Posterior Facet Syndrome – an injury of the joints in the back
I’ve had a hell of a day explaining to a very important lawyer why his back is hurting him. He has had a hell of a day refusing to hear what I have said and done, even though I’ve allowed him to stand upright for the first time in a few days (I suspect this is because he’s in the thrall of his denialist shrew of a wife).
However, the thrust of what I was banging on about is this:
Firstly, where are these Posterior Facet Joint things? The facet joints, or incredibly the zygapophyseal joints, are the relatively small joints on the outside of the bridge of bone that protects your spinal cord. They control the range of motion available at each level of the spine and you have them at every level. However, they do look different as you move up or down your spine, because ‘form follows function’ and they have to do different jobs in different parts of your spine- see?
Each joint, like most joints, is enclosed in a joint capsule which is a complex structure that provides feedback to the brain about the state of the joint, as well as a host of other tasks such as supplying synovial fluid to the joint space as well as some joint stability. Research has shown that in the low-back there can be a ‘meniscoid’ structure in the joint space, just like a mini version of the meniscus in the knee joint.
So that’s what the thing is like. Now what can go wrong?
Posterior Facet Syndrome (PFS). Contrary to what the physios may say this is a hugely prevalent problem and is, arguably, our bread and butter. It is a syndrome because the injury it involves far more than one structure and a whole raft of unpleasant things can go on.
In a severe, acute, PFS there may be some injury to the faces of the joint but rarely. There have also been several theories put forward about some nipping of the joint capsule or the meniscoid tissue between the two bones. However, there will certainly be some sprain/strain of the very sensitive structures of the capsule, the surrounding micro-ligaments and local muscles. Your body will rightly respond to this injury by stabilising the joint with whatever it can – in this case it will be the surrounding muscles and in the low-back these muscles are really powerful.
Your brain can stabilise your back very quickly and is why you will have seen people bending over and suddenly being unable to move or coming into work unable to move their heads. What your brain does is sacrifice these powerful muscles in favour of the PF joints and force the muscles to remain contracted for as long as required. Now, try holding a weight in your flexed arm for any length of time and you’ll see how painful this continued contraction can be. This is the same thing that is going on in your back BUT the contraction will be even stronger as it has to hold your body still and so far more painful. Also, your brain will not turn these stabilising muscles off until the problem is resolved and nor should you – so no early massage madness and NO MUSCLE RELAXANTS (aaahhhhh).
PFS will really sting. In a severe acute phase you may not be able walk and when I did mine after a rowing session I had to remain still until I was driven to stand by my bladder that was about to explode and even then I nearly passed out. The structures that hurt were the injured joint capsule; this will be the white hot sharp pain, and then the large paraspinal muscles that my body had wisely recruited in to span the joint like scaffolding which was a deeper burning pain.
As with trauma to any joint, such as spraining an ankle, there will be an inflammatory reaction with loads of swelling and pain around the joint, which may last for several days. This may also irritate the spinal nerves that pass out of the spine at this point and you may get a referred pain. Typically, this will be less defined and usually a burning pain. To check if your pain is a referred pain give the area a gently prod and if you can’t get a finger on a pain generating structure then, as a rule of thumb, it’ll be a referred pain (clear?). Please don’t call it sciatica unless you are still using terms like lumbago and ague as sciatica is a description of pain along the sciatic nerve distribution which goes far further than the hip and groin.
Typically, you’ll find back pain just to one side of the spine in the paraspinal muscles that are stabilising the joint. Side bending toward the affected side or backward bending will compress the facet joint faces together and make the pain worse – some physios find this concept a challenges as they tend to be muscle focused. The back will generally feel stiff in the morning as a post inflammatory response. Often the problem is made worse by prolonged sitting or standing in one position as the joints get compressed and start to sing.
What causes PFS?
A severe acute episode of PFS pain may be due to sudden, aberrant, movement, which traumatises the joint such as the classic lifting injury as a result of poor core stability. More commonly PFS is chronic with the underlying cause due to long term changes in the joint that are often again associated with poor core stability, wear and tear and poor posture.
What you can do?
Ice – it’s an inflammatory issue at heart so DON’T heat it up. If you listen to the stabilising muscles you will hear them shouting for heat as this is a muscle injury but the contraction is intentional and unless you have torn these in the initial injury (unlikely) you must ignore the cry. Get this wrong with an ankle joint and it can extend the time to recover by up to 5 times and I’d suggest that PFS is an ankle sprain/strain of the back joints and so the same thing will happen – so no hot baths, please.
It may be worth taking some non-steroidal anti-inflammatory (NSAIDs) with all the risks associated with these things.
“Get thee to a chiropractor” who will manipulate the joint with a controlled thrust to reduce the compression, restore correct movement and so reduce inflammation and pain.
DO NOT heat it up until much later. DO NOT wear a brace.
However, what I found on the web!
This: “In a more chronic type of Facet joint problem, the management is more difficult. The treatment outlined above will usually be attempted first, with the Chartered Physiotherapist giving symptomatic relief of the stiffness using heat packs and mobilisation techniques. However, where there is persistent pain originating from a Facet joint problem, this has to be addressed. An injection of long acting local anaesthetic and anti-inflammatory corticosteroid into the Facet joint may be effective in relieving symptoms and, if successful, it confirms the diagnosis. In order for this approach to work the injection is best done by a Consultant Radiologist under an image intensifier. This device allows the doctor to see exactly where the injection is going. This approach can give very good pain relief, but the effects may wear off after a while. It may be necessary to repeat the procedure at a later date.”
Good grief! all that radiation and then some powerful steroids when all it really needed was a dose of ice and some decent care. Try anything else first, please.
And then:
“In cases of Facet Syndrome that cause constant unremitting pain, a more lasting approach for pain relief is a procedure known as ‘Radiofrequency denervation’. Radiofrequency denervation is a technique where the nerves that supply the Facet joint are destroyed by ionizing radiation rather than surgery. This is effective for the relief of pain, but will not stop or reverse the underlying joint degeneration.”
Killing nerves! Can this really work?
The evidence from NICE and MEADE and others is that chiropractic and other manipulative therapies are the way forward. Give it a go and see what I mean.