New research on a common condition among older patients – facet joint pain – has highlighted to the importance of understanding “events” that might cause this condition among younger patients. According to a study conducted at Johns Hopkins University and presented to the American Society of Regional Anesthesia and Pain Medicine (ASRA), there is a correlation between specific precipitating events and their treatment outcomes.
This condition is typically caused by the wear and tear of the facet (pronounced fa SET) joints and can lead to their deterioration and pain among the nerves surrounding them. It also affects younger patients to a lesser degree. The objective of this research was to determine how injuries from sports or whiplash from automobile accidents respond to the current treatments for this condition. Patients in the study who reported a specific precipitating event were one-and-a-half times more likely to have a positive outcome than those who could not recall a specific event leading to their pain.
What Causes Facet Joint Pain
“The facet joints are the connecting joints located between each of the vertebrae in the spine,” Dr. Patel said. “We have a pair of facet joints on the back part of our spine, from the neck all the way to our lower back.
“The reasons for pain among these joints could include wear and tear, which can lead to arthritis, or it could be some specific trauma or injury that causes a strain on these joints or associated ligaments. It is a common condition, especially among older patients, and it usually affects the lower back (lumbar region) with the next most common area being the neck. It is rare to find this condition in the mid-back.”
Treatment or Facet Joint Pain
Texas Back Institute treats hundreds of patients each year who present with this painful condition. Dr. Patel explains the standard treatment approach.
“If it is an acute onset and no other treatments have been provided,” he said. “We have the patient start on an anti-inflammatory medication for two weeks, start physical therapy and see how they respond to non-invasive measures.
“However, if the patient does not respond to these non-invasive measures and the pain is relentless, we will use what is known as facet joint injections. These are done for both diagnostic and therapeutic reasons. From these injections, we can confirm that these facet joints are the cause of the patient’s pain and treat the pain with small amounts of steroids. If this treatment calms down the pain and inflammation, we have a starting point.
“In a case where the patient gets a good response from the anesthetic, meaning their pain disappears or improves significantly over the next 48 hours, but they don’t get long-term pain relief, we employ a procedure called radiofrequency ablation of the facet joint, also known as a rhizotomy. This is a needle procedure, performed on an out-patient basis, that is done to anesthetize the facet joint. Many patients think this procedure is surgery, but it’s not. In fact, it is only slightly more invasive than an injection. It takes a little longer to perform than the injection, but we are essentially going to the same area of the spine with a similarly sized needle.”
The Importance of Understanding the Injury
This Johns Hopkins research points to the importance in the determination of the “participating event” in the treatment of facet joint pain. Why is this important?
“It may indicate a specific injury or trauma that led to this pain,” Dr. Patel said. “In my practice, I will typically see facet joint pain among patients who are middle age or elderly who, over the years, have developed arthritis. They will complain of pain from certain movements – whether it is twisting or hyperextension – that aggravate their pain. Typically, the patients describe a sharp, stabbing pain on one side or both sides of their spine, which is usually worse in the morning hours.
“If it is a younger patient, understanding the participating event is more important because there is less wear and tear than with older patients. For example, they might say they had been participating in a sports activity and they twisted and suddenly got the acute pain on either right, left or both sides. This helps the doctor determine whether it is the facet joint that might be causing this pain. When this is suspected, the next step is to ‘load’ the facet joints during the clinical exam and see if the physical pain is aggravated.”
How the Radiofrequency Ablation (Rhizotomy) Treatment Works
“Each facet joint has a pair of pain nerves that are associated with it,” Dr. Patel said. “They are microscopic in size and their only function is to conduct pain signals from that joint to the brain.
“If we put a numbing agent in or around that nerve or the joint, the patient will typically feel relief. That’s how we diagnose the problem. If they only derive short-term results, we go in with a needle to that pain nerve and turn on a radiofrequency cautery that heats up to a certain number of degrees. This cauterizes that pain nerve.
“Patients are sometimes concerned about whether this procedure will affect their function, such as moving a certain muscle or sensing something in that area. The answer is no. There are other pain nerves in the disc and around the muscle that will sense pain. This is a very targeted procedure to stop that chronic, ongoing pain in the facet joint.”