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Thoracic Facet Arthropathy

Background & Etiology

Facet Joints

Each vertebral level of the spine consists of three joints. There is a joint between the bodies of two vertebra connected by an intervertebral disc, and two facet joints which connect one vertebra to the other. The facet joints are on the posterior aspect of the spine, with one located on each side. These three joints form a tripod system. The function of the facet joints is to provide support, stability and mobility to the spine. In addition to promoting mobility, these joints also help restrict excessive motion. This ensures that the spine moves with precision.

The facet joints are synovial joints, which have articular cartilage that covers the ends of the bones. Articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other. In addition, each joint is surrounded by a protective sleeve of soft tissue called a capsule, and is lubricated by synovial fluid. Each joint can be a source of pain if irritated or inflamed.

Arthritis is described as the wearing, degeneration, or loss of articular cartilage in a joint. The three most common types of joint arthritis are osteoarthritis, rheumatoid arthritis, and traumatic arthritis. Arthropathy occurs when arthritis affects the facet joints.

Causes

Facet joints, like other synovial joints, are susceptible to wear and tear, degeneration, inflammation and arthritic changes. Inflammation and degenerative changes to the facet joints may result in pain, loss of motion, and if severe encroachment or pinching of the nerve exiting the spinal column. Causes of facet joint arthropathy include:

  • Degeneration or general wear and tear of the joint, can cause arthritis.
  • Disc degeneration may cause loss of height between vertebra, placing a greater compression force on the posterior facet joints.
  • Extension (backward) motions can produce compression on the facet joints which can lead to degenerative and eventual arthritic changes.
  • Sudden fall or trauma like a motor vehicle accident can result in a facet joint irritation.
  • Genetic factors can contribute to the likelihood of degenerative joint disease.
  • Repetitive stress injuries like those from lifting or carrying heavy loads, or performing over the head motions that keep the neck and head in an extended position can cause facet joint irritation.
  • Muscle weakness and poor posture.
  • Joint stiffness.
  • Sedentary lifestyle.

Symptoms

When a facet joint is irritated the symptoms will depend on the location of the facet joint and what soft tissue structures are affected. Symptoms can vary from mild to severe and may mimic the symptoms of a disc problem. Other common symptoms include:

  • Pain in the neck, shoulder blade or radicular to the shoulder into the arm. Pain is rarely felt in the hand or fingers.
  • Pain and tenderness localized at the level of the involved facet joint.
  • Muscle spasm and changes in posture in response to the injury.
  • Loss of motion of the neck including an inability to turn the head, look up or bend backward, or move sideways to the effected side.
  • Sitting for extended periods of time or performing activities overhead will be difficult.
  • Increased size or visible deformity of the joint.
  • A sensation of “cracking” or “crunching” with movement of the spine.

Treatment

Treatment of facet joint arthropathy will depend on the severity of the condition. Treatment recommendations for thoracic facet joint arthropathy include:

  • Rest: avoid the activities that produce the pain (overhead activities, lifting, or twisting, of back)
  • Medication to reduce inflammation (anti-inflammatory drugs and pain medication)
  • Ice: apply ice to the cervical spine to help reduce pain and associated muscle spasm. Apply ice right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
  • An exercise regiment designed specifically to address the cause of the symptoms and facet joint irritation.
  • Bracing or the use of supports may be necessary to reduce stress on the facet joints, muscles and thoracic spine.
  • Steroidal medication to reduced inflammation in moderate to severe conditions.
  • Facet joint injections directly to the involved joint.
  • Physical therapy to reduce inflammation, restore joint function, improve motion, and help return to full function.

Mild

In mild cases rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.

Moderate to Severe

If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.

Medical Interventions

In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:

  • X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
  • MRI to determine any soft tissue involvement including visualization of the discs, spinal cord and nerve roots.
  • CT scans, which can give a cross section view of the spinal structures

Medications

Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasms that may be associated with facet joint injuries.

  • Over the counter medications for mild to moderate pain.
  • If over the counter medications are not effective your physician may prescribe stronger pain medication.
  • Anti-inflammatory drugs or prescription NSAIDS (non-steroidal anti-inflammatory drugs) to reduce inflammation following acute injury.
  • Muscle relaxers to reduce acute muscle spasm.
  • Injections such as facet injections, nerve blocks or epidural injections. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.

Severe or Non-Responsive Condition

In the case of conditions that do not respond to conservative care surgery may be indicated. If you continue to experience some of the following symptoms surgery may be necessary:

  • An increase in radiating or radicular pain
  • Pain or nerve irritation that gets worse
  • Associated disc involvement

Surgical Intervention

If symptoms persist destruction of the tiny nerves at the facet joint may be performed. If there continues to be significant pain a joint fusion may be indicated.

Physical Therapy

Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.

Your physical therapist will perform a thorough evaluation to assess and determine the following:

  • Spinal examination where the patient is put through a series of movements and tests to determine the most probable cause of your current back condition.
  • Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
  • Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making one more susceptible to disc and back injuries.
  • Posture Analysis, ADL’s and technique: discuss and observe the activity that may have started the problem. Examination of dynamic and static postures that may have cause or contributed to your current back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.

Physical therapy for back and facet joint problems must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved while improving strength and stability to the spine. Your program design will be based on the structure and cause of your symptoms. A program not tailored to your problem could aggravate your symptoms.

Physical Therapy Interventions

Common Physical Therapy interventions in the treatment of facet joint arthropathy include:

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the thoracic spine. Use of mobilization techniques also help to modulate pain.
  • Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the back and abdominals to support, stabilize and decrease the stresses place on the spinal joints, and discs.
  • Neuromuscular Reeducation (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured spine.
  • Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation spinal structures.
  • Home programs including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.

Prognosis

Most facet problems improve without surgery and return to normal function. Duration of treatment can range from 4 to 12 weeks depending on the severity of the symptoms. Patients need to continue with a regiment of stretching, strengthening and stabilization exercises. Use of proper mechanics, proper posture, body mechanics and awareness of the do’s and don’ts for a healthy back is necessary for a good prognosis long term. Remember, “once you have a neck problem, you have a neck problem” goes a long way to preventing further injury.