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12/19/19

Back pain and lumbar facet joint arthritis

The lumbar facet joints are moving parts situated in the back of the lumbar spine. Together with the lumbar discs, the facet joints help us support and move our spine, and protect the lumbar nerve roots.

Just like any other load-bearing joints, the facet joint can sustain wear and tear, known as degeneration, osteoarthritis, or arthritis for short. Sometimes, but not all the time, joint arthritis can be painful. This is manifested as back pain, but also buttock, groin, thigh pain.

There is an important caveat at this point: do not be fooled by the appearance of these joints on X-rays, MRIs, etc. Normal-looking joints can be painful and very degenerated joints can be completely painless. This is why we can only find out whether these joints are painful or not by means of spinal injections.

Pain from the facet joints is transmitted to the spinal cord and ultimately to the brain through small nerve twigs called medial branches, which sit in bony grooves of the lumbar spine.

For back pain that has not improved with rest, time, physical therapy, chiropractic therapy, anti-inflammatory medication, we can find out whether this pain comes from the lumbar facet joints by performing simple lumbar injections called medial branch blocks. These are X-ray-guided injections of local anesthetics over the bony grooves I mentioned earlier aimed at numbing the medial branches, and therefore cutting off the pain transmission from the facet joints to the spinal cord and brain. The principle is simple: if the pain goes away while the medial branches are numb (generally several hours), then it is highly likely that the facet joints are causing the pain.

There is a second important caveat here: the medial branch blocks need to be performed twice, with different local anesthetics. Only if the pain goes away both times we can establish a correct diagnosis of facet joint pain.

Once we found the off-switch for pain to be in the facet joints, then we can proceed with treatment.

Although injections of corticosteroids inside the facet joints is not a proven treatment, sometimes this intervention offers several months of pain relief. In my experience, only 10-15% of patients benefit from this, with pain relief of 3 months or longer.

The proven treatment for facet joint pain is called radiofrequency treatment of the medial branches. This is sometimes called neurotomy or rhizotomy, meaning destruction of the medial branches.

The radiofrequency neurotomy classically employs placement of needles close to the medial branches, in the bony grooves mentioned above, and heating the needle tips to destroy the medial branch. This is of course done with local anesthetics, with or without sedation. More recently, the radiofrequency neurotomy can be done endoscopically. This allows direct visualization of the target tissues by using tiny cameras.

After radiofrequency neurotomy, pain relief may be delayed up to 4 weeks, and may last anywhere from 6-18 months. Pain may return after this period of time because of regeneration of the medial branches. If or when pain returns, the radiofrequency treatment may be repeated.

Some of the common questions from patients regarding radiofrequency treatment are:

If you destroy my nerves, will I lose sensation to other spinal structures? The answer is no. The medial branches are very specialized small nerves that only transmit pain from the facet joints. Sensation from the other surrounding spinal structures is not affected.

Patients also frequently ask: If I don’t feel pain, will I hurt my back more? Again, the answer is no. Pain from other lumbar structures will continue to be felt, and in case of a more serious bone contusion, deeper pain receptors will be stimulated with pain signals felt by the injured person.

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