Degenerative lesions of the facet joints (spondyloarthrosis)

In order to prevent excessive movement (twisting or tilting), there are a number of structures in the spinal segments that stabilize the vertebrae while maintaining the flexibility necessary for turning the torso, turning the head and walking in a circle. Facet joints (literally "little face" joints) are present at every level of the spine and provide about 20% of torsional stabilization (twisting) in the neck and lumbar spine. The vertebrae in the thoracic region are usually much less mobile and the range of motion is limited to only a certain range of motion back and forth and a very small range of rotation or twisting.

In the lower back, forward-backward bending is limited to approximately 12 degrees and lateral rotation to 5 degrees. In the lumbar spine, rotation in the segment is limited to 2 degrees because excessive rotation can cause damage to the spinal cord or nerve roots.

At each level, the edges of the facets correspond to a plane passing through the body from front to back - and vary from more parallel to more perpendicular. In each section, the facet joints are positioned in such a way that they limit the range of motion, especially rotation and slipping of the vertebrae (spondylolisthesis).

Each upper half of a pair of facet joints is attached on both sides on the back of each vertebra, extending slightly to the side beyond it, then extending downward. These halves go forward or to the side. The other half of the joints form one vertebra below and then extend upward, with the surface back or away from the midline to connect the surface to the top of the joint.

The articular surfaces rub against each other, and both sliding surfaces are usually covered with moist cartilage with a very low coefficient of friction. A capsule surrounds each facet joint, providing a sticky lubricant for the joints. Each bag is richly innervated by nerve fibers that respond to the slightest irritation.

The facet joints are in almost constant motion with the spine and quite often simply wear out or degenerate in many patients. When articular cartilage thins or disappears, bone tissue responds by overgrowth, leading to the formation of osteophytes and enlarged joints. In such cases, it is believed that arthritis (osteoarthritis) is developing, which can cause significant back pain when moving. This arthritis of the facet joints is called facet joint syndrome.

A protective reflex, which leads to spasm of nearby muscles, occurs when the facet joints become inflamed. Due to powerful muscle spasms, postural disturbances and the appearance of antalgic scoliosis may occur. And the effectiveness of manual therapy for restoring the curvature of the spine in such cases, in fact, depends on the relaxation of spastic muscles, and not on changes in bone structures. Disorders of the facet joints are one of the most common causes of problems in the neck and lower back, often with severe symptoms and disability. However, facet joint syndrome does not affect the nerves. Facet joint syndrome is often confused with other spinal diseases. Acute inflammation of the facet joints can mimic either a herniated disc, a vertebral fracture or an acute abdominal infection. On the other hand, abdominal infections can manifest as symptoms of joint problems of the spine, and therefore a good differential diagnosis is necessary to avoid dangerous diagnostic errors.

Mechanism of disease development

In the facet joints there are quite a lot of non-encapsulated and encapsulated nerve endings that are responsible for pain sensitivity and spatial orientation.

With arthrosis of the facet joints (spondyloarthrosis or facet arthropathy), degenerative changes occur in the facet and cartilaginous tissues connecting the lower and upper vertebral processes. This condition is accompanied by their thinning due to friction and loss of elasticity.

The pathological process may involve nearby soft tissues and the joint capsule, which, in addition to the inflammatory process, is accompanied by the formation of bone growths (osteophytes) that block movement in the vertebrae. Gradually, the destruction intensifies and leads to severe arthrosis.

Causes of pathology

Depletion and deformation of the tissues of the facet joints of the spine are formed in absolutely all people, starting from the age of 40–45 years, and are caused by the processes of physiological aging of the body. However, with aging, joints deteriorate very slowly, and significant changes in them should not normally be observed (even by the age of 90). The following four factors play a much more serious role in the development of spondyloarthrosis, including at a young age:

Various minor anomalies of skeletal development: irregular or asymmetrical arrangement of paired processes, fusion of the vertebrae, splitting of the vertebral arches. Such anomalies are not at all uncommon; at first they have no symptoms, and many people do not even realize they exist until, for some reason, they have to take an x-ray of the spine.

Injuries and microtraumas, chronic overloads of the spine (sports injuries, heavy physical work, injuries in road accidents, overweight, sedentary lifestyle, etc.).

Excessive mobility (instability) of the lumbar vertebra, when it easily moves backward or forward relative to the underlying vertebra.

Metabolic disorders, endocrine diseases leading to malnutrition and subsequent cartilage degeneration.

With constant exposure to provoking factors, changes in the facet joints also increase: the cartilage gradually loses its elasticity, the articular surfaces are exposed, the articular capsule, nearby areas of bone, ligaments and muscles are involved in the pathological process, spiky outgrowths form on the bones - arthrosis develops.

Provoking factors

Gradual degenerative changes in the intervertebral discs and joints are present in almost every person over 45 years old, which is due to the load on the spine and its joints.

The development of the disease is facilitated by injuries to the spine, especially in the area of ​​the facet processes, which the body is not able to compensate for.

Often the disease can be triggered by congenital and acquired anomalies of the skeletal structure, for example, asymmetry of paired processes or fusion of the vertebrae, as well as past infectious diseases.

Quite often, arthrosis is caused by disturbances in the functioning of metabolic processes and the endocrine system, as well as a deficiency of substances necessary for the body. The severity of the inflammatory process depends on the stage of the disease.

Characteristic symptoms

The main symptom of arthrosis of the facet joints, which have a specific numerical and letter classification, is pain. Any facet joint, as well as the periarticular space, is innervated by 2-3 nearby levels, which mutually overlap the pain localized in adjacent areas of the facet joints.

Initially, pain from the L5-S1 facet joint radiates to the hip joint, tailbone, groin and posterofemoral surface. Pain in the L4–L5 facet joint radiates to the hip joint, back of the thigh, buttock, and very rarely to the tailbone.

Pain in the L3–L4 joint spreads to the side of the abdomen, chest and groin. When the facet joints Th12–L1, L1–L2, L2–L3 are irritated, pain symptoms are localized in the thoracic region, neck and upper abdomen and back.

Typical symptoms of arthrosis of the facet joints are accompanied by the following signs:

• the appearance of pain symptoms in the spinal column at the end of the working day, which significantly decreases after a short rest;
• there is a decrease in mobility in the spine, especially in the morning and evening, which is due to a decrease in the flexibility of the facet joints, processes and bone outgrowths;
• gradually temporary pain transforms into permanent pain, regardless of the patient’s physical activity;
• the inflammatory process may be accompanied by symptoms of general malaise (hyperthermia, weakness, chills, etc.);
• at a late stage of arthrosis development, movement is impaired and a specific crunching sound is heard in the joints, which is due to the formation of osteophytes. The motor amplitude, especially in the cervical region, decreases and in the absence of therapeutic measures, the formation of muscle contractures is possible.

Arthrosis of the facet joints in the lumbar region is accompanied by prolonged pain as a result of prolonged sitting. The flexion function is gradually limited, and the pain becomes permanent. Spondyloarthrosis of the facet joints of the thoracic region occurs extremely rarely and, as in other cases, is accompanied by severe pain.

Pain syndrome in the neck: a rheumatologist's view

N.A. Shostak, N.G. Pravdyuk Department of Faculty Therapy named after. A.I. Nesterova State Educational Institution of Higher Professional Education RGMU Roszdrav, Moscow Neck pain (cervicalgia) is present in the clinical picture of a whole spectrum of neurological, rheumatological, therapeutic, traumatological and other diseases (Table 1). The most common causes of neck pain include dysfunction of the facet joints and ligamentous apparatus (functional blocks), myofascial syndrome, combined into the group of nonspecific cervicalgia, as well as degenerative lesions of the spine - spondylosis, arthrosis of the facet joints.

Facet joint dysfunction

Clinical manifestations: o dull (less often acute) pain in the neck, often in the morning, after sleeping in an uncomfortable position (patients often say that they are “blown away”). The pain increases with movement and decreases with rest; o irradiation of pain to the back of the head, ear, face and temple (with damage to the upper cervical spine) or to the shoulder, especially in the suprascapular region (with damage to the lower cervical spine); irradiation of pain to the arm is uncharacteristic; o increased pain with movement and decreased pain at rest; On examination: o tension in the neck muscles, unilateral pain in the projection of the affected joint; o there are no changes on radiographs [1]. Myofascial syndrome The muscles of the neck and shoulder girdle (sternocleidomastoid, trapezius, levator scapulae, multifidus and erector spinae, etc.) play an important role in the origin of cervicalgia. For example, myofascial syndrome of the sternocleidomastoid muscle develops during cooling and prolonged postural tension (sleeping in an uncomfortable position). Trigger points in the upper portion of the muscle have a characteristic pattern of pain with the occurrence of cervicocephalgia. Spondylosis Spondylosis combines the entire complex of lesions of the vertebral motion segment (decrease in the height of the intervertebral disc - IVD, osteophytosis, protrusion and hernia of the IVD) of a degenerative nature, which most often affects the upper and lower cervical vertebrae. Posterior osteophytes, which can act as a source of radiculopathy, myelopathy and compression of the vertebral arteries, are of clinical importance in spondylosis. Symptomatic IVD hernia Most often develops in young and middle-aged people, localized at the level of C5-C6 and C6-C7. Pain syndrome due to hernial protrusion of the cervical IVD has the following features [2]: o acute onset after physical activity, awkward movement or injury; o increased pain in the neck and arm when coughing, sneezing, straining, compression of the jugular veins (due to increased pressure in the epidural space); o increased pain in the neck and arm when tilting the head, when rotating the head to the painful side and throwing it back; o “forced” position of the head with a slight tilt forward and the side opposite to the localization of pain; o impaired sensitivity (paresthesia) in the hand, and sometimes muscle weakness indicate the addition of radiculopathy (diagnostic tests for determining radiculopathy are presented in Table 2). Osteoarthritis of the facet joints Its contribution to the origin of neck pain increases with age. Features of the pain syndrome in cervical spondyloarthrosis [4]: ​​o neck pain is provoked by minor injury, unsuccessful movement, hypothermia, prolonged stay in an uncomfortable position (including during sleep). Some patients have a permanent cervicalgia; o pain increases with neck extension and/or bending towards the more affected joint; o when the upper cervical joints are involved, the pain radiates to the area of ​​the back of the head and forehead, the middle cervical joints - to the area of ​​the shoulder girdle and shoulder, the lower cervical joints - to the scapula and interscapular area; o limited mobility of the cervical spine, especially during extension. Flexion and rotation are usually preserved. Palpation of the facet joints is painful (usually on both sides); o X-ray signs of spondylosis are detected (decrease in the height of the IVD, osteophytes), arthrosis of the facet joints. Other causes As part of degenerative lesions of the spine, diffuse idiopathic skeletal hyperostosis is distinguished. With intense ossification of the anterior longitudinal ligament, severe restrictions of mobility in the cervical spine and dysphagia with compression of the esophagus may appear, and ossification of the posterior longitudinal ligament at the cervical level may be complicated by myelopathy with quadraplegia [5].

In rheumatoid arthritis, cervicalgia can occur due to involvement in the pathological process of the atlantoaxial complex (C1-C2) with anterior or posterior subluxation with or without an erosive-destructive process in the odontoid process, arthritis of the lateral facet joint at the level of C1-C2 and/or the atlanto-occipital joint with lateral subluxation, as well as due to rheumatoid disc damage - spondylodiscitis at the C2-C7 level. Symptoms of damage to the cervical spine vary from local pain in the neck and occipital region to neurological manifestations in the form of paresthesia, radiating to the arm, increasing with flexion, extension and rotation of the head. Severe neurological complications, manifested by “long path” symptoms: urinary and fecal incontinence, weakness of the lower extremities, are quite rare in rheumatoid arthritis. Diagnosis of vertebral displacement is carried out by radiography of the cervical spine in the position of maximum flexion and extension.

Other causes of atlantoaxial subluxation include trauma, psoriatic and idiopathic spondylitis, and retropharyngeal abscess.

With ankylosing spondylitis, in 5-10% of cases, neck pain develops in the absence of pain in the lower back. The onset of the disease with lesions of the cervical spine is most typical for females, and therefore in clinical practice the “female” variant of this disease is identified [6]. Cervicalgia caused by spondylodiscitis in patients with ankylosing spondylitis can develop in the first 10 years of the disease, while radiological signs of disc damage are detected in 1-28% of patients. Among the rare complications of spondylitis is a vertebral fracture, which develops in men over 55 years of age with an average disease duration of 25 years [4]. Microcrystalline arthritis can also be accompanied by cervicalgia. In gout, deposits of uric acid are detected in the intervertebral disc, intradurally. In pyrophosphate arthropathy, hydroxyapatite crystals are detected in the longitudinal ligament, synovial membrane of the facet joints, and in the ligamentum flavum [4]. Features of medical tactics When clinically examining a patient with cervicalgia, it is proposed to use a set of symptoms and signs that reflect pathology that requires immediate examination and treatment (Table 3) [1]. A special commission to study the problem of neck pain (Neck Pain Task Force, 2008) proposed recommendations for the management and treatment of patients with cervicalgia (Tables 4, 5) [7]. It must be remembered that cervicalgia is a syndromic diagnosis, therefore, in each specific case, the doctor must follow the algorithm for examining patients, strive for nosological identification, in order, from the standpoint of a multidisciplinary approach to this problem, to draw up an individual treatment and rehabilitation program for the patient, based on the principles of evidence-based medicine. References 1. Murphy DR. Clinical Model for the Diagnosis and Management of Patients with Cervical Spine Syndromes. ACO 2004; 12 (2): 57-71. 2. Levin O.S. Diagnosis and treatment of pain in the neck and upper extremities. Rus. honey. magazine 2006; 14 (9): 713-8. 3. Hardin JG, Halla JT. Cervical spine syndromes. Arthritis and Allied conditions: a textbook of rheumatology, 13th ed. Ed. by William J. Koopman. Williams & Wilkins. 1997; 2: 1803-11. 4. Mertha J. Neck pain. Directory of General Practice. M.: Praktika, 1998. 5. Kritzer RO, Rose JE. Diffuse idiopathic skeletal hyperoxtosis presenting with thoracic outlet syndrome and dysphagia. Neurosurgery 1988; 22: 1072-4. 6. John B, Imboden, David B. Hellmann, John Henry Stone. Сurrent Rheumatology. Diagnosis & Treatment. Medical 2004. 7. Haldeman S, Carroll L, Cassidy JD, Schubert J. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Executive Summary. Spine 2008; 33(4S):S5-7. SOURCE CONSILIUM-MEDICUM NEUROLOGY No. 1/2010

Diagnostics

To clarify the picture of the disease, as well as make the right decision about the need for one or another method of therapy, the doctor may prescribe a diagnostic examination, including:

• collection of anamnestic data to identify hereditary predisposition to arthrosis and the reasons that triggered the development of the disease;
• appointment of CT and MRI;
• X-ray examination for a more accurate determination of destructive processes in cartilage tissue.

Without treatment, complete destruction of the affected joint with loss of ability to move is possible. In this case, the only optimal solution is surgery and replacement of the joint with a prosthesis.

Treatment options

After the diagnosis has been clarified, comprehensive treatment and lifestyle adjustments are prescribed. The need for therapeutic measures depends on the stage of the disease, phase and severity of symptoms.

Drug therapy

The most common drug therapy is prescribed in the acute stage of the inflammatory process. During treatment, the patient is recommended to be prescribed a course of medications aimed at eliminating negative symptoms. To relieve pain, drugs from the NSAID group (Nimesulide, Ketotifen, Diclofenac, etc.) are prescribed.

If the inflammatory process is viral or bacterial in nature, drugs of the appropriate group are prescribed, aimed at suppressing the pathogen. As an addition, for accelerated restoration of cartilage tissue, it is recommended to take chondroprotectors (Arthra, Chondroitin, etc.)

Physiotherapy

An alternative method of treating arthrosis of the facet joints is physiotherapy, which is prescribed at an early stage of the disease, but in the absence of acute symptoms.

Basic treatment methods

Treatment of spondyloarthrosis is prescribed only by a doctor. Specific measures depend on the stage of the disease (determined radiographically), the phase of the disease (exacerbation or remission) and the severity of symptoms. Treatment of arthrosis of the intervertebral joints is always complex, combining medicinal and non-medicinal methods of treatment.

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Non-drug methods are an essential component of the treatment of spondyloarthrosis. Without their implementation, it will be impossible to achieve lasting improvement and prevent further progression of the disease. The main methods of such influence are physical therapy, massage and physiotherapy.

It is also necessary to eliminate the factors that provoke the disease (excessive loads, sedentary lifestyle, excess weight, etc.).

Spondyloarthrosis is treated with the same groups of drugs as arthrosis of other localizations - these are painkillers and non-steroidal anti-inflammatory drugs, chondroprotectors, and in severe cases - hormones. The dosage of the drug and the duration of treatment are determined by the doctor.

Any pain in the back and neck is a cause for concern. If pain is accompanied by limited mobility, even temporary, a visit to the doctor should not be postponed under any circumstances. Timely initiation of treatment can completely restore (preserve) the functions of the spine, but delays always lead to severe progression of the disease.

Author of the article: Nivelichuk Taras, head of the department of anesthesiology and intensive care, work experience 8 years. Higher education in the specialty “General Medicine”.

Facet joints

The facet joints, articulationes zygapophysiales (see, Fig. 220, 221, 226), are formed between the upper articular process, processus articularis superior, of the underlying vertebra and the lower articular process, processus articularis inferior, of the overlying vertebra. The articular capsule is strengthened along the edge of the articular cartilage. The articular cavity is located according to the position and direction of the articular surfaces, approaching the horizontal plane in the cervical region. in the thoracic region - to the frontal and in the lumbar region - to the sagittal plane. The facet joints in the cervical and thoracic parts of the spinal column are classified as flat joints; in the lumbar spine they are classified as cylindrical. Functionally, they belong to the group of low-moving joints.

Symmetrical facet joints are combined joints, i.e., those in which movement in one joint necessarily entails displacement in the other, since both joints are formations of articular processes on the same bone.

Ligaments of the spinal column

Ligaments of the spinal column, ligg. сlumnae verlebralis, can be divided into long and short (Fig. 222 - 227).

To the group of long ligaments

The spinal column includes the following:

1. Anterior longitudinal ligament

. lig. longitudinale anterius (see Fig. 221,224,226), runs along the anterior surface and partly along the lateral surfaces of the vertebral bodies from the anterior tubercle of the atlas to the sacrum, where it is lost in the periosteum of the 1st and 2nd sacral vertebrae. The anterior longitudinal ligament in the lower parts of the spinal column is significant; wider and stronger. It connects loosely with the vertebral bodies and tightly with the intervertebral discs, since it is woven into the perichondrium (perichondrium) covering them; on the sides of the vertebrae it continues into their periosteum. The deep layers of the bundles of this ligament are somewhat shorter than the superficial ones, due to which they connect adjacent vertebrae with each other, and the superficial, longer bundles lie over 4–5 vertebrae. The anterior longitudinal ligament limits excessive extension of the spinal column,

Facet arthrosis

Facet arthropathy or facet joint arthrosis is a disease of the spinal column during which deformation of the articular tissue is observed. Facet joints are the joints between the lower and upper processes of the vertebrae. The disease is characterized by severe pain, as well as serious dysfunction of the spine.

Causes of arthrosis

The chronic disease arthrosis of the facet joints of the spine in the lumbar region develops in all people over 45-50 years of age. The disease is caused, first of all, by the physiological aging of the body, but this is far from the main factor of the disease. The development of the disease is more influenced by the following factors:

• injuries and chronic overloads of the spine;
• excess weight;
• sedentary lifestyle;
• endocrine diseases leading to cartilage dystrophy;
• congenital anomalies of skeletal development;
• some infections (tuberculosis, purulent arthritis);
• instability of the lumbar vertebra, when it easily moves forward or backward.

How to recognize pathology?

The main sign that indicates that deformation of the facet joints is occurring is pain. The joints of the cervical spine are predominantly affected. During this pathology, patients note the occurrence of dull pain that is localized in the neck area. At rest, the pain subsides and can leave the person for a certain time. However, after physical activity it will make itself felt again. As the disease progresses, it becomes difficult to turn the head, this is most noticeable in the morning.

If the disease progresses, then when turning the head a person may feel a crunch in the neck.

With advanced arthrosis of the facet joints, during neck movements, patients note the occurrence of a crunching sound, which occurs due to the appearance of the spinous processes. The pain syndrome is constant in nature, noticeably increasing with loads and changes in the position of the body. In addition, pain can also react to the weather.

Less common is arthrosis of the facet joints of the lumbar spine. At the same time, people complain of pain in the lumbar region, which in the initial stages of the pathology manifests itself after a long stay in a standing position. As the disease progresses, the pain syndrome becomes permanent and begins to disturb patients when bending and turning the body. It does not leave the patient even at rest. Pain can radiate to the lower limbs and hip area.

Arthrosis of the thoracic spinal column is rare. In addition to pain that is localized in the back, people also complain of pain in the sternum. At the same time, the pain syndrome is sometimes difficult to distinguish from the manifestation of pain that can provoke other pathologies, for example, heart and lung diseases.

Symptoms of the disease

When the facet joints of the lumbar region are affected, aching pain appears in the sacrum, spreading to the hips and buttocks. At first, painful sensations occur only when sitting for a long time, when lifting heavy objects, or when changing posture. If spinal arthrosis is not treated, then over time the pain begins to bother a person in a supine position, intensifying at night.

When the facet joints of the lower back are deformed, tingling, numbness, weakness in the hips are felt, muscle tone in the buttocks and lower back increases, and pelvic movement is limited. In the later stages of the disease, lumbar pain becomes so severe that a person cannot not only walk, but also sit, lie, and stand. In the morning, the patient experiences severe stiffness with any movement of the spine, which is associated with inflammatory processes in the lumbar region.

Diagnosis of arthrosis of the facet joints

If the patient suspects that arthrosis of the facet joints has developed, it is important to immediately visit a medical facility. At the appointment, the doctor will initially conduct a survey of the patient, during which he will find out how long ago the pain in the spine arose. Then the doctor will begin to examine and palpate the spinal column, paying attention to the crunch when bending the torso and increased pain when changing position. To distinguish the described disease from other pathologies of the musculoskeletal system, the person will be sent for the following examinations:

• radiography;
• computer or magnetic resonance imaging.

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Diagnostic methods

If you have any pain in the lower back, you should consult a rheumatologist, who will take into account the following clinical manifestations to make a diagnosis:

• crunching when bending the lower back;
• increased pain when changing position;
• morning stiffness;
• limitation of mobility.

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To exclude other pathologies of the spine, the doctor will refer the patient for laboratory diagnostics and x-rays of the lumbosacral region. To assess the osteochondral structure of the spine, the degree of compression of tendons and muscles, as well as the level of involvement in soft tissue arthrosis, the patient may also be referred for computed tomography (CT) and magnetic resonance (MRI) imaging.

How is the treatment carried out?

Effective medicines

If the patient has arthrosis and facet hypertrophy, resort to the following medications indicated in the table:

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ethnoscience

Doctors draw the attention of patients to the fact that if arthrosis has affected the facet joints of the spine, it is permissible to resort to the help of healers’ prescriptions only after consultation with a specialist. In combination with traditional methods of treatment, it is recommended to use the following folk remedies that will relieve pain:

• Horsetail, St. John's wort flowers, birch buds and juniper. Raw materials are taken in equal quantities and crushed. The ingredients are mixed and poured with 2 cups of boiling water. Send to a dark and warm place to infuse for about 2 hours. Take half a glass before meals three times a day. The duration of the course of therapy is at least a month.
• Cabbage. Juice is extracted from the ingredient, which you will need to drink a glass twice a day half an hour before meals. The duration of treatment is 30 days.
• Eucalyptus. You will need to take 100 g of plant leaves, pour 0.5 liters of alcohol into them and leave for 5 days in a warm place. After the time has elapsed, the product is ready for use. It should be rubbed into the area where the affected facet joints are located every day before going to bed. Use the rub for 40 days.

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Physiotherapy

Thanks to physiotherapeutic procedures, it is possible to strengthen the immune system and improve blood circulation. When a patient is diagnosed with arthritis or arthrosis, they first resort to laser therapy, during which a laser beam passing through the skin acts on the affected facet joints and accelerates their recovery.

Laser light anesthetizes the nerve roots and improves blood flow in the affected segment of the spine.

An equally common procedure for arthrosis is electrophoresis. Medicines are injected under the skin using an electric current. In this way, it is possible to prevent the occurrence of unwanted reactions from medications and enhance their therapeutic effect. Magnetic therapy is often used, during which the tissues are heated and the tone of the blood vessels increases. With this, damaged ligaments, cartilage tissue, and joints are restored. Magnetic treatment makes it possible to stop inflammation.