Facet joint treatments
The Facet Joint or Zygapophysial joint Treatments
The spine is made up of many bones called vertebrae. They are linked together at the front by the disc and at the back by the facet joints. This allows one bone to move on the other enabling us to move. Most of the body weight goes through the front half of the spine and the discs. However if these joints are over stressed then they can become inflamed and painful. This is either because the joints are damaged or too much weight is going through them. This can result in changes to the cartilage of the joint and its ability to move smoothly.
There will often be a background ache which can be made very bad by sudden jerking or twisting movements. The pain will be felt in the area of the damaged joint but can also be felt in the buttocks and even down the back of the thigh. Occasionally the pain can even be felt in the lower leg. Many people will find that bending backwards is painful and complain of stiffness first thing in the mornings or if they are in one position for long periods, either sitting or bent forwards doing something. They may not feel the pain while sitting but when they try to get up to start moving, that is when the pain comes on. Often once the person has been able to get moving and shake off the stiffness the intense sharp pain will subside.
By keeping the joint mobile through exercise and stretching not only will you prevent it getting stiff but the strong muscles of the back can provide additional support and help carry the body weight. Simple pain killers and anti-inflammatories can be very helpful. If the spine becomes very stiff then manual treatments such as massage, chiropractic and osteopathic treatments may help to get the spine moving, but it is essential to continue the exercises and stretches yourself to prevent them becoming stiff again.
A spinal practitioner will help you to confirm the diagnosis. If keeping a healthy lifestyle does not control the symptoms then you may need to consider if your pain is bad enough to warrant an intervention. Steroid injections into the facet joints will not reverse the damage that has already occurred. They will help to confirm the diagnosis and may reduce the pain to levels such that you are able to start to exercise and move more normally to prevent the joints from stiffening up again. Facet joint denervation is a treatment performed to try to stop the activity of the nerve supplying this joint sending pain messages to the brain and is very effective for some people. If nothing has worked and the pain is still significantly affecting your lifestyle then you may wan to consider an operation to off load these joints. This is obviously a serious step and you should talk to your surgeon who will be able to go through the procedures and the risks and benefits with you and guide to make the correct decision for you.
Facet Joint Injections
Injecting steroid and local anaesthetic into your facet joint has two purposes. If the pain that you experiences goes away with the injections then it does suggest that that is where the pain is coming from. The relief of the pain will hopefully allow you to start stretching and moving more normally which would prevent the pain from coming back. The steroid will also act to try to reduce inflammation which will also help to counter the pain from an inflamed joint. The procedure will be done as a day case and it is always sensible to organise for someone to escort you home.
The injections are performed under x-ray guidance. You will be positioned on a table and the area of skin overlying the joint will be cleaned. Local anaesthetic will be injected into the area to reduce the discomfort. Under the x-ray guidance needles will be passed through the skin, fat and muscle and into the joint. The steroid and local anaesthetic will then be injected.
There are risks involved. Infection is possible but rare. Bleeding and damage to the local structures such as the nerves could occur but less than 1%. It is also possible that the injection into the joint could irritate it further and for a while you may find that the pain is more intense. If the needles used pierce the sac that contains the nerves some of the spinal fluid could leak out which can cause a migraine type headache that if you stay flat should subside. As the sac containing the nerves is within the bony spine it is uncommon for this to occur.
After the injection it is important for you to keep some sort of a diary of effect of the injection. This information will shape the discussion you have with me after the injection and help determine the next steps.
Facet Joint Denervation
If facet joint injections have been of short term benefit it suggests that this is the cause of your pain. If the pain returns it is possible to try to alter the nerves to the joints by using radiofrequency. This treatment involves passing a needle in a manner similar to a facet joint injection and then passing the radiofrequency down the needle rather than a steroid and local anaesthetic injection. This treatment is successful 50% of the time. It may be performed as a day case procedure in the operating theatre under x-ray guidance just as the facet joint injection was.
If a lasting solution has not been achieved then an operation which is able to load share and offload the facet joints may produce relief. The interspinous spacer, there are many different types, sits between the interspinous processes. As the body weight is passed through the spine, some of it may be transmitted through this device, hence off loading the facet joints to some degree. In addition they prevent the degree of extension or bending backwards at this level. This movement in particular is irritable for facet joints. It does not restrict bending but may prevent the painful movements. It does require an operation though.
Before the operation
You will be contacted by the hospital and invited to come for a pre-assessment. You will have some routine blood tests and have your pulse and blood pressure checked. You may also need to have an electric tracing of your heart activity. You will need to come into hospital on the day of your surgery. When you come in the nurses will check that you are ready for your surgery and will fit stockings on your legs to reduce the risk of getting a deep vein thrombosis. I will visit you in your room and check that you are prepared to have your surgery. You will also be visited by the anaesthetist who will review all the tests that you have had and discuss the anaesthetic with you. You will be escorted down to the operating theatre. Your anaesthetic will be administered and you will then be asleep.
We will carefully position you on to your front. Based on an x-ray I will localise the level that we will be operating at. The skin will be cleaned with a liquid to reduce the number of bacteria on the skin and reduce the risk of infection. An antibiotic will also be given to do this. A cut will be made in your back. The cut will be deepened through the fat and a cut will be made into the covering layer of the muscle. The muscle is then peeled away from the spine to expose the bones on one side. The level at which I am operating is checked again to be totally certain that we are operating at the correct level. A small window is created between the spinous processes of the spine and gradually made bigger. The gap is sized and the corresponding size device is inserted into this gap. Care is taken because if too big an implant is inserted it will produce bending at the site, and if too small a device is used it will not share the load or restrict the extension satisfactorily. This is all done with the assistance of x-ray control. The are is washed out and then stitched up. The stitch will be buried under the skin and paper stitches will be used. This will all be covered with a waterproof dressing.
The operation is designed to relieve your back pain. Although this is a routine procedure it is important to be aware of the risks involved. Infection
- Surgery always carries with it a risk of infection although this is rare. This may lead to a temporary increase in back pain and an antibiotic may need to be prescribed. An increase in back pain may occur for up to a year may be permanent. The risks of infection are approximately 1%.
- Damage to nerves is very rare as the operation does not enter the area where the nerves run.
- Wrong level. The incision or cut that is made in your back is quite small and it would be easy to be operating at the wrong level of the spine as the bones look very similar. That is why I take multiple x-rays during the operation to be sure that I am working at the correct level.
- Ongoing back pain because these procedures are not always successful. Often back pain is due to multiple causes and eliminating the pain from the facet joints may make the other problems more noticeable. Also by changing the way one level of the spine moves this could have a knock on effect on the other levels which may not have been painful before, but because they are now under greater stress may start to do so.
Risks Related to Anaesthetics
Modern anaesthetics are extremely safe. However, as with all general anaesthetics, there is a very small risk of complication concerning the anaesthetic during the procedure. Any existing medical conditions will be taken into consideration.
There are a number of complications that can occur in any operation e.g. blood clots, heart attacks, and chest infections. The risk of these complications in a person of average good health is low. If you have any medical conditions or are taking any medicines it is very important that you inform the pre-assessment nurse, surgeon and the anaesthetist. Constipation is common after any spinal surgery and I will encourage you to take laxatives if you have any difficulty opening your bowels. Some people find that they are left with a tender scar, to prevent this I will suggest that once the wound has healed, at about two weeks, you start to massage the scar itself. You can use a cream or oil if you want.
After the Procedure.
You will then be placed back in your bed, woken up and taken to the recovery area. Here your pulse, blood pressure and breathing will be closely monitored. Once the staff are sure that you have woken up fully from the anaesthetic and that your pain is well controlled they will organise for you to transferred back to the ward. Later the same day either the physiotherapists, nurses or myself will get you out of bed and start you standing and walking. So long as you have fully recovered from the anaesthetic and your blood pressure is normal, we will encourage you to walk.
Although it may even be the same day, it is usually the next day that the physiotherapists will ensure that you are able to walk a reasonable distance and safely manage the stairs. Once you have done this you will be ready to go home. Do not be surprised if initially your back pain is worse as a result of the operation.