The following explanations, insights and advice about osteoarthritis and facet joint problems are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.com.
Patients frequently e-mail us questions about spinal arthritis and facet joint problems, and while we don’t provide individual responses, periodically, Dr. Ullrich will take time to respond to the more frequently asked questions and we publish the responses in this section of the site.
Please understand that the following responses to questions about osteoarthritis, spinal arthritis and facet joints represent the opinion of one physician, and are intended for informational purposes only and not as a substitute for professional medical help or advice.
Osteoarthritis and facet joint questions and physician responses
Question: My wife has low back pain only when lying down in bed at night. Her back feels the same in any position; nothing seems to relieve or increase the pain. She also has pain in the morning when she wakes up. No pain during the day. Can you tell me what this might be? She is active and 41 years old.
Doctor’s response: Your wife’s pain may be from osteoarthritis of the facet joints in the back, or some other sort of joint dysfunction. If there is pain in a joint, sometimes movement helps decrease it by lubricating the joint. Laying still allows it to ache more. Mostly, manual treatments such as physical therapy or chiropractic tend to be good for this type of pain. However, prior to starting any further treatment, your wife should be seen and evaluated by a spine specialist (e.g. physiatrist or orthopedic surgeon/neurosurgeon).
Question: I have had tolerable back pain for many years. It has gotten progressively worse over the years. I started to see a chiropractor in January. He provided some relief but I stopped in April due to a work schedule. Sometime in late May, I started to experience massive pain in my left toes. My back pain is on my left side, and the pain is so intense I almost pass out.
I had a meeting with a neurologist who tested my reflexes and then sent me for an EMG test, which resulted negative. I had X-rays of my feet and left side by both an arthritis specialist and orthopedic surgeon. I also had an MRI done, which resulted as follows: disc bulge is seen at L2-3 with mild degree of canal narrowing. The L3-4 level demonstrates Grade I retrolisthesis. I have a mild degree of canal stenosis. The L4-5 level demonstrates degenerative endplate changes with Grade I retrolisthesis with disc bulge.
I returned to chiropractic care in June and experienced more pain than I could handle and stopped the care. I started to take two drugs, Celebrex (200mg) and Neurontin (300mg) in July and was pain free until I started minor exercise therapy. Now the pain is back with a vengeance, and I stopped the therapy this week.
The pain comes in any position, sitting, standing, lying down in bed or walking. It is inconsistent, without warning, at any time of day. The pain is off the charts, I can only say it feels like touching my toes to an exposed electrical wire. I am about to take a small regiment of Prednisone as prescribed by my doctor. Please steer me in the right direction. Who do I see next?
Doctor’s response: The pain you are describing sounds mechanical in nature. Pain that comes and goes is often related to joint dysfunction. It can be very frustrating and difficult to both accurately diagnose and treat. The only specific finding on your MRI scan may be the anterolisthesis of L3 on L4. If this is also associated with foraminal stenosis, you could be having some nerve root pinching which could account for your leg pain.
Mechanical back pain and joint dysfunction are usually best handled with joint manipulation and exercise. Your treatment so far sounds appropriate, but you may want to try a different manual therapist (a physical therapist with manipulation training, a different chiropractor, or an osteopathic physician). It is encouraging that for a period of time you were pain-free. Be patient, and expect to go through setbacks as you continue your rehabilitation.
If you fail to make progress with rehabilitation, you should be seen and evaluated by a spine specialist to see if there is any significant nerve root pinching that can account for your pain. If there is a pinched nerve, you may be a candidate for an injection or possibly a surgical decompression.
Question: A physiatrist diagnosed me as having lumbar radiculopathy, based on his examination, and recommended an MRI which showed: (1) At L4-L5, mild degenerative changes of disc and marked proliferate degenerative changes of facet joints, associated with minimal degenerative spondylolisthesis of L4onL5. (2) L5-S1: mild degenerative changes of disc and a small, broad-based midline posterior disc protrusion, mildly encroaching upon the canal and an annular tear. Also found asymmetric hyertrophic degenerative changes of left facet joint and a small extra-spinal synovial cyst along posterior margin of the left facet joint. (3) Remainder of intervertebral discs appears maintained and remainder of canal and neural foramina appear free of encroachment and no significant areas of stenosis. The physiatrist concluded that the bulging disc would cause symptoms in my left leg (I have none) and he thought that my main problem is spinal osteoarthritis.
What in this MRI indicates osteoarthritis? How severe is it? I'm 53, in excellent health, pre-menopausal, exercise regularly and have a BMI of 21. How many of these MRI findings are normal for someone of my age and physical condition? Note that I have a strong family history of severe osteoarthritis, particularly in postmenopausal women and therefore am quite concerned about being told that I have osteoarthritis that is bad enough to be causing these symptoms in spite of my good health and lifestyle.
Doctor’s response: Without seeing the MRI scans it is difficult for me to accurately advise you, but it seems as though you were given an accurate diagnosis and counseling in regards to osteoarthritis.
If you have a strong family history of osteoarthritis (OA) it is not surprising that you have some early changes on your scan. You are doing the right things in that the more in shape you are, the healthier your back will be. Concentrate on stretching, especially the hamstring muscles, as this will keep some of the stress off the low back. Otherwise, try to stay as active as possible within your tolerance for the discomfort. Some people feel chondroitin sulfate or glucosamine sulfate nutritional supplements can help those with OA. Fortunately, significant osteoarthritis and breakdown of a facet joint mainly happens at the L4-L5 level, and does not always significantly affect the other levels. If it gets bad enough, you would probably be a good candidate for a one level decompression, instrumentation and fusion.
Question: My 90 year old mother suffers from spinal stenosis. A recent Wall Street Journal article mentions that in patients with back pain due to arthritis, doctors are using radio-frequency heat to deaden nerves. Do you know where this procedure is being performed? I would take her anywhere this is being done, as she is not a candidate for surgery.
Doctor’s response: If she has spinal stenosis and her pain is mainly from the stenosis then the radiofrequency rhizotomy would not be useful for her.
If her pain is from osteoarthritis of the facet joints then she may be a candidate. Usually, three separate injections into the facet joint would first be performed to see if injection with Lidocaine would be useful. If it gives her consistent but temporary relief of her pain, then the radiofrequency rhizotomy may be an option. Unfortunately, it only helps in 30-40% of patients and the pain relief is often temporary (6-12 months). It is actually an old treatment, and any spine clinic or center would probably be able to do it for her.
Question: In August 2001, I was diagnosed with a synovial cyst. Prior to the diagnosis, I was a fitness walker but was unable to continue until this past spring. No doctor has been able to tell me what caused this cyst and the chance of recurring problems from it. Can you?
Doctor’s response: A synovial cyst is caused by osteoarthritis and degeneration of the facet joint. As the joints become more arthritic they produce more fluid. A synovial cyst is where a ball valve develops that lets the synovial fluid out but not back into the joint. This creates a cyst that usually fills into the spinal canal and causes compression (stenosis) of the nerve roots. Usually, there is both the compression problem and instability at that joint. The treatment and natural history is most akin to a degenerative spondylolisthesis and spinal stenosis.
The treatment choices for a synovial cyst from osteoarthritis and degeneration of the facet joint are a facet injection, an epidural injection or a surgical decompression of the nerve root. The surgery, however is usually also done with a fusion since there usually is instability. The cyst does tend to cause recurring problems until it is surgically excised. However, surgery is only suggested if the cyst limits your activity greatly.
If you are having problems finding answers and treatment, I would suggest seeing a spine specialist (for either conservative or surgical treatment).
What next?
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April 19, 2005
Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health.com’s Medical Advisory Board.
