a diagnostic tool more than a treatment. With this procedure, you physician will target the small medial branch nerves that carry pain signals from the facet joints.

With the help of X-Ray guidance (fluoroscopy), you physician will use needles to inject numbing medication over these medial branch nerves. This serves to numb the facet joints for several hours.

If your pain is significantly improved during this period of time, then your physician has confirmed your diagnosis of facet joint pain. You can then move on to having a radiofrequency ablation (RFA) for much longer term relief.

Radiofrequency Ablation (RFA):

If you had good relief with your medial branch block, then you’ve confirmed that the facet joints are the source of your pain. Then, you can move on to the radiofrequency ablation procedure, which provides a much longer duration of pain relief.

With this procedure, you physician will direct special needles into place directly over the medial branch nerves. After doing stimulation testing for safety, each area is numbed with medication. Next, the tip of each needle is heated up, creating small burn over the medial branch nerves.

Afterwards, the medial branch nerves can no longer carry pain signals, blocking the facet joint pain for a long period of time, often up to 12 months!

Personally, the RFA is one of my favorite procedures to do, because it has a lot of strong scientific evidence supporting it, and it just works really well in properly selected patients.

Exercise and Lifestyle

Furthermore, as I discussed earlier, these facet joints are surrounded by multiple layers of muscle.

These include the small intrinsic muscles that are deep along the spine, as well as the large erector spinae muscles that closer to the outside.

These muscles are absolutely essential for providing stability and protection to the facet joints. As they become stronger, wear and tear on the joints decreases. This can help slow down the degeneration of those joints.

More importantly, this also means less frequent and intense flare-ups.

This why I emphasize the importance of physical therapy and developing a long-term home exercise program for every single one of my patients with facet pain—regardless of whether or not they are getting injections also.

The core muscles serve as crucial scaffolding for the spine, and you need to develop these muscles so that your facet joints are supported and protected in the long term.

Often times when the joints are very acutely inflamed and the pain is very severe, it can be difficult to participate in physical therapy or do the home exercises properly.

This is why, in my opinion, it’s best to initially control acute facet pain with an intervention such as a facet injection or radiofrequency ablation, and then follow it with physical therapy and a consistent home exercise program.

Injections are a big part of my practice and definitely can be very helpful, but in the long term there is no substitute for diligent work on your part!

Lastly, I also want to mention a few lifestyle factors that can be very important.

It has been shown that age, sex, and weight, are all factors that affect facet pain.

Obviously, you can’t change your age or gender.

However, you do have tremendous control over your weight.

It has been shown that higher levels of obesity correlate with worsened severity of facet joint arthritis, as well as back pain in general.

Hence, putting in the effort to lose weight not only is great for preventing heart disease and diabetes, it can also help to prevent back pain flare-ups.

Many of my patients have noticed significant improvements in their facet joint pain from losing as little as 10 pounds!

I know that losing weight is far easier said than done. The majority of my patients struggle with it, and I have yet to hear a single patient say it was an easy journey. It takes tremendous willpower and discipline. However, the myriad of health benefits of getting to a healthy weight, especially with regards to spine health, makes it so worthwhile to invest consistent effort into nutrition and exercise.

References:

Gellhorn AC, Katz JN, and Suri P. Osteoarthritis of the spine: the facet joints. National Review of Rheumatology. 2013 Apr; 9(4): 216–224.

Jentzsch T, Geiger J, Slankamenac K, Werner CM. Obesity measured by outer abdominal fat may cause facet joint arthritis at the lumbar spine. Journal of Back and Musculoskeletal Rehabilitation. 2015; 28(1):85-91.

Manchikanti L, Hirsch JA, Falco FJ, and Boswell, MV. Management of lumbar zygapophysial (facet) joint pain. World Journal of Orthopedics. 2016 May 18; 7(5): 315–337.

Saravanakumar K, Harvey A. Lumbar Zygapophyseal (Facet) Joint Pain. Reviews in Pain. 2008 Sep; 2(1):8-13.

Son JH, Kim SD, Kim SH, Lim DJ, Park JY. The Efficacy of Repeated Radiofrequency Medial Branch Neurotomy for Lumbar Facet Syndrome. Journal of Korean Neurosurgical Society. 2010 Sep; 48(3): 240–243.