ORIGINAL ARTICLE
Septic Arthritis of Lumbar Facet Joints Without
Predisposing Infection
Minoru Doita, MD,* Yuji Nabeshima, MD,w Kotaro Nishida, MD,* Hiroyuki Fujioka, MD,*
and Masahiro Kurosaka, MD*
Abstract: Septic arthritis of a lumbar facet joint is a rare clinical
entity and most articles have reported a single case. There have
been few studies that have evaluated the clinical and imaging
features of septic arthritis of lumbar facet joints. The clinical
data of 5 patients diagnosed with septic arthritis of lumbar facet
joints were retrospectively studied. The average age of 5 patients
was 73.6 years. All patients had elevated temperature at
admission (37.71C). Leukocyte count was tested in all 5 patients
and was elevated in only 2 patients. Erythrocyte sedimentation
rate and C-reactive protein were examined and were elevated
in all 5 cases. Magnetic resonance imaging was accurate in
identifying the septic joint and associated abscess formation. All
patients were treated with bed rest and received intravenous
antibiotics for an average of 33.3 days. Four of 5 patients had
positive outcomes with full recoveries and no evidence of
recurrent infections. One patient exhibited evidence of recurrent
infection and required open facet arthrotomy and paraspinal
muscle debridement after intravenous administration of anti-
biotics. Septic arthritis of the lumbar facet joint is a rare cause of
low back pain. It is important to ascertain the diagnosis at the
earliest possible stage and to start intravenous antibiotics
therapy as soon as possible. Magnetic resonance imaging is
quite a sensitive modality for identifying infection of the lumbar
facet joint. Familiarity with its clinical symptoms and radio-
graphic features is necessary to avoid misdiagnosis of this
condition.
Key Words: septic arthritis, facet joint, lumbar spine, MRI,
treatment
(J Spinal Disord Tech 2007;20:290–295)
S eptic arthritis of the peripheral joints most frequently
involves the knee, followed by the hips, shoulders,
wrists, ankles, and elbows, respectively.1 However, septic
arthritis of a lumbar facet joint is a rare clinical entity and
most articles have reported only a single case.1–26 There
have been few studies that have evaluated the clinical
Received for publication March 24, 2006; accepted August 23, 2006.
From the *Department of Orthopaedic Surgery, Kobe University
Graduate School of Medicine, Kobe, Japan; and wDepartment of
Orthopedic Surgery, Himeji St Mary Hospital, Himeji, Japan.
Reprints: Minoru Doita, MD, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe
650-0017, Japan (e-mail: doita@med.kobe-u.ac.jp).
Copyright r 2007 by Lippincott Williams & Wilkins
290
and imaging features of septic arthritis of lumbar facet
joints.27,28
Because the clinical symptoms are similar to those
seen in other kinds of spinal infections, usually this lesion
is not correctly diagnosed until abnormalities of the
involved facet joint could be recognized in some imaging
studies.18,28 The exact incidence of this entity is unknown.
However, the frequency of this type of arthritis could be
underestimated due to the possibility of spontaneous
evacuation of the arthritis either into the posterior soft
tissue or into the epidural space, thus leading to
spontaneous resolution of symptoms.2,6,12
The symptoms associated with pyogenic facet joint
infection tend to be unilateral and present more acutely
and with greater severity in the early stages, when
compared with spondylodiscitis.7,8,27,28 Without appro-
priate treatment, pyogenic infection involves the epidural
space and paraspinal musculature, with a high risk of
abscess development and possible fatal outcome.2,9
The purpose of this retrospective review of septic
arthritis of lumbar facet joints is to characterize the
clinical and magnetic resonance (MR) features of patients
with septic arthritis of lumbar facet joints.
MATERIALS AND METHODS
This is a retrospective review of all cases of septic
arthritis of lumbar facet joints at our institution from
January 2000 to December 2003. The study was
conducted through review of patient records, laboratory
data, and imaging studies. Leukocyte counts, erythrocyte
sedimentation rate (ESR), C-reactive protein (CRP), and
tissue or blood cultures were obtained. Imaging studies
included plain radiographs, and magnetic resonance
imaging (MRI). Imaging studies were reviewed with a
neuroradiologist for evidence of intra-articular changes,
soft tissue edema, paraspinal or epidural abscess collec-
tions, and concomitant spondylodiscitis. The diagnosis of
septic arthritis of lumbar facet joint was confirmed by
clinical findings of acute onset of low back pain that does
not abate with inactivity,27,28 MRI, and/or positive
bacteriologic culture (by blood or needle biopsy). Patients
with the predisposing conditions such as current usage of
intravenous drugs, overt evidence of concurrent infection
elsewhere, pregnancy, or a recent episode of pelvic trauma
were excluded. Five patients were included in the study
J Spinal Disord Tech  Volume 20, Number 4, June 2007
J Spinal Disord Tech  Volume 20, Number 4, June 2007 Facet Joint Septic Arthritis

Antibiotics Antibiotics (d)

and were reviewed, with follow-up periods of 9 months to

Duration of

Operation
36 months (average 18 mo).

35

53

22
23
Each patient had low back pain and localized
tenderness over the facet joint associated with fever. All
patients had MR examinations (with gadolinium con-
trast). MR images demonstrated erosion of the affected

Kind of

CEZ

CEZ

CEZ
IPM
joints with significant intra-articular widening and con-
trast enhancement of paraspinal muscle. No evidence of
discitis, vertebral body osteomyelitis, or psoas abscess
formation was observed. Four patients were treated with

Blood

Blood

Blood
Blood
Site
intravenous antibiotic administration for average 33 days,
combined with bed rest with body cast for 8 weeks. One
patient was treated with administration of broad-spec-
trum antibiotics and with complete bed rest without

Not available
Organism
S. agalactie
permission of sitting and standing. Despite the initial

Negative

Negative
Negative
response to intravenous antibiotic therapy and improve-
ment of clinical symptoms, the patient’s temperature
remained elevated, and neither ESR nor CRP was
normalized. Laminectomy and debridement of the facet

TABLE 1. Demographics, Presentation, Laboratory, and Microbiologic Data of Pyogenic Arthritis of Facet Joints

(mg/dL)
CRP

25.5

6.1

30.0

11.9
11.5
joints were performed because the bilateral facet joints
were involved and paraspinal abscess formation was
observed in this case.

(mm/h)
ESR

131

69

111

59
77
RESULTS
Clinical Presentation
Demographic and presenting data are shown in

(¾103/mm3)
15300

5600

10500
8000

8400
WBC
Table 1. All patients were women and the average age was
73.6 years (range 70 to 78 y). All patients presented with
an acute onset of low back pain that became constant and
would not abate with rest. All patients were febrile. Two
of the 5 patients had radicular pain in the legs without
Temperture

motor weakness. The duration of symptoms on admission

Body

37.5

37.0

37.4

37.4
39.0
(8C)

ranged from 0 to 19 days (average 7.2 d).

In our series 2 patients had history of the operation,
and 1 was treated with breast cancer and the other was
treated with cervical myelopathy. No patients had a
Interval From

Admission (d)

recent extraspinal focus of infection. Risk factors predis-

Onset to

posing to infection were present in 2 patients who had

19
8

5
4

diabetes mellitus.

Diagnosis
Patient 5* was reported previously as a single case report.22
CEZ, cefazolin sodium; IMP, imipenem; L, left; R, right.
L buttock pain
Low back pain
Low back pain

Low back pain

Low back pain

Low back pain

Laboratory and microbiologic data are also pre-

Symptoms

sented in Table 1. All patients had elevated temperature

L leg pain

L leg pain

on admission (range 37.01C to 39.01C, mean 37.71C).

Leukocyte count was tested in all 5 patients and was
elevated in only 2 patients. ESR and CRP were examined
and were elevated in all 5 cases. Blood cultures were
Predisposing
Conditions

performed in 4 cases with 1 patient returning positive

None

None
None
DM

DM

culture and growing Staphylococcus agalactie. Cultures

from facet joint aspirations or from open decompression
were obtained in 2 patients returning negative culture.
In only 1 patient oblique, plain radiograph has been
Age
(y)
75

78

70

73
72

shown to demonstrate a widening of the bilateral facet

joint spaces and sclerotic changes of the joints,22 although
Sex
F

F
F

plain radiographs revealed no specific evidence of

infection in other 4 patients.
Patient

Sagittal and axial MRI scans with gadolinium

5*

contrast were done in all of our cases. Contrast-enhanced

1

r 2007 Lippincott Williams & Wilkins 291

Doita et al J Spinal Disord Tech  Volume 20, Number 4, June 2007

FIGURE 1. Axial MRI demonstrating left-sided facet joint

infection with associated abscess formation in both epidural
space (white arrows) and paraspinal muscle (black arrows)
with hyperintense signal intensity on T2-weighted images (A).
Contrast-enhanced axial MRI showing high-signal peripheral
rim enhancement (B).

images demonstrated epidural abscess formation in 2

patients (cases 1, 3) (Figs. 1A, B), epidural granulation
tissue without abscess in 2 cases (cases 2, 5) (Figs. 2A, B), FIGURE 3. Axial, contrast-enhanced T1-weighted MRI de-
and posterior, paraspinal abscess in 3 cases (cases 1, 4, 5) monstrating paraspinal muscle enhancement and abscess
formation (arrow).
(Fig. 3). Three of our patients had single facet joint
involvement and 2 patients had bilateral facet joint
involvement at 1 level (cases 4, 5) (Fig. 4). There was no evidence of recurrent infections or functional dis-
no evidence of discitis, vertebral body osteomyelitis, or abilities after conservative treatment. One patient was
psoas abscess formation by MRI in any of our patients. treated for 10 days with intravenous antibiotic therapy
(cefazolin sodium) and complete bed rest. This led to
Management and Outcome progressive improvement in the low back pain and
All patients were treated with bed rest and received disappearance of the fever. However, severe low back
intravenous antibiotics for an average of 33.3 days (range
22 to 53 d) and then oral antibiotics for an additional 2 or
3 weeks. Four patients were treated with intravenous
administration of Staphylococcus aureus sensitive anti-
biotics such as cefazolin sodium, because S. aureus was
reported to be the infecting organism in approximately
80% of the cases. One patient was initially admitted at
the department of rheumatology and was treated with
imipenem. Percutaneous drainage was not performed,
although 3 of the patients had paraspinal abscess. Four of
5 patients had positive outcomes with full recoveries and

FIGURE 2. Axial T2-weighted MRI showing unilateral, right

facet joint involvement with granulation tissue formation in FIGURE 4. Axial, contrast-enhanced T1-weighted MRI show-
the epidural space (black arrow) (A). Contrast-enhanced MRI ing bilateral facet joints infections with associated inflamma-
showing diffuse enhancement of the granulation (black arrow) tory changes in the adjacent paraspinal muscles (black
(B). arrows).

292 r 2007 Lippincott Williams & Wilkins

J Spinal Disord Tech  Volume 20, Number 4, June 2007
pain with high fever recurred and the patient underwent
open facet debridement and decompressive laminectomy
after intravenous administration of antibiotics (flomoxef
sodium) for 3 weeks after surgery. At the latest follow up
assessment, the patient remained afebrile and had a
marked reduction of low back pain.
DISCUSSION
Spinal infections due to pyogenic organisms usually
involve the discs and adjacent endplates. Infection of
neural arch is exceedingly rare. Septic arthritis of spinal
facet joint has only been reported in the lumbar spine and
is a relatively rare finding. Most articles have been
described as case reports,1–26 and there have been only 2
studies of a series of cases of lumbar facet joint septic
arthritis.27,28 Muffoletto et al28 studied 6 cases of
hematogeneous pyogenic facet joint infections retrospec-
tively and summarized the literature to characterize this
condition and its findings. In their series 5 of 6 patients
had recent extraspinal focus of infections. We studied 5
cases of septic arthritis of lumbar facet joints without any
preexisting extraspinal infection.
As in other joint infections, septic arthritis of a
lumbar facet joint can be caused hematogenously, by
direct inoculation, or by transmission from nearby
infections.13,16,20 It is shown that 58% of all reported
cases of facet joint infections had risk factors predispos-
ing them to spinal infection, with extraspinal infection
and diabetes mellitus being the most common risk
factors.28 Direct spread of the microorganism from an
adjacent structures is less frequent and usually follows
spinal procedures, facet joint injection,13,16,23 epidural
anesthesia,29 and paraspinal pyomiositis.20 Immunocom-
promised patients (eg, diabetes mellitus, liver disease,
alcohol abuse, intravenous drug abuse, chronic steroid
usage) may be at risk for developing a facet joint infection
without clinical evidence of infection elsewhere in the
body.3–5,7–10,27,28 Average age of our patients is 73.6 years
(range 70 to 78 y) and is older than that of the patients
reviewed by Ergan et al27 (mean age is 63 y) or
by Muffoletto et al28 (mean age is 55 y). Therefore, aging
itself may also be a risk factor for a facet joint infection.
Thus, this previously rare disease will become more
prevalent, because of an increase in the elderly popula-
tion, which is generally more susceptible to infections and
a rising number of immunocompromised patients.
The clinical presentations of septic arthritis of facet
joints were similar to those of spondylodiscitis, with fever,
low back pain, and in some instances nerve root
symptoms. However, when compared with spondylodis-
citis, the symptoms associated with facet joint infection
tend to be unilateral, and present more acutely and with
greater severity in the early stages.7,8,27,28 It was also
reported that the average duration of symptoms before
diagnosis is approximately 4 weeks1–26 compared with 2
to 3 months of spondylodiscitis.30,31 In our series, the
interval from onset to admission was on average 7.2 days.
r 2007 Lippincott Williams & Wilkins
Facet Joint Septic Arthritis
Thus, in cases of acute low back severe pain with fever,
a high clinical suspicion is necessary.
Laboratory tests showed an inflammatory blood
picture. Leukocyte count was tested in all 5 patients and
was elevated in only 2 patients, although both the ESR
and CRP were elevated in all cases tested. Similarly, it
was demonstrated that leukocyte counts were inconsis-
tently elevated (47%), but that ESR and CRP were
uniformly elevated.28 Laboratory data are similar to those
found in patients afflicted with an epidural abscess, either
primary hematogeneous or secondary to spondylodiscitis.
Therefore, considering the differences between clinical
manifestation of facet joint infection and spondylodisci-
tis, it is still difficult to discriminate between the 2
conditions.
Our data demonstrate that imaging studies are
essential to the diagnosis of facet joint septic arthritis and
also to the documentation of spread to the adjacent
epidural space and/or muscles. Oblique plain radiographs
may demonstrate changes consistent with erosive arthritis
of the facet joints after 6 to 12 weeks.2,3,8,12,27 How-
ever, plain radiographs usually are of no value in the early
stage of the disease.2,3,8,12,27 In contrast, technetium-99
bone scintigraphy was 100% sensitive in detecting facet
infection as early as 3 days after symptom onset.32
Computed tomography (CT) allows to select section
orientations and bony windows that provide a detailed
assessment of the facet joints. However, CT findings
similar to those seen in facet joint septic arthritis have
been reported in patients with osteoarthritis, other
rheumatic conditions, or neoplasias. Bone scintigraphy
and CT can be viewed as complementary investigations,
with the former drawing attention to the neural arch and
determining the level of involvement early in the disease
process, and the latter subsequently confirming the site of
the lesions and their infectious nature. However, MRI
was the best technique in our series for showing
abnormalities in the signal from the facet joint and for
demonstrating epidural and muscular lesions. MRI has
been shown to be both sensitive and specific in diagnosing
septic arthritis of a facet joint in the early stages.
Furthermore, high-quality MRI with contrast enhance-
ment seems to be the imaging modality of choice in
diagnosing this condition in its earliest stages and in
delineating the extent of soft tissue involvement, including
abscess formation.11,18,19,33 We believe that MRI has a
place in the diagnosis of facet joint septic arthritis, and
that T1 axial sections with gadolinium can be useful when
a MRI study done because of spinal symptoms with fever
fails to demonstrate spondylodiscitis.
The pathogenesis of facet joint septic arthritis and
the reason why this condition is considerably less
common than discitis remain unclear. It has been
demonstrated that discitis is secondary to infection of
the vertebral endplates, which receive a large number of
collateral branches from the lumbar artery. The terminal
branches of this same artery supply the facet joints, the
posterior epidural space, and the paraspinal muscles,
which may explain why these structures are often infected
293
Doita et al
concomitantly.27 Thus, the intravenous antibiotics could
be more effective than the other joints in the body because
of the characteristics of the blood supply to the facet
joints.
The management of facet joint septic arthritis rests
on antibiotics with activity against the causative organ-
ism, which is usually a Staphylococcus aureus.28 It is
difficult to determine the optimal therapeutic regimen
based on our small series and on the heterogeneous cases
in the literature. However, it is suggested that regimens
designed for the treatment of spondylodiscitis are also
effective on facet joint septic arthritis and it has been
recommended that antibiotics should be given for 4 to 6
weeks and continue them until the pain has disappeared
or the ESR has normalized. Percutaneous CT or
fluoroscopically guided drainage of the involved facet
joint or paraspinal muscle abscess is reported to be
successful approximately 85% of the time in cases
without associated epidural or paraspinal abscess forma-
tion.5,6,12,27,28 Percutaneous drainage of the facet joint
was not performed in our series, because paraspinal
abscess formation was observed before the initiation of
antimicrobial therapy and intravenous administrations of
antibiotics combined with bed rest were very effective,
although one of 5 patients needed open drainage and of
the infected joint. Surgical intervention is indicated when
neurologic dysfunction is present or when treatment with
appropriate antibiotics fails to control the infection as
manifested by continued evidence of sepsis.3,8,10
CONCLUSIONS
Septic arthritis of the lumbar facet joint is a rare
cause of low back pain. Because of very serious
complications, it is of the utmost importance to ascertain
the diagnosis at the earliest possible stage and to start
intravenous antibiotics therapy as soon as possible. This
possibility should especially be considered in patients who
present with severe, spontaneous onset, unilateral back
pain including a nocturnal pain component, and high
fever. The diagnosis is established on the basis of clinical
and radiologic evidence. MRI is quite sensitive at
identifying infection of the lumbar facet joint and ruling
out involvement of the disc space and vertebral body.
The prognosis of septic arthritis is usually favorable.
Although current treatment recommendations suggest
that intravenous antibiotics alone should be the first line
of treatment for this condition, surgical debridement may
be necessary in the face of failure of antibiotic therapy.
Familiarity with its clinical symptoms and radiographic
features is necessary to avoid misdiagnosis of this
condition.
ACKNOWLEDGMENT
The authors thank Ms Janina Tubby for her help in
preparing the manuscript.
294
J Spinal Disord Tech  Volume 20, Number 4, June 2007
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