Facet Related Interventions

Who, When and Where

 Prof & HOD Dept. of
 Anesthesia & Pain, B.H.I.M.S.,
Pain Physician, Lilavati,
Raheja, Shushrusha Hospital
 Ex.President, IndianSociety
for Study of Pain,
 Executive President, Pain
Management and Research
Foundation
 Hobbies-Music, Sports
Dr.D.K. Baheti
 Email-dr.baheti@gmail.com
 Web-www.paincure.in
 Facet Related Interventions
Who, When and Where

Dr.D.K.Baheti MD
Prof & HOD
Dept. Of Anaesthesia and Pain Management
B.H.I.M.S.,Mumbai-India
What are the Facet Joint?

 Facet joints are located at the posterior (back)

aspect of the spine.
 Each back bone (vertebra) has four facet joints, an
upper and a lower pair.
 These joints link the back of the spine together.
 They are designed to provide stability and control
motion between the vertebrae.
Facet Jt. Pain Syndrome (FJPS)?

FJts are prone to injury, deterioration, &

inflammation. FJPS can occur anywhere in the
spine including the low back.
 FJP is usually at the level of the affected facet
joint(s), and is made worse by activities that put
pressure on these joints i.e. leaning backwards
and "extending" the lower back or twisting at the
waist.
 Occasionally the pain may radiate to other areas
such as the buttocks.
PAIN DISTRIBUTION
What causes Facet Jt. Syndrome?-2
Degenerative Disc Disease occurs
1-Irritated from trauma, repetitive movements,
arthritic changes
2-The damaged disc looses cushioning effect which
leads to more stress on facet joints , which may result
in degeneration of the facet joint.
3-Poor posture can also cause undue stress on the facet
joints.
What cause Facet jt. Syndrome?3
 The natural inward curve in the lumbar (low back) are
designed and positioned to handle a certain amount of
stress.
 When the natural curve of the lumbar spine is
exaggerated excess stress is placed on the facet joints.
 Poor body mechanics or how we use our body such as
bending from the back, improper lifting, poor rest
positions, and prolonged sitting in poorly designed
chairs can all cause undo stress on the facet joints.
Facet Joint Pain Syndrome-Diagnosis?
 Good medical history and a physical examination.
 X-rays- AP/LAT/OBLIQUE of the lower back may
help to rule out degenerative changes in the facet
joints or degenerative disc disease.
 MRI and CT scans.
 Diagnostic blocks
Differential Diagnosis!!!

 Herniated disc infllamation

 Fracture
 Torn back muscle
 Acute Intra abdominal problem
SITES OF PAIN
Symptoms FJPS
 Persistent joint tenderness
 Muscle guarding
 Discomfort in leaning forwards/backwards
 Radiating pain Lumbar- in to buttock and leg
 Cervical- Shouldar, front and down arm even fingers
 WHO
A 38 year old woman presented with
Low Back
Pain with radiation along the Postero-
Lateral
aspect of the Left Thigh to just above
the
knee and also out to the Left Hip
lateral aspect.
 Pain

The pain was described as a constant dull ache with a

sharp stabbing in left paravertebrally and over the SI
joint.
Pain varied between VAS 0.8----7.0: 4.5 mean
 Worse

= Sitting especially in a soft sofa.

= Mornings
= Standing still
= Long walks
= Much pain when tired, often in the evenings
after work
Weight Bearing on
the Left Leg and
pushing with the
Right leg
 Better

When she had got going in the mornings after getting up

Short Walks
Best

Not too Little ___ Not too Much Movement

Stand a Little, Sit a Little, Walk a Little
 Examination

Inspection Para-Vertebral muscle spasm

Palpation Tender Mid-line and Left Paravertebral
Movement Stiff, careful, reduced flexion, pain on
extension.
SLR Left 80º C Right 90º C
Reflexes Brisk, Equal both sides
Sensory Reduced along Postero-Lateral aspect
Left thigh.
Motor Normal
 Clinical Diagnosis
?
Facet (Z joint) Pain
 Medication

Gabapentin 300mg x 3 Daily

Paracetamol 1 g x 3 Daily
Tramadol 50 – 100 mg occasionally when
bad
Sertralin (Zoloft) 50 mg Daily (Anti-
depressant)
 Previous Treatment Attempts

Physiotherapy, massage, exercise programs, twice a week

4 years -- No Effect.
Acupuncture -- No Effect.
TNS -- No Effect.
ESI x 3 -- Minimal Effect.

MRI -- slightly bulging disc

Orthopedic surgeon -- surgery not indicated.

Condition -- variable but stable. Works half time now

after Rehab, been off-sick for 4 years
Pain Left Gluteal and P/L Left Thigh
Trans – Foraminal ESI L5 Left

“ Fantastic” 80% Better 2 Months

Pains gradually back
Now only 10% Better
 Repeat L5 Trans – Foraminal ESI

“Not as Good” -- Shorter Effect

Now Most Pain Both Hips Laterally and
Paravertebral more on left
BUT Better in the Leg
Pain Still provoked by
Sitting and Extension
 3 Months Later
Back Again, Was Fine 2 Months
Now only 40% Better
Patient mentions that she has
Even More Problems Passing Urine
Been to Urologists and Gynaecologists 4 Years
Did not mention it before as she thought it was not
relevant
Temp. Left foot 1,8ºC colder than right
Patient admits that Left Foot often ‘Feels’ Colder
 Medial Branch Blocks

L3 - L4 - L5 - S1 Left
Bupivacaine 5 mg/ml
40 – 50% Better first 3 hours
50% Better 3 Weeks
Repeat Medial Branch Blocks L3–L4–L5–S1

Initially 60% better

then 70% better 10 days
But only 20% better at follow-up
6 weeks later.
 Re-Examined

Tender Para-vertebral Upper Lumbar

So Medial Branch Blocks L1 – L2 – L3 Left
30 minutes later - 90% Better
BUT
Still Tender Left Para-vertebral Low Lumbar
Medial Branch Blocks L4 – L5 – S1 Left
Pain free
 Lumbar Sympathetic Block

10 ml of Bupivacaine Injected at Antero-Lat

aspect lower border L4 Left

Temp Rise 13,6º C Left Big Toe

Passes Urine normally first time in 4 years
 Radio Frequency Lesioning L4 –S1
with 40% Improvement
2 Months Later No More Leg Pain, Still cant Sit,
Slight Urinary Problems only

Radio Frequency Lesioning L1 – L4

3 Months Later 70% Better
Leg ‘Feels’ Colder and still some Urinary Problems
Repeat Lumbar Sympathetic Block x 2

Patient Been completely Painfree

Not had ANY Urinary Problems

At 6, 12 and 18 months Follow-up.

Has worked full time last 2 years

Has stopped all medication
R.F. LUMBAR FACET JOINT
FACET JOINT INJECTION
Treatment
 Physical therapy (joint mobilization or
manipulation)
 Exercise, and education on good spine
posture,
 Anti-inflammatory medications,
 Pain medications and activity modification.
 Injections (with a steroid) or R.F. to block the
pain messages from the nerves
 Rarely, surgery is required.
Treatment-2
 Heat (e.g. heat wraps, a hot water bottle, hot
showers) or cold (e.g. cold pad applications)
 Changes in daily activities (e.g. shortening or
eliminating a long daily commute), and adding
frequent rest breaks
 Chiropractic manipulations or osteopathic
manipulations may provide pain relief
Treatment-3
For the neck, a restraining collar may
bring temporary
relief, as may also cervical traction.
 A suitable supportive neck pillow is often
essential and abnormal nighttime flexion
positioning of the neck, such as when using a
pile of pillows, is to be avoided.
PART OF THE PRESENTATION
COURTESY

DR.S.NATH(SWEDEN)