Facet Joint Pain Explained

hello this is dr grant cooper from princeton spine and joint center what i'd like to do with this video is talk to you about facet joint pain and specifically how you go about diagnosing facet joint pain because it's an area where there's often a lot of confusion and it's very important if you're dealing with facet joint pain so what i'd like to say at the outset is that if you have facet joint pain or if your you and your doctor are thinking that you might have it and you're curious about it then i think this is going to be a very valuable uh discussion we're about to have if you don't have facet joint pain or you're not interested in facet joint pain then i appreciate you tuning in but this is going to get pretty into the weeds on facet joints so this one might not be for you all right that said let's jump into the facet joints whether or not you have in your lower back or neck we're going to address both of them because the way we go about diagnosing them is actually sort of the same so the first thing just to mention um is when you talk about when you talk about diagnosing something often we start with a history right the person the patient will say when do they experience the pain what makes it better what makes it worse etc in the lower back the facet joints are usually worse when you're standing and leaning backwards because that loads the facet joints and they usually feel better when you're bending forward and sitting if you lined up 10 fellowship-trained spine people in a room we would all say the same thing that that's that's what we would understand to be true and at the same time what we would all have to acknowledge is that whenever we do studies to look at it we're never able to prove that that actually is the case and in fact facet joints can can present in in lots of different ways so we can't rely um on the history in order to make the diagnosis but certainly with a lower back if if um if standing and leaning backward makes the pain worse and bending forward makes the pain better we start to think facet joint pain in the neck facet joint pain looks really identical to disc pain so the history isn't going to be very helpful in that regard in the neck the facet joints are by far the most common cause of chronic neck pain in the lower back they are the second most common cause of chronic back pain so that's good to keep in mind as well physical exam um again in the lower back if we load the facets by having the person extend backwards and especially to the sides and that reproduces the pain that's suggestive of facet joint pain but it's not diagnostic of it similarly in the neck if the person you know leans their their knit their head back extends the neck and that reproduces it that could be facetune it could be disc it's not diagnostic of the pain mri is going to be the best diagnostic tool in terms of imaging study that we have to look at the facet joints the good thing is you can see the facet joints really well on mri the bad thing is they're not going to be able to make a diagnosis of facet joint pain because there's so much background noise basically so many people have facet joint arthritis facet joint arthropathy is the term you'll hear a lot and don't have any symptoms from it even if they're having symptoms from one facet joint there'll be lots of facet joints that look arthritic and they're not having symptoms from all of them that's important to keep in mind and sometimes the facet joint will look great on the mri however the facet joint is still causing the pain and the reason for that is that you can have micro tears on the inside of the facet joint that uh you're not going to pick up on an mri and sometimes you will see um an exception to what i just said is sometimes you will see a large effusion a lot of swelling acute swelling in in a facet joint on an mri it'll really light up now that also is not diagnostic of the facet joint but it certainly it certainly is very suggestive that that might be what you're dealing with but still you can't hang your hat on the mri findings and say that that's that the facet joint is what's causing um the pain i mean you can even have stress fractures running through the pars into articularis which is which is right next to the facet joint um in the back and those can be asymptomatic in about six to nine percent of people um who used to play who used to play certain sports they're walking around with their stress fractures and never have any symptoms from it so the point is you have to take your mri findings with a grain of salt and treat the person not the mri finding per se so the way we go about diagnosing facet joint pain at long last right we're finally getting to the gold standard way is by injecting it really you use fluoroscopic guidance using x-ray guidance to take a needle and put it next to the facet joint and if you inject the joint and it gets better then you've found the source of the pain sort of and this is where i think it's really important that we dive into the weeds so that we understand this there's two ways that you can block a facet joint the way that's most common especially in america is we do basically a joint injection intra-articular injection like you would with a knee a hip a shoulder or finger you can take a needle go under x-ray and put medicine directly into the joint and usually what you're injecting when you do this is lidocaine and steroid the lidocaine is there because we're interested in when the lidocaine is put into the joint does the pain go away immediately right lidocaine is an anesthetic so if you get up off the off the the procedure table and you move around and the pain is gone then that suggests that the facet joint is causing the pain because when we blocked it the pain went away now the steroids there as an anti-inflammatory because we're hoping that the lidocaine will wear off and the steroids will have a chance to kick in um and that usually takes a couple of days to a week and it crescendos over a couple weeks and we're trying to use the steroids to help fix the problem as the the steroids kick in it's uh uh it serves to take away the inflammation and then we can use that as a window of opportunity to work on stretching and strengthening the muscles so that hopefully the pain doesn't return as the steroids wear off but let's come back to the diagnosis so if you use an intra-articular joint injection that's that's a good way to get a sense of are the facets causing the pain i say a sense of for a few reasons number one we have to remember there's about a 30 placebo rate so when you block someone meaning when you put lidocaine out into the facet joint and they get up and the pain is gone it could still be placebo right for one there's a lot of adrenaline when you get an injection and for another placebo is just a very real phenomenon so we have to be aware of that before we hang our hat on a diagnosis now the other thing when you do an intra-articular facet joint is that a lot of times the capsule of the joint is going to have small holes in it and so you you can have some some leaking of the medicine that you put into the facet joint some of that depending on how much volume you use will leak out of the facet joint and onto the adjacent structures in the back and so that makes the diagnosis again a little bit more messy the way it's often done in america is you'll do an intra-articular facet joint injection first if that takes away the pain immediately from the lidocaine then great if the steroids don't work then the question is okay well were the is the facet joint really the source of pain and we think that there's probably about a 30 chance that there's not for the reasons we just mentioned primarily because of the placebo response so then you do a repeat injection but the second time because you're not trying to fix it at that point because the steroids didn't help in the first injection you do what's called a medial branch of the dorsal very muscles basically you're blocking the sensory nerve that innervates the joint again you're using x-ray guidance and you're going in with a needle and you're using a very small amount of lidocaine of numbing to just numb the little sensory nerve that goes to the joint so that you're using such a small amount because you don't want the lidocaine to extravazate out into other structures you want it to stay right at the part that you're testing if the person gets up and usually you'll give that you'll give the patient a pain diary to see how they feel over the next several hours and what you're looking for is does the pain go away for a few hours when you put the lidocaine in if that happens again so now we have two diagnostic blocks the first the facet joint injection and then we've repeated it weeks later with the medial branch block and if the pain goes away the second time with the medial branch block well now our false positive rate drops down to about eight percent so we have about a ninety percent probability that we've got the right spot that that facet joint is really causing the pain and that's really important because the next step in treating the pain in that instance would be a radio frequency rhizotomy where we're taking another needle and we're going back to that same nerve that we blocked in the second block the medial branch of the dorsal ramus the little sensory nerve that's going to the joint and we're using radio frequency energy which is basically an oscillating current that goes back and forth really fast that generates heat that then denatures the sensory nerve going to the joint so basically you're burning the the little sensory nerve so you can't feel the joint anymore it's like the it's like the phone's ringing but you cut the cord so you can't hear so we really want to know that we have the right uh joint before we go in and we burn it and that's why we go to such pains to make sure that we're in the right spot by far the most common reason why the radiofrequency procedure doesn't help people with facet joint pain is either it wasn't done right or was rushed but more commonly is because the diagnosis wasn't wasn't appropriately made in the first place either because only one block was used or no blocks were used other various reasons now that's the way that that facet joints are often diagnosed in america in the united states um the the and it's because you're combining the joint injection with the medial with with the block of the sensory nerve the medial branch of the dorsal ramus a more proper way to get to the diagnosis is actually using two medial branch blocks so in in the if you're just purely trying to diagnose the joint and you don't care about trying to use intra-articular and intra-articular steroid injection um because you're basically not thinking that you're going to use steroids to try and help fix the pain but instead you're going to work directly towards the radio frequency rhizotomy procedure the way you would go about that is you do is you first do the medial branch block of the dorsal ramus you first block only the sensory nerve you block that nerve the patient gets up they keep a pain diary for the rest of the day and then they come back and you do it again assuming the first one was positive if the pain goes away the first day they come back the next day the next week whenever and you block it again now here's here's the trick in one of those blocks you're going to use lidocaine to block the sensory nerve now lidocaine lasts for typically about four hours four to six hours let's say in the other block you're going to use marking bupivacaine that's a longer lasting anesthetic than the lidocaine and what you're looking for when you use these two different anesthetics is that the patient has a shorter acting relief with the shorter acting anesthetic the lidocaine and they have a longer acting relief with the marking and you don't tell the patient right the patient doesn't know which they've had they don't know if they were blocked with marking or or the lidocaine all they know is that they had an injection ideally the doctor also doesn't know ideally the doctor is blinded to whether or not he or she is injecting lidocaine or marking so that way they don't inadvertently influence the results but what's most important is that the patient receive at one point lidocaine and one point marking and they keep a pain diary both times and you want to see that they have longer acting relief with a marking and shorter acting relief for the lidocaine now the other thing that we should mention is when we say relief what we really mean is about 80 pain relief right we're really looking for do we turn off do we do we turn the pain off like a light switch when we when we block the sensory nerves we're not looking for nuance of you know is it 30 better or 35 or 50 or 55 or 60 we're looking for does does blocking the sensory nerve make the pain go away hard stop right it doesn't be 100 but at least 80 percent one caveat to that is sometimes what you'll find is that when you block the sensory nerve you block the joint one part of the pain goes away completely and one part of the pain stays there and with that we're talking geographic regions so let's say that the top part of the pain is still there but the bottom part of the pain went away completely the reason why that's important is because what what that tells you is that the facet joint in that instance is only responsible for the bottom part of the pain so therefore what you can tell the patient what you can know is okay if we go in and we burn we use the radio frequency rhizotomy to burn the sensory nerve of the joint then what we can reasonably expect is the bottom part of the pain is going to go away but the top part of the pain we still haven't figured out so we're going to have to return to that to figure out what's called maybe that's coming from the disc maybe it's coming from uh something different or a different facet joint level but from that one disc from sorry from that one joint that we just blocked what we can say is that's responsible for the lower pain not the upper pain because that's what went away when we blocked it i think i covered everything that i meant to with the the diagnosis of a facet joint pain so um [Music] sometimes what what we've found in in our office is that we have we we go through great pains to try and understand the diagnostic to try to explain the diagnostic process um because sometimes people have the diagnostic block and then they're disappointed when you know a day later the pain returns but really you know it'd be nice if it went away but that's really what's supposed to happen when you only use lidocaine because you're only putting in an anesthetic and we're really doing it to diagnose the problem because we need an accurate diagnosis so that we we know what our our real treatment options are i hope you found this video useful uh if you have uh please like the video subscribe to the channel uh and please tell a friend who you think might find it useful as well because that's the that's the best way that we can spread good health information and achieve good health outcomes together yeah as always if you have any questions or comments you can reach me at dr cooper princetonsjc.com or feel free to leave any comments or questions in the comments section here thank you very much

Channel: Princeton Spine & Joint Center

Views: 16,955

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Id: pbdiafjppl4

Length: 15min 35sec (935 seconds)

Published: Mon May 02 2022