Neurosurgery notes/Spine/Spinal Degenerative Diseases/Lumbar degenerative disease/Facet joint arthropathy

Facet joint arthropathy

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Lumbar degenerative disease

Pathology

  • The facet joints support 20% of the spinal load.
  • Segmental degeneration increases loading of the facets and arthropathy.
  • The more sagittal orientation of the lower lumbar facets and facet isotropy is associated with accelerated degeneration, instability, deformity, and pain.
  • The pathological changes seen in facet degeneration include
    • Cartilaginous thinning and fibrillation
    • Effusions
    • Capsule laxity
    • Joint subluxation
    • Osteophytosis
    • Synovial hypertrophy with cyst formation

Radiology

  • Facet arthropathy is best appreciated on CT.
    • Weishaupt grading system
        • Describe the severity of facet arthropathy on CT and MRI.
        • Grade 0
          • Normal facet joint space (2–4 mm width)
        • Grade 1
          • Narrowing of the facet joint space (<2 mm) and/or
          • Small osteophytes, and/or
          • Mild hypertrophy of the articular process;
        • Grade 2
          • Narrowing of the facet joint space and/or moderate osteophytes, and/or
          • Moderate hypertrophy of the articular process, and/or
          • Mild subarticular bone erosions;
        • Grade 3
          • Narrowing of the facet joint space and/or
          • Large osteophytes, and/or
          • Severe hypertrophy of the articular process, and/or
          • Severe subarticular bone erosions, and/or
          • Subchondral cysts
        notion image
  • Single-photon emission computed tomography (SPECT)
    • may aid in localizing active disease when MR and CT reveal multilevel degenerative changes.
    • Facet effusions on MRI correlate with SPECT activity.

Clinical features

  • Stiffness in the morning which improves with activity,
  • Pain
    • Exacerbated on extension and twisting movements.
    • May be referred to the groin, buttock, or posterior thigh,
    • Pain localized paraspinal tenderness.

Management

  • Conservative management
    • Spinal injections performed by a pain specialist are the mainstay of treatment.
      • Medial branch blockade (MBB) is superior to intra- articular injections.
      • Injections should be performed on multiple occasions to increase diagnostic validity.
      • There is some evidence to suggest that a positive response to MBB is predictive of a good response to radiofrequency ablation.
      • Limited data suggests that radiofrequency ablation provides short and long- term relief of facet mediated pain in selected patients.