Facet and Axial Spine Pain

Disclosures • I have nothing to disclose.

Diane M. Rowles, MS, ACNP, BC, CRRN Nurse Practitioner, University Neurosurgery Rush University Medical Center Adjunct Assistant Professor, Feinberg School of Medicine Northwestern University

Objectives • Participant will be able to state incidence of back and neck pain in the US. • Participant will be able to distinguish symptoms of axial and facet spine pain. • Participant will identify key exam components when assessing neck and back for pain.

Incidence of Pain Compared to other Major Conditions Pain affects more Americans than diabetes, heart disease and cancer combined: • Chronic Pain - 100 million (Institute of Medicine of The National Academies) • Diabetes (diagnosed and estimated undiagnosed) - 25.8 million (American Diabetes Association) • Coronary Heart Disease (heart attack and chest pain) - 16.3 million (Americans American Heart Association) • Stroke - 7.0 million (National Stroke Association)

Incidence of Back and Neck Pain • Range is inconsistent but in careful review of a lot of literature at ¼ to over 1/3 of US population report back and neck pain • ½ as many neck as back • Women more neck pain – found in multiple studies • Computer and office jobs more neck pain • Upper class more neck pain • The United States' National Center for Health Statistics reported 7.0% of men and 9.4% of women had neck pain in the period between 1976-1980.

Low Back Pain (LBP) 3 things that account for 80% of chronic LBP #1 disc pain– annular tear; inflammatory process causing pain. (Not herniated which irritates nerve causing leg and buttock symptoms). No nerve fibers in center of disc have nerves in the outside of the disc. #2 facet joints – become arthritic and painful better with sitting and worse with standing because facets are loaded. After age 65 facet pain is more likely. #3 SI joint - pain in lower portion and buttock 10-20% of lower back pain.

• Cancer - 11.9 million (American Cancer Society) Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. October; 16(10): 1539–1550

Anatomy and Physiology Anatomy and Physiology

FitzGordon J (2012). Spinal Movement: Facet Joints. Core Walking Blog. October 3, http://blog.corewalking.com/spinal-movement-facet-joints/

Facet Joints in Motion

Facet Pain - Definition • Deterioration of facet joint • Lined with cartilage and in a capsule • Damage from wear and tear, injury, degeneration of inter vertebral disc • Can lead to growth of bone spurs • Cervical – pain in neck, shoulders, upper or middle back and headaches • Lumbar - pain in low back, buttocks and posterior thigh

FitzGordon J (2012). Spinal Movement: Facet Joints. Core Walking Blog. October 3, http://blog.corewalking.com/spinal-movement-facet-joints/

Facet Pain - Symptoms

Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spinehealth.com/conditions/arthritis/facet-joint-disorders-and -back-pain

Cervical facet pain map

• Acute episodes of lumbar and cervical facet joint pain are typically intermittent, generally unpredictable • Persisting point tenderness overlying the inflamed facet joints and some degree of loss in the spinal muscle flexibility (guarding) • Typically more discomfort leaning backward than forward (closing up the space) • LBP from facet joints often radiates down into the buttocks and back of the upper leg. • Rarely presents in the front of the leg, or rarely radiates below the knee or into the foot, as pain from a disc herniation often does. • Cervical facet joint problems radiate pain locally or into the shoulders or upper back, and rarely radiate in the front or down an arm into the fingers as a herniated disc might • Lumbar, standing may be somewhat limited but sitting or riding in a car is the worst. • Muscle spasm can be constant and fatigue the muscle

Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spine-health.com/conditions/arthritis/facet-joint-disorders-and -back-pain.

Dwyer AB, Aprill C, Bogduk N. (1990). Cervical zygapophysical joint pain patterns. 1: A study of normal volunteers. Spine; 15:453-457.

Figure 3 Cervical and lumbar facet joint pain referral patterns

Acute Low Back Pain - Axial • If self limiting, the diagnosis as to which structure is causing the low back pain rarely has significance to treatment.

Part a adapted with permission from Lippincott Williams & Wilkins © Dwyer, A. et al. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976) 15, 453–457 (1990) Gellhorn, A. C. et al. (2012) Osteoarthritis of the spine: the facet joints Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2012.199

Acute Low Back Pain - Axial • Presence of an anatomical lesion that can be seen on an MRI scan, such as a herniated disc, may have nothing to do with the low back pain episode, making diagnosis difficult. • Structures in the low back that can cause axial or mechanical lower back pain: ▫ degenerated disc ▫ facet joint problems ▫ damage to soft tissues – muscles, ligaments, and tendons

• Can not overlook possible serious conditions, such as an infection, tumor or fracture.

• Only in chronic and severe cases is further evaluation and diagnosis helpful. (Ben-Yishay, 2012)

Do you agree?

Axial Pain - Symptoms • Varies widely: Sharp or dull pain, constant or intermittent, mild to severe • Worse with certain activities • Worse with certain position (eg sitting for long periods)

• Relieved by rest • Confined to the central area (back or neck) • Often describes as “mechanical” (Hancock et al 2007)

(Ben-Yishay, 2012)

Back Assessment and Exam Observation: • • • • • • • • •

General : skin (attention to scars), teeth, hair Facial characteristics Body position and posture Standing posture Sitting posture Muscle Atrophy Fasciculations Involuntary movements Deformity

Back Assessment and Exam Strength • Unilateral vs. bilateral complaints • Compare to opposite side • Describe strength if 0-5/5 is not presenting the picture

Back Assessment and Exam Palpation: • • • •

Hips SI joint Sciatic notch Tenderness: exact location and amount of pressure • Patient’s response: withdrawal, grimacing, guarding

Back Assessment and Exam Reflex: • Normal: DTR • Abnormal: ▫ ▫ ▫ ▫

Hoffman’s Spurling Babinski Others as appropriate pending exam and history

Cervical Assessment and Exam Palpation: Tenderness: exact location and amount of pressure Patient’s response: withdrawal, grimacing, guarding

Back Assessment and Exam Strength • Unilateral vs. bilateral complaints • Compare to opposite side • Describe strength if 0-5/5 is not presenting the picture • Transition movements

Cervical Assessment and Exam Observation: • • • • • • • •

General : skin, teeth, hair Facial characteristics Head position and posture Muscle Atrophy Fasciculations Involuntary movements Deformity of neck, body, extremities Note voice and scars

Cervical Assessment and Exam Sensory: • Dull/sharp • Change in temperature

ROM: • Smooth and painless

Cervical Assessment and Exam Strength • Unilateral vs. bilateral complaints • Compare to opposite side • Describe strength if 0-5/5 is not presenting the picture.

Axial Pain - Diagnostics • X-ray. These images show the alignment of your bones and whether you have arthritis or broken bones. X-ray images won't directly show problems with your spinal cord, muscles, nerves or disks….include flexion and extension • Magnetic resonance imaging (MRI) or computerized tomography (CT) scans. These scans can generate images that may reveal herniated disks or problems with bones, muscles, tissue, tendons, nerves, ligaments and blood vessels. • Bone scan. In rare cases, your doctor may use a bone scan to look for bone tumors or compression fractures caused by osteoporosis. • Nerve studies (electromyography, or EMG). This test measures the electrical impulses produced by the nerves and the responses of your muscles. This test can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis). • Myelogram and post myelogram CT • Some literature supports very little diagnostics.

Cervical Assessment and Exam Reflex: • Normal: DTR • Abnormal: ▫ ▫ ▫ ▫

Hoffman’s Spurling’s Babinski Others as appropriate pending exam findings and history

Facet Pain - Diagnostics • Xray: include oblique and flexion/extension views • CT scan: visualize facet joints and other structures of the spinal segment • MRI: not quite as useful for diagnosing this particular spinal problem, but is extremely helpful when investigating possible disc or abdominal pain contributors • Myelogram and post myelo CT • Bone scan • Facet joint injection (or facet joint block): perhaps the most definitive diagnosis of facet joint. Relief of the acute or chronic problem during the time of action of this combination of drugs is diagnostic

Facet Pain - Treatment Axial Pain - Treatment • Rest • Ice/heat • NSAIDs/ Cox2 Inhibitors • Oral Meds • Steroids

• • • • •

Acupuncture Therapy ESI Fusion Spinal Cord Stimulator

• • • • • • • • • •

Rest Posture (try cervical collar) Ice/heat NSAIDs/Cox2 Inhibitors Oral meds PT Manipulation Facet joint block (diagnose and treat) Facet rhizotomy (Radiofrequency Ablation-RFA) Fusion (Ray,2002)

References Facet Injection

1.

Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spine-health.com/conditions/arthritis/facet-joint-disorders-and -back-pain.

2.

Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. October; 16(10): 1539–1550.

3.

Berger T. (2013). Facet Injection & Facet Rhizotomy. Mayfield Clinic and Spine Institute. www.mayfieldclinic.com

4.

Ben-Yishay A. (2012). Axial Back Pain: Most Common Low Back Pain. www.spine-health.com

5.

Gore DR. ( 2001). The Evaluation of Patients With Neck Pain. Medscape Orthopaedics & Sports Medicine eJourn;5(4)

6.

NIH ( 2003). Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke (NNINDS).

7.

Strine TW, Hootman JM. (2007). US national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum.. May 15;57(4): 656-65.

8.

Hoy MD, Protani M, De R, Bushbinder R. (2010). The epidemiology of neck pain. Best Pracit Res Clin Rheumatol. Dec;24(6):783-92.

9.

Dwyer A, Aprill C, Bogduk N. (1990). Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976) 15, 453–457.

10. Gellhorn, A. C. et al. (2012) Osteoarthritis of the spine: the facet joints. Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2012.199 11.

FitzGordon J (2012). Spinal Movement: Facet Joints. Core Walking Blog. October 3, http://blog.corewalking.com/spinal-movement-facet-joints/

Berger T. (2013). Facet Injection & Facet Rhizotomy. Mayfield Clinic and Spine Institute. www.mayfieldclinic.com

Neck Pain

Definitions • Vertebral body: bony building blocks of the spine • Facet joint: small stabilizing joints located between and behind adjacent vertebrae “small faces” at every spinal level (except top C1) and provide about 20% of the torsional (twisting) stability in the neck and low back. Thoracic less mobile with ribs. • Intervertebral disc: cushion between each of the vertebral bodies and bindds them together • Facet pain • Axial (midline) discs • Axial pain •

Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spine-health.com/conditions/arthritis/facet-

.

joint-disorders-and -back-pain

• Neck pain is common in the general population and even more common in a chronic pain management practice. • Far less common than LBP • Some epidemiologic studies mostly done in Europe identify about 1/3 of the population have neck pain but only about 14% have neck pain lasting longer than 6 months.