Facet joint pain (facet arthropathy or osteoarthritis of the spine) originates from the small, paired joints located on the posterior aspect of each vertebra. These joints provide stability and guide movement. When they become inflamed or degenerate, they cause localized discomfort, stiffness, and a dull ache in the neck or lower back. Pain often intensifies with movements like twisting or arching the back backward. Successful management requires a stepwise, multidisciplinary approach involving various medical specialists because symptoms can mimic other conditions.
Initial Assessment and Conservative Care
The journey to diagnosis often begins with a Primary Care Provider (PCP). The PCP conducts a physical examination, assesses symptoms, and orders preliminary imaging such as X-rays or magnetic resonance imaging (MRI). If the pain is persistent, the PCP may initiate the first line of non-invasive treatments, typically involving nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation.
For a more specialized non-surgical evaluation, a referral is often made to a Physiatrist (Physical Medicine and Rehabilitation, or PM&R specialist). These doctors are musculoskeletal experts who focus on restoring function without surgical intervention. They design comprehensive treatment plans that integrate physical therapy, which is a foundational component of conservative care.
Physical therapy concentrates on targeted exercises to stretch and strengthen the muscles surrounding the spine. This helps stabilize the joint and restore flexibility. The rehabilitation program may also include guidance on posture correction and lifestyle modifications, such as weight management, to reduce mechanical stress on the spinal joints. If pain fails to resolve after a dedicated period of conservative management, usually six weeks to three months, the next step involves targeted procedural interventions.
Interventional Pain Management Specialists
When conservative measures are insufficient, the patient is referred to an Interventional Pain Management Specialist. These physicians have backgrounds in Anesthesiology or PM&R and have completed specialized fellowship training. Their expertise focuses on performing minimally invasive, image-guided procedures to diagnose and treat the specific nerves transmitting pain signals from the facet joints.
The initial procedure is a diagnostic Medial Branch Block (MBB) used for confirming the source of the pain. During this test, a local anesthetic is injected near the small medial branch nerves that innervate the facet joint. This procedure is performed under fluoroscopy (real-time X-ray guidance). If the patient experiences a significant, temporary reduction in pain, it confirms the facet joint as the primary pain generator.
If the diagnostic block is successful, the specialist may perform Radiofrequency Ablation (RFA), also known as a rhizotomy. This therapeutic procedure uses radio waves to generate heat, delivered through a specialized probe, to disrupt the pain-transmitting capability of the medial branch nerves. RFA provides sustained pain control, lasting between six and 24 months, by essentially turning off the nerve signals without requiring surgery.
Surgical Options and Spine Surgeons
Surgery for facet joint pain is a last resort, reserved for patients whose symptoms remain debilitating despite exhaustive conservative and interventional treatments, or for those who have developed spinal instability. When surgery is necessary, the patient consults with a Spine Surgeon, who may be an Orthopedic Spine Surgeon or a Neurosurgeon.
Orthopedic Spine Surgeons specialize in the musculoskeletal system, focusing on the bones, joints, and ligaments of the spine. Their surgical interventions for chronic facet joint pain often involve procedures aimed at mechanical stabilization, such as spinal fusion. Fusion permanently connects two or more vertebrae, eliminating motion in the painful facet joint segment.
Neurosurgeons specialize in conditions of the nervous system, including the spinal cord and nerve roots. While their training emphasizes complex nerve decompression, they are highly skilled in performing structural stabilization surgeries, including spinal fusion. Both types of surgeons frequently collaborate in multidisciplinary spine centers, ensuring the chosen surgical approach addresses structural mechanics and any potential neurological compromise.