Symptoms and diagnosis of facet joint problems

Facet joint disorders are some of the most common of all the recurrent, disabling low back and neck problems, and can cause serious symptoms and disability for patients. However, facet joint problems rarely involve the spinal nerves.

Back conditions that may be confused with facet joint problems
Interestingly, when the acute lumbar or cervical facet joint inflammation is at its peak, the symptoms may closely imitate those of a herniated disc, a deep infection, a fracture or a torn muscle of the spine, or in the low back, sometimes an acute intra-abdominal problem. Clearly, such episodes can be very disabling and frightening.

On the other hand, serious problems in the abdomen may mimic lumbar facet joint problems and deep anterior neck problems may imitate cervical facet disorders, so a good differential diagnosis must rule out such things. True arthritis as a source of facet degeneration and pain can also be involved and this possibility should be examined.

Symptoms of facet joint problems
A correct diagnosis must await subsidence of the acute problem. Symptoms may include the following:

• Acute episodes of lumbar and cervical facet joint pain are typically intermittent, generally unpredictable, and occur a few times per month or per year.

• Most patients will have a persisting point tenderness overlying the inflamed facet joints and some degree of loss in the spinal muscle flexibility (called guarding).

• There will typically be more discomfort on slightly leaning backwards than on leaning forwards.

• Low back pain from the facet joints often radiates down into the buttocks and down the back of the upper leg. The pain is rarely present in the front of the leg, or rarely radiates below the knee or into the foot, as pain from a disc herniation often does.

• Similarly, cervical facet joint problems may radiate pain locally or into the shoulders or upper back, and rarely radiate in the front or down an arm or into the fingers as a herniated disc might.

Recurrent painful episodes can be frequent and quite unpredictable in both timing and extent. Patients are often left with the notion that this is a psychosomatic problem, and it may even be implied that “it’s all in your head.”

In the lumbar case, standing may be somewhat limited but sitting and riding in a car is the worst. So-called “limited duty” (sitting) assignments for patients with low back pain are paradoxically bad. When at its height of pain and disability, the muscle spasm is so continuous that the fatigued muscles begin to hurt themselves and a vicious cycle begins.

Diagnosis of facet joint problems
When the almost unpredictable painful episodes recur on a monthly basis or more often, plain anterior-posterior (front-back), lateral (side view) and oblique (off angle) X-ray films should be made and examined. Usually the abnormal facet changes can be seen. However, a CT scan can obtain more information about not only the facet joints but also other structures of the spinal segment.

The MRI scan is not quite as useful for diagnosing this particular spinal problem, but is extremely helpful when investigating possible disc or abdominal pain contributors.

Perhaps the most definitive diagnosis of facet joint pain can be made by a facet joint injection (or facet joint block), which injects the suspicious facet joints with a small volume of a combination of x-ray contrast material, local anesthetic and cortisone. Relief of the acute or chronic problem during the time of action of this combination of drugs is diagnostic.