Facet Joint Injuries

Facet Joint Injuries Mark H. Dean, D.O. Osteopathic Pain Management

Facet Joint Injuries • 55-60% of neck pain after whiplash is due to facet injury • Results in a referred pain pattern distribution called “Sclerotomes” • Adjacent sclerotomes have significant overlap • Makes diagnosis based on clinical findings alone difficult

Stage 1 Facet Injury • Acute injury of normal joint • Results in damage to the medial branch of the facet nerve • When a ligament is damaged, nerve fibers of the facet capsule are also injured

Stage 1 Facet Injury • 3 grades of capsular ligament injury: • Grade 1- stretch • Grade 2- stretch and partial tear • Grade 3 total tear

Stage 1 Facet Injury • Damage to nerve fibers cause the nerve to “die back” within the myelin sheath for 2-3 cm. • Result of ligament injury • inflammation at the joint • stiffness and local pain lasting for several days to weeks

Stage 2 Facet Injury6 weeks – 6 months later • Abnormal, non-myelinated c-nerve fibers “re-grow” through the broken tips of the myelin sheath into the damaged joint capsule

Stage 2 Facet Injury • Non-myelinated c-nerve fibers are highly sensitive to stretch and pressure. • Cause locally attached muscles and fascia to contract when they are irritated or stretched.

Stage 3 Facet Injury18 months or later • Joint capsule becomes encased in abnormal nerve fibers • Results in regional stiffness and reproducible radiating pain patterns known as sclerotomal patterns

Sclerotomal Pain Patterns

Stage 3 Facet Injury18 months – 5 years • Arthritic changes are associated but not always present with joints that have been injured for greater than 18 months - 5 years

Re-injury of Stage 3 Facet Injury • Acute re-injury of a joint results in radiating sclerotomal pain patterns • The pain typically “appears” to be more severe than the level expected from the injury (Maybe a minor incident).

Stage 1 Facet Injury

Diagnosis • History-History-History • Previous injuries • Description of sclerotomal pain patterns • History of manipulative therapy on an ongoing basis • Multiple specialist history • Able to reproduce pain by specific position or actions • Chronic NSAID, Steroid or narcotic use for pain that is non cancerous. • Develop depression and myofascial pain syndromes

Diagnosis • Physical exam • Neurologically intact i.e. (reflexes, pinprick and vibratory sensation, muscle strength, straight leg test, etc.) • MRI: may have disk disease however does not fit pain pattern picture • Plain film X-rays: no obvious fractures • Muscle texture • Boggy and painful in acute (stage 1) • Rope like and painful in chronic (stage 2-3) • Limited range of Motion (short term in stage 1 and long term I stage 2-3)

Diagnosis • X-ray cinematography of the spine and joints. • Pinpoints joints that have gapping injuries and allows for accurate treatment without years of missed diagnosis and unnecessary treatment • Reduces the error rate of plain film x-rays by 15%. (plain film x-rays have a 20-25% error rate) • Radiation level is the same or less than plain films studies depending on the study completed

Indications • Bulging, protruded, prolapsed or herniated discs without free fragment and are not surgical candidates • Frozen or fixated articulations • Epidural / Spinal Nerve Root Adhesions • Failed low back surgery • Compression syndromes with or without radiculopathies caused from adhesion formation, but not associated with osteophyic entrapment • Restricted motion, which causes pain and apprehension from the patient • Unresponsive to manipulation and adjustment when they are the therapy of choice

Indications, cont’d • Unresponsive pain, which interferes with the function of daily life and sleep patterns, but which falls within the parameters for manipulative treatment • Unresponsive muscle contraction, which is preventing normal daily activities and function • Post-traumatic syndrome injuries from acceleration/deceleration or deceleration/acceleration types of injuries, which result in painful exacerbation of chronic fixations • Chronic recurrent neuromusculoskeletal dysfunction syndromes, which result in a regular periodic treatment series, that are always exacerbations of the same condition • Neuromusculoskeletal conditions that are not surgical candidates but have reached MMI especially with occupational injuries

Contraindications • Any form of malignancy • Metastatic bone disease • TB of bone • Acute bone fractures • Direct manipulation of old compression fractures • Acute inflammatory arthritis • Acute inflammatory gout • Syphilitic articular or periarticular lesion

Contraindications, cont’d • Gonorrheal spinal arthritis • Advanced osteoporosis • Evidence of cord or caudal compression by tumor or disc herniation beyond 5mm • Osteomyelitis • Widespread staph/strep infection • Sign/symptom of aneurysm • Unstable apondylosis • Active Hepatitis B or C

Treatment • Stage 1 • Physical therapy and manual therapies are critical to prevent abnormal nerve fiber formation • Cinematography Imaging studies as soon as initial stiffness and pain has resolved to document injury • If sclerotomal pain patterns start developing then consider treatment for stage 2 or 3 injury • Avoid long term NSAIDS and steroid for pain. They result in the development of C-nerve fiber.

Treatment • Stage 2 - 3 • Manual therapy and physical therapy 4-6 weeks. • Cinematography Imaging studies to document injury • If not resolved completely then: • Interventional pain management of the affected joints • Spinal Manipulation under general anesthesia with interventional pain management if needed • Both followed with 4-6 weeks of intensive physical and manual therapy • Avoid long term use of NSAIDS and steroids (short term ok –several days) • Narcotics for short period of time for post procedure pain only

Treatment • Stage 3 • Cinematography Imaging studies as soon as initial stiffness and pain has resolved to document injury • Interventional pain management of the affected joints in a series (steroid may be needed initially due to pain, radiofrequency rhizotomy or micro-rhizotomy series for long term resolution) • Spinal manipulation under anesthesia if unable to tolerate therapies • Followed with 4-6 weeks of intensive physical and manual therapy • Avoid long term use of NSAIDS and steroids (short term ok –several days) • Narcotics for short period of time for post procedure pain only

Treatment • Interventional pain management procedures: • Facet injections- medial branch block • Anesthetic-steroid combinations- short term improvement only good to reduce immediate pain (stage 1 or stage 3B) • Radiofrequency Rhizotomies of facet nerve • Better longer term results repeated every 4-6 months for years (Stage 2 or 3A-B) • Chemical Micro-Rhizotomy of the facet capsule nerves • Better long term results. Repeated 2-4 times per joint several weeks apart to treat the un-mylenated C-nerve fibers that are the source of pain. Generally, the result is permanent after completion of treatment (Stage 2 or 3A-B)

Treatment • Spinal Manipulation under General Anesthesia: • Osteopathic procedure used in stage 2-3 injuries that require “deeper” stretching of affected joints to manually breakup the abnormal nerve fibers and scar tissue that forms around stage 2-3 injuries. • Performed in surgical center or hospital only • Can be used to reduce herniated disks of the spine as well.

Indications and Limitations of Coverage and/or Medical Necessity: “ Because of refinements in manipulative medicine techniques and improvements in physical therapy modalities, this procedure should only be performed on select patients who have failed to respond to conservative therapy.” Scott Haldeman, M.D. in AAOS 2003, in the most recent RCT, “Medication – Assisted Manipulation for Low Back Pain” Department of Neurology, University of California, Irvine reported that: “Medication-assisted manipulation offers patients increased improvement in low back pain and disabilirt when compared to usual chiropractic care.” Published in THE SPINE JOURNAL in 2002, the authors, Frank Kohlbeck, DC and Scott Haldeman, DC, MD, PhD, performed a literature review of MUA (49 published articles) and concluded the following: “Medicine-assisted spinal manipulation therapies have a relatively long history of clinical use and have been reported in the literature for over 70 years. If a clinician recommends MUA it would be difficult to deny the use of medication-assisted manipulation or fail to reimburse for it.”

Daniel West et al reported in a 1998 study of 177 patients that 68.6% of patients out of work returned to unrestricted work activities after a series of three consecutive MUA procedures at 6 months post MUA, that 58.4% of he MUA patients receiving medications prior to the procedure required no prescription medication post procedure and finally that 60.1% of patients with lumbar pain resolved post MUA series of procedures. • Samuel Turek, M.D., orthopedic surgeon, reports in his textbook, Principles and Applications of Orthopedics, that “good to excellent results” can be expected in 50% of patients with acute herniated nucleus pulposus with manipulation under anesthesia. • Thomas Dorman, M.D., orthopedist, recommends in his textbook, Diagnostic Techniques in Orthopedic Medicine, manipulation under anesthesia when the patient has failed at conservative in office care.

Robert Mensor, M.D., orthopedic surgeon, conducted a large clinical trial of over 600 patients with EMG verified radiculopathy and found that 83% responded well to manipulation under anesthesia. • These findings were verified by Donald Chrisman, M.D., orthopedic surgeon, reporting that 51% of patients with unrelieved symptoms after conservative care had good to excellent results even three years after MUA. • Bradford and Siehl reported on 723 MUA patients, the largest trial conducted on MUA procedures, and found that 71% had good results (normal activity, relatively symptom free) and that 25.3% had fair results (improvement, return to relatively normal activity with some residual symptoms) and that flexibility, elasticity and range of motion can be restored to patients with chronic back pain.

Paul Kuo, M.D., Professor of Orthopedic Surgery, reported his clinical investigation in 1986 of 517 patients treated with MUA with 83.9% of the cases responding well. • Further research is ongoing. Well designed prospective controlled clinical trials are being conducted to evaluate the clinical and cost effectiveness of MUA procedures in selected patient populations. • It is important to note that to date there has been no clinical trial that demonstrates MUA to be ineffective in an appropriately selected patient population. Clinical outcome assessments from these and previous studies will further delineate the parameters and the patient population within which MUA can be anticipated to be most effective.

Facet Joint Injuries