2/5/2019. Facet Joint Pain. Biomechanics

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1 Facet Arthropathy as a Pain Source Evaluation and Management Shelby Spine Jan 31 st Feb 2 nd, 2019 Kushagra Verma MD, MS Adult and Pediatric Scoliosis And Spine Deformity Beach Orthopaedics Specialty Institute Long Beach and Miller Children's Memorial Hospital Faculty, Long Beach Sports Fellowship Volunteer, Global Spine Outreach Facet Arthropathy Patients and professionals tend to focus on the intervertebral disc as a cause is one of the most common causes pain Facet Arthropathy Facet Arthropathy has received very little attention with only a few publications discussing these joints as sources of pain Nat Rev Rheumatol

2 Articular capsule The joint is surrounded by an articular capsule : consists of two layers 1. Outer fibrous membrane 2. Inner synovial membrane 1. The outer fibrous membrane is highly innervated, but avascular receives nutrition via diffusion Facet Arthropathy 2. the inner synovial membrane possess nociceptive nerve endings secretes the lubricating, synovial fluid. Facet Arthropathy The medial branch of a L2 posterior ramus AJNR: 26, April

3 Articular capsule Pain sensation from the capsule and synovium are transmitted through the medial branches of the dorsal ramus of spinal nerves Facet Joint Pain Definition : pain resulting from any integral structure of the facet joints, including the fibrous capsule, synovial membrane, hyaline cartilage surfaces and bony articulation Cohen S, Raja S. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology Biomechanics these joints function to support and stabilize the Spine Facets come into maximal contact with one other during extension and axial rotation, thus contributing more to overall load sharing under these conditions. 3

4 Hirsch1963, injected hypertonic NS in facet joints with production of LBP. Mooney and Robertson confirmed this with intra-articular injections of hypertonic saline in Hirsch C, Ingelmark B-E, Miller M. The anatomical basis for low back pain. Acta Orthop. Scand Mooney V, Robertson J. The facet syndrome. Clin Orthop Degenerative Cascade Kirkaldy-Willis( ) changed the entire focus of treatment for low back pain proposed the concept of a close interaction between the two facet joints and the intervertebral disc in a so-called threejoint complex President of the North American Spine Society ( ) three-joint complex. There are two facet joints in the back and a large disc in front 4

5 Degenerative Cascade Model 1978 Stage I: Dysfunction Stage II: Instability Stage III: Stabilization Kirkaldy-Willis and coworkers (1978), Dysfunction Discs Annular tears, release of inflammatory chemical Local ischemia As a result, overload of the facet joints Treatment Stage I: Dysfunction Stage II: Instability Stage III: Stabilization 5

6 Dysfunction Discs Annular tears, release of inflammatory chemical Local ischemia As a result, overload of the facet joints Patients with positive scans have an excellent response to facet joint injections Pneumaticos SG, Chatziioannou SN, Radiology 2006 Instability Discs Increasing frequency of tear with Increased translational forces, Disc height decreases, Spinal canal or neural foramen stenosis, Radicular pain Facets Increasing cartilaginous deterioration Capsular laxity Yu et al, 1988, Urban et al, Stabilization Auto fusion of facet joints Minimal Movement Presumably less pain 6

7 Third phase: Stabilization At the third phase, the disc lost height and facet hypertrophy promotes segment stabilization, but also narrowing the neural foramen and the vertebral canal stenosis Diagnosis, of lumbar joint pain Pain from degenerative diseases may arise from: Stenosis Facet overload, the disc itself Vertebral endplate Diagnosis No correlation between clinical picture, MRI, CT scan, Dynamic bending fields, SPECT scan, and radionuclide bone scanning Manchikanti: Pain Physician, Vol 3,

8 NASS 2016 Coverage Recommendations Medial Branch Blocks are valid and reliable diagnostic procedures The ability of the lumbar medial branch blocks to anesthetize the zygapophyseal joint:; Spine, Vol 23, #17, pp ; 1998 NASS 2016 Coverage Recommendations When diagnostic MBBs are performed, the following criteria apply: 1. Dual blocks, performed in the same location(s) on 2 separate occasions, are necessary to confirm the diagnosis due to the unacceptably high false positive rate of single diagnostic anesthetic injections in the spine A second confirmatory injection is indicated only if the first injections produces 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed. This confirmatory block confirms the tested joint as the source if the index pain is reduced by > 80% A second injection may also be performed at a different or additional level if the pain is believed to be arising from a different joint (and the pain relief from the initial block was<80%). Treatment Nonsurgical management must be considered, in low back pain, especially in patients without radicular compression signs 8

9 Isolated facet joint disease is rare Medial Branch Radiofrequency Neurotomy Facet Joints RFN is offered to patients only if dual diagnostic MBB injections each produce 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed. Spine Intervention SocietyHumana Medical Coverage Policy - Injections for Chronic Pain Conditions, 2018 The lumbar spine Facet Joints RFN should be performed at the same level no more than twice annually and only if the initial radiofrequency lesion results insignificant pain relief (> 50%) for at least 6 months. In those situations, a repeat procedure in that year is appropriate.the recurrence rate 6 12 months after radiofrequency denervation is over 60% Spine Intervention SocietyHumana Medical Coverage Policy - Injections for Chronic Pain Conditions, 2018 Schofferman J, Kine G () Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine2004 9

10 Juxtafacet Synovial Cyst Surgical resection remains a definitive treatment for symptomatic synovial cysts. Hemilaminotomy approach If Spinal instability - fusion should be performed With cyst excision, recurrence is common. In the study by Allen et al, 37.5% had experienced a symptomatic cyst recurrence. Xu R, McGirt MJ, Parker SL, et al. Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases. Spine Treatment In the last phases, 2 and 3, patients often have stenosis, or deformities, like degenerative scoliosis, often requiring surgery for stabilization, decompression and/or correction of the deformity TFAS Total Facet Arthroplasty System Non-fusion spinal implant indicated for treatment of patients with moderate to severe spinal stenosis comprehensive decompression via complete removal of the facets 10

11 Facet Arthroplasty System 1.Exclusion Criteria: 2. Male or female less than 50 or greater than 85 years old Grade 2 or higher spondylolisthesis or any retrolisthesis 3. More than 3 vertebral levels of degenerative spinal stenosis requiring decompression 4. More than 1 vertebral level of degenerative spinal stenosis requiring instrumentation 5. Not available for long term follow-up and interval visits 6. Prior or concurrently planned lumbar fusion or disc replacement at any level of the lumbar spine 7. Two or more previous surgeries to the lumbar spine at the same level to be implanted 8. Is being treated with other devices for the same disorder (e.g. pain control devices) 9. Active systemic infection or infection at the operating site 10. Osteoporosis 11. Known sensitivity to device materials 12. Has an immunosuppressive disorder 13. Has a medical condition that may interfere with clinical evaluations 14. Is obese defined by a patient body mass index greater than Has significant scoliosis (Cobb >25 ) 16. Is pregnant or planning to become pregnant within the proposed three year investigation Facetectomy Medial facetectomy Complete facetectomy Medial facetectomy Indications Facet hypertrophy resulting in foraminal stenosis Facet hypertrophy resulting in symptomatic central stenosis Foraminal stenosis caused by other osteophytic changes Presence of a symptomatic synovial cyst 11

12 Multilevel Laminectomy L3 L4 L5 Potential for iatrogenic instability Multilevel Laminectomy L3 L4 L5 Summary Diagnosis of Z-joint mediated pain remains a challenge Clinical diagnosis of exclusion Isolated facet joint disease is rare surgery is indicated in cases refractory to conservative treatment Partial facetectomy: preservation of at least 50% of the facet joint Complete facetectomy : spinal fusion should be done 12

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