Facet arthropathy is a common source of chronic back or neck pain resulting from wear and tear on the small joints of the spine. These joints, called facet joints, are located on the back of each vertebra, providing stability and guiding movement. As the cushioning cartilage degrades, the bones may rub together, causing inflammation, discomfort, and stiffness. Management follows a progressive approach, beginning with the least invasive methods and advancing to more complex procedures only if initial treatments do not provide sufficient relief.
Initial Conservative Management
The first line of defense involves therapies aimed at controlling pain and improving the function of the surrounding spinal structures. This initial phase centers on non-pharmacological methods and basic medication to address symptoms like inflammation and muscle tension. Many individuals find that a dedicated conservative approach is enough to manage their symptoms and return to normal daily activities.
Physical therapy is a cornerstone of this early treatment, focusing on strengthening the muscles that support the spine, particularly the core musculature. A physical therapist designs an individualized program that includes exercises to improve posture, increase flexibility, and enhance spinal stability. The goal is to reduce mechanical stress on the arthritic facet joints by creating a stronger support system.
Activity modification involves identifying and avoiding specific movements that aggravate the facet joints, such as excessive hyperextension or twisting. This means adapting daily routines and exercise habits to reduce painful flare-ups and prevent further irritation. Alongside physical therapy, pharmacological agents provide symptomatic relief.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are commonly used to decrease inflammation and pain. For patients experiencing painful muscle spasms, a short course of muscle relaxants may be prescribed to ease tension in the surrounding paraspinal muscles. Topical pain relievers, including creams or patches containing lidocaine or capsaicin, offer an alternative for localized pain management with fewer systemic side effects.
Targeted Interventional Procedures
When conservative management fails to provide adequate pain control, the next step involves targeted interventional procedures. These treatments are typically performed under fluoroscopic (X-ray) guidance to ensure the precise delivery of medication or energy to the specific nerves or joints causing the pain. These procedures are often preferred over surgery due to their minimally invasive nature.
The diagnostic medial branch block has a dual purpose: confirming the pain source and providing temporary relief. A small amount of local anesthetic is injected near the medial branch nerves, which transmit pain signals from the facet joints. If a patient experiences a significant reduction in pain, it confirms that the facet joint is the primary cause of the discomfort, guiding future treatment decisions.
Following a positive response to the diagnostic block, corticosteroid injections may be considered, although they are not a long-term solution. These involve injecting a mixture of a local anesthetic and a potent anti-inflammatory corticosteroid directly into the facet joint capsule. The steroid reduces inflammation within the joint, which can temporarily alleviate pain and stiffness.
The most definitive non-surgical treatment for facet arthropathy is radiofrequency ablation (RFA), also known as radiofrequency neurotomy. This procedure is performed only after a patient has demonstrated a successful, temporary response to diagnostic nerve blocks. RFA uses heat generated by radio waves to create a controlled lesion on the medial branch nerves, disrupting their ability to transmit pain signals.
The RFA procedure involves guiding a specialized needle electrode to the precise location of the medial branch nerves using X-ray imaging. A radiofrequency current then heats the tip of the electrode, cauterizing the nerve. Since these nerves are solely responsible for sensing pain and do not control muscle movement, this disruption provides pain relief without causing motor weakness.
RFA is considered a long-term solution because pain relief can last anywhere from six months to over a year as the nerves slowly regenerate. Because the nerves grow back, the procedure may need to be repeated if the pain returns. However, RFA offers a substantial window of pain relief during which patients can fully engage in physical therapy and rehabilitation.
Surgical Considerations
Surgery is reserved as a last resort for facet arthropathy and is only considered after all conservative and interventional treatments have failed to provide adequate relief. The primary role of surgery is to address underlying structural problems resulting from advanced joint degeneration, such as instability or nerve compression.
Spinal fusion is the most common surgical option for advanced facet arthropathy, particularly when the condition has led to spinal instability, such as vertebral slippage (spondylolisthesis). The goal is to permanently fuse the affected vertebrae together, eliminating movement at the painful facet joint. This stabilization removes the source of mechanical pain but results in a loss of flexibility in that spinal segment.
In cases where severe facet overgrowth or bone spurs are compressing a spinal nerve, a decompression surgery, such as a laminectomy or facetectomy, may be performed to relieve the pressure. For isolated facet joint pain without significant neurological compromise or instability, the evidence supporting fusion surgery is limited. The decision to proceed with surgery is made carefully, as the vast majority of facet arthropathy cases are successfully managed without it.