Author(s): Dylan Banks, MD, Erica Kwong, MD, Margaret Martinez, DO, Salvador Portugal, DO, MBA
Originally published: November 11, 2011 Last updated: January 17, 2025
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Disease/Disorder

Definition

Facet mediated pain (facet joint pain) refers to pain arising from the vertebral facets (zygapophyseal joints) in the cervical, thoracic, or lumbar spine.

Etiology

Facet mediated pain results from repetitive and excessive biomechanical strain on the zygapophyseal joints. It can be caused by arthropathy of the joint or stretching of the joint capsule. Potential sources include anatomic abnormalities, trauma (e.g., whiplash in the cervical spine), fracture, inflammation, degenerative disc changes, degenerative facet arthropathy or spondylolisthesis.1 It is important to note that while facet joint arthropathy may predispose facet mediated pain, it is often an asymptomatic age-related degenerative change, and thus highlights the importance of clinical correlation.2

Epidemiology including risk factors and primary prevention

Low back pain is the most common cause of disability in adults over 45 years old, with an estimated global lifetime prevalence of approximately 40%.3 The prevalence of facet mediated pain varies between sources, in part due to challenging diagnostic criteria. In a systematic review, the estimated prevalence of facet mediated pain as confirmed with diagnostic blocks ranges from 27-67% in the cervical spine, 34-48% in the thoracic spine, and 15-50% in the lumbar spine.1 The prevalence of facet joint arthropathy increases with age, as expected with a degenerative process, with the highest prevalence in those 50 and older.4 Predisposition to injury includes general medical health, genetics, obesity, other spine-related conditions, and occupational environmental factors. Primary prevention is directed at early identification and modification of risk factors such as weight management and promotion of a healthy lifestyle.

Patho-anatomy/physiology

Facet joints are diarthrodial synovial joints formed by the articulation of the superior articular process of the inferior vertebra and the inferior articular process of the superior vertebra. The joint contains a fibrous capsule, synovial membrane, articular cartilage, menisci, and subchondral bone. The facet joints are considered part of the posterior column of the spine and help to stabilize the spine by limiting excessive flexion, extension, side bending, and axial rotation.

The facet joints are highly innervated by the medial branch of the dorsal ramus innervating the corresponding facet joint and one level below, with the presence of free and encapsulated nerve endings.5 These provide rich nociceptive feedback to capsular stretching or compression.6

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Acute phase (<6 weeks) – Facet arthropathy is usually a chronic pathology that results from years of accumulated repetitive strain and minor trauma. The exception is most notably whiplash-associated injuries of the cervical spine. In response to an acute tearing of the joint capsule or stretching beyond its limits, the synovial joints may fill with fluid and distend, resulting in pain associated with this capsular stretch. Acute clinical features of whiplash-associated injuries may include local muscle guarding or pain, headaches, limited range of motion, and hypersensitivity.7

Subacute phase (6 weeks to 3 months) – Without the removal of the pathogenic stimulus, disease progression is mediated by an inflammatory, angiogenic, and neurogenic cascade. It is characterized by proinflammatory cytokines and cartilage-degrading enzymes in addition to angiogenic factors promoting new sensory fiber growth and immune cell infiltration. This sensory nerve growth likely links the joint degeneration with the ongoing perception of pain via the dorsal root ganglia.8

Chronic phase (>3 months) – As facet joint arthropathy progresses chronically, cartilage breakdown will often extend deeper and involve the entire joint and may expose the subchondral bone. The initial angiogenic cascade may be replaced with further fibrocartilage production.9 Osteophyte development, alongside subchondral bone remodeling leading to sclerosis and subchondral cyst formation, can be hallmarks of more advanced disease pathology.10

Specific secondary or associated conditions and complications

As part of the three-joint spinal unit, in combination with the intervertebral disc, the facet joints are interdependent with their surrounding spinal anatomy. Given their load-sharing relationship, a pathologic abnormality in one aspect may lead to pathologic changes in adjacent segments. Most often, degenerative disc disease will lead to facet joint arthropathy of adjacent segments.10 This relationship can be reversed when facet joint arthropathy is suspected to hasten degenerative disc disease, though this is less common.

In addition, the facet joints are interconnected with their surrounding musculature, which provides physical support and proprioception. With increased age, there is often a correlation between facet joint arthropathy and decreased paraspinal musculature.10

Additional complications that can arise from facet arthropathy include headaches (particularly with C1-2 and C2-3 joints), degenerative spondylolisthesis, facet joint cysts, and neuroforaminal stenosis, which can result in cervical or lumbar radiculopathy. Inflammatory autoimmune arthritis, infection, or local inflammation like synovitis can also affect the facet joints.11

Essentials of Assessment

History

The primary pain pattern for facet joint arthropathy includes axial, non-radiating pain without neurological abnormalities. For the cervical spine, this includes the neck and shoulders with common referral sites including the posterior occiput, upper back, and interscapular region. Cervicogenic headaches are a common presentation of cervical facet joint pain.12 In the lumbar spine, pain is generally in the lower back with common referral sites including the groin, flank, and thigh.11 Facet mediated pain does not usually radiate below the elbow or knee.13 Symptoms may lack specificity and can be confused with herniated discs or compressed nerve roots.14 History is useful in excluding alternative etiologies, in particular radiculopathies, fractures, infections, neoplasms, or rheumatologic conditions.10,15

Physical examination

Although multiple studies have failed to demonstrate statistically significant clinical features that are highly specific for lumbar facet joint pain, the physical exam still serves an essential role when assessing for facet mediated pain.11 The physical exam is equally important to rule out alternative etiologies of neck or back pain.

Inspection of posture is essential as increased or decreased lordosis, muscle atrophy, or postural asymmetry are clinically important. Palpation of tender points along paravertebral regions and transverse processes as well as pain referral patterns adds to the formulation of a focused differential diagnosis. Range of motion evaluation should include limits and pain evoked with flexion, extension, rotation, and lateral flexion. In the cervical spine, protrusion and retraction of the scapula should be included. Neurologic examination is necessary to assess the presence of radiculopathy due to nerve root compression.

It is important to note that most exam maneuvers will stress several key structures at once (e.g., facets, muscles, discs), making true facet joint isolation difficult.1 Salient characteristics of facet pain include pain on extension, often provoked with combined extension and ipsilateral rotation as performed with Kemp’s test. 

Functional assessment 

It is important to assess posture during functional movement, such as during transfers or while lifting objects, to ensure proper body mechanics. Triggers for symptom amplification, as well as signs of apprehension or anxiety, should also be noted.

Laboratory studies 

Laboratory studies are sometimes indicated to evaluate for cancer, rheumatologic diagnoses, inflammatory disease, infection, or other systemic conditions. 

Imaging

There is low to moderate evidence to support the use of imaging to identify painful lumbar facets given the poor correlation between radiographic findings and clinical symptoms.16 Therefore, it is often advised to limit imaging for acute low back pain with no red flag symptoms (e.g., neurologic deficits).17 Imaging should always be used in conjunction with clinical assessment when evaluating for facet mediated pain.

Plain radiographs, including flexion and extension views, are a beneficial tool to detect instability and fractures. Osteoarthritis can be assessed using an oblique view to show the spaces of these joints. Single-photon emission computed tomography (SPECT) images and, less optimally, bone scans are useful for the detection of bone remodeling as in spondylolysis, metastasis, infection, or occult fracture. SPECT radionuclide scanning has been a reliable technique to identify facet syndrome for research studies, though it received a grade C recommendation for use in identifying painful lumbar facets before MBB.16

Computed tomography (CT) can be used to evaluate facet arthropathy, fractures, or progression of fusion when magnetic resonance imaging (MRI) is contraindicated, though MRI is generally preferred.14 MRI is beneficial to evaluate for possible disc herniation or facet joint cyst causing nerve root entrapment.

Supplemental assessment tools

Diagnostic fluoroscopically guided MBBs are the primary means of confirming a diagnosis of facet mediated pain and are considered the ‘gold standard’.16 For a positive response, at least 50% and preferably 75% to 90% reduction of pain should be reported in correlation with the anesthetic duration. For MBBs, the false positive rate in the lumbar spine is between 17-44% and the false negative rate is about 8%.1,13,15 To minimize the false positive response, guidelines recommend two separate blocks using different duration anesthetics. The evidence for the accuracy of diagnostic facet joint blocks is level 1 or 2 in the diagnosis of lumbar and cervical facet joint pain.13

Early predictors of outcomes

Psychiatric comorbidity is associated with diminished pain relief after medial branch nerve blocks in the cervical and lumbar spine. There is some evidence that supports the use of antidepressants for chronic low back pain and muscle relaxants in acute back pain.18

Environmental

Low socioeconomic status and lower level of education are associated with disability retirement from back pain. Poor ergonomic positioning, worker dissatisfaction, repetitive  tasks, tobacco use, and perceived poor general health are factors that make a patient vulnerable to disability from low back pain.19 

Social role and social support system

Patients can adopt a “sick role” in which interaction with their environment, social obligations, and normal responsibilities become more difficult. Depression, poor coping skills, lack of home/community support, somatization, secondary gain issues (e.g., ongoing litigation), and greater disease burden (e.g., high dose opioid use, previous spinal surgery) can lead to harder-to-treat pain and worse interventional outcomes. Poor patient selection for invasive treatments is perhaps the most common reason for treatment failure.10,16 Support at work may serve as a protective feature, reducing the chronicity of back pain.20

Professional issues

Due to the complexity of facet mediated pain, multiple different professional societies have published guidelines on its evaluation and treatment. This can lead to a natural variance in management approaches.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Multiple organizations have published guidelines on the management of low back pain stemming from facet mediated pain with many undergoing multiple revisions and updates through the years. The North American Spine Society (NASS) as a combined effort with the American Academy of Physical Medicine & Rehabilitation (AAPMR) and the American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANS/CNS) released guidelines in 2020 and last updated them in January of 2021.21 The American Society of Regional Anesthesia and Pain Management (ASRA)7,16 and the American Society of Interventional Pain Physicians (ASIPP)13 released updated guidelines in 2020. A non-exhaustive list of additional guidelines includes the American College of Occupational and Environmental Medicine (ACOEM) updated in 202122 and the Centers of Medicare and Medicaid Services (CMS) updated in 2024.

Although there is variation among different guidelines, there are common themes in treatment recommendations. Conservative management with physical therapy (PT), medications, and/or other modalities is generally recommended before facet joint injections. In the cervical and lumbar spine, there is a moderate strength of recommendation for therapeutic facet joint nerve blocks and RFA. In the thoracic spine, there is growing evidence to support the use of these two treatment options. Intraarticular facet joint injections, with or without steroids, are only weakly recommended or even recommended against for facet mediated pain.

RFA continues to be the most popular neurolytic technique for the treatment of facet mediated pain. RFA to denervate the facets is performed with either conventional continuous radiofrequency (RF) current (standard of care) or pulsed RF current. In conventional continuous radiofrequency therapy, probe tip temperatures reach between 80°C and 85°C and are intended to produce long-term pain relief through a more uniform and larger lesion.23 Pulsed RF, which consists of short bursts of current, is suggested as a possibly safer alternative to conventional RF to avoid potential damage to adjacent nerve roots and muscle denervation. However, temperatures for pulsed RF do not exceed 42°C and therefore produce a primarily temporary neural blockade. If the therapy proves beneficial, the pain relief attained by pulsed RFA will be of shorter duration than that provided by conventional RF therapy.24

At different disease stages

Acute phase (<6 weeks) – Most guidelines recommend a 3-month trial of conservative management, including PT, nonsteroidal anti-inflammatory drugs (NSAIDs) and other non-opioid oral analgesics, weight reduction, topical agents such as capsaicin, thermal treatments, and integrative modalities.7,13,16 Aerobic exercise has been shown to improve pain, disability, and mental health in patients with nonspecific low back pain at short-term follow-up. Furthermore, cognitive behavioral therapy in combination with PT has been shown to be more effective than PT alone.25 It is suggested that the use of oral or intravenous steroids is not effective, and opioids should not be used for the treatment of acute low back pain.26

Sub-acute phase (6 weeks to 3 months) – The focus of this phase is to improve stability, increase core strength, and restore motion. Rehabilitation exercises are done primarily with the spine in a neutral or flexion-biased posture to reduce stress on the facet joints. The focus of PT is spine and core stabilization, posture correction, and a strengthening program followed by restoring functional movements. “Back School”, a form of psychosocial education for patients and family, has been shown to improve pain and function more than general medical care, modality care, or a simple handout at 6-12 months’ follow-up for chronic low back pain. If symptoms have been present for greater than three months and have not responded to conservative treatment, interventional methods are often pursued. The gold standard for confirming a diagnosis of facet mediated pain remains two MBBs. If the patient responds positively to these blocks, RFA is recommended.

Chronic phase (>3 months) – This is the maintenance phase in which strengthening exercises using eccentric muscle contraction are prioritized, followed by functional exercises (standing in multiple planes) with the transition to a home program. If RFA has yielded positive results (relief for at least 3 months, but preferably 6 months) it can be repeated every six months with expected relief lasting up to 13-24 months for repeat treatments.27 The success rate for repeat RFA decreases for successive procedures but remains above 50%.16 Acupuncture in conjunction with usual care can also provide short-term improvement of pain and function.21

Opioid therapy for chronic low back pain is generally not recommended. There is no good evidence that opioids improve pain or function with long-term use, and there is an increased risk of serious harms.26 Clinicians should use extreme caution when considering opioids for chronic low back pain and should follow current guidelines.26 There is currently insufficient evidence to support the use of surgical intervention for facet mediated low back pain.21 However, surgical interventions may be considered in cases of concomitant spondylolisthesis or dynamic instability of the spine.

Patient & family education

Patient education appears to reduce the negative consequences of fear-avoidance behavior that occurs when attempting active exercise-based rehabilitation and thus promotes treatment compliance.21 Patient and family education should be focused on risk factor modification, the importance of physical activity in recovery, and implementation of a feasible home exercise program after discharge. 

Emerging/unique interventions

Impairment-based measurements

In the 6th edition of the AMA Guides to the Evaluation of Permanent Impairment, an individual with facet joint dysfunction who is at the point of maximal medical improvement will be classified as Class 0 or Class 1 depending on symptoms, physical exam, nonorganic findings, and the Pain Disability Questionnaire. This classification results in a whole-person impairment of 0% for Class 0 or 1% to 3% for class 1, depending on net adjustment equation results.28

Measurement of patient outcomes

Questionnaires such as the Oswestry Low Back Pain Questionnaire, Neck Disability Index, Pain Disability Questionnaire, Roland-Morris Disability Questionnaire, the visual analog scale, numeric pain rating, SF-12 or SF-36, and McGill Pain Questionnaire facilitate the evaluation of treatment effectiveness, functional improvement, and quality of life. 

Translation into practice: practice “pearls/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

The standard of care for facet mediated pain remains education, activity modification, PT, medications, and various other modalities. After failing conservative treatment, diagnostic facet joint blocks and RFA can be considered. RFA remains the current standard of care for chronic facet mediated pain, but cutoffs for candidate selection and aspects of procedural techniques vary among different guidelines. It is important to follow established guidelines to minimize false positive results and unnecessary interventions.

Cutting Edge/Emerging and Unique Concepts and Practice

Percutaneous peripheral nerve stimulation (PNS) is an emerging treatment modality that builds on the concept of RFA, but potentially carries fewer disadvantages.29  Percutaneous PNS is a minimally invasive treatment designed to use electrical stimulation of nerve fibers to modulate central sensitization. This stimulation of afferent sensory fibers engages the gate mechanism to decrease pain signals. Efferent fibers are also stimulated, activating the multifidi and possibly the erector spinae muscles. Because percutaneous PNS is not ablative, there is no denervation of the multifidi and the stability of the spinal column is preserved. Additionally, there have been no reports to date of percutaneous PNS-induced neuritis, a complication that can be seen with RFA. To date, percutaneous PNS has only been studied in the context of general chronic low back pain and has not specifically been studied for facet mediated back pain. While still novel, this procedure has shown promise in recent case series.30

Cooled RFA (CRFA) is a promising alternative to conventional continuous RFA. This technique uses water circulation through an isolated channel around the electrode tip to create a continuous cooling of the needle tip to 60°C. It produces larger lesions at lower temperatures than conventional RFA, which helps compensate for the anatomic variability in the region.31 CRFA has shown comparable outcomes to conventional RFA in the lumbar spine and is an effective treatment in the cervical and thoracic spine.31–33

Cryoneurolysis (CN) is becoming more popular for the use of neuropathic pain management, including lumbar facet blocks. Two hypothermic freezing cycles to temperatures of -50°C cause temporary neuroablation without the complications of neuralgia or neuroma formation. With CN, ice crystals cause vascular damage to the vasa vasorum, leading to endoneurial edema and cell death. The procedure can be repeated after axonal regeneration occurs, usually within 3-6 months, with some analgesic effects lasting up to 2 years.34

Chemical neurolysis using either alcohol or phenol to denature the proteins of neural structures has also been described. However, the use of these agents can cause necrosis of surrounding tissue, uncontrolled diffusion, neuritis, and neuroma formation and thus, is rarely utilized.35

The use of ultrasound guidance for intraarticular injections and MBBs has garnered interest, with multiple studies demonstrating its feasibility and benefits including lack of radiation exposure and possibly faster performance time.16 Ultrasound can also be safely and effectively utilized to aid in cryoneurolysis.36

Dorsal root neurotomy has shown promise in providing significant pain reduction in facet mediated pain. The dorsal root supplies the medial branches and thus serves as a reasonable target. Recent studies have found longer-lasting pain reduction with dorsal root neurotomy compared to MBB.13,37 There is also emerging evidence that endoscopic neurotomy may be more effective than traditional percutaneous radiofrequency.35

Recent studies have also demonstrated the efficacy of platelet rich plasma (PRP) intraarticular injections when compared to local anesthetic/steroid.38

Gaps in the Evidence-Based Knowledge

More research is necessary to further establish the short-term and long-term benefits of current and novel treatment options. Little is known about potential long-term side effects such as multifidus atrophy after RFA and other emerging treatment options.39 Future studies can investigate safer and more efficient ways of performing RFA, including identifying ways to prolong benefit from treatment.16

References

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  39. Tieppo Francio V, Glicksman M, Leavitt L, et al. Multifidus atrophy and/or dysfunction following lumbar radiofrequency ablation: A systematic review. PM R. Published online May 16, 2024. doi:10.1002/pmrj.13202

Original Version of the Topic

Ricardo Nieves, MD. Facet Mediated Pain. 5/19/2013

Previous Revision(s) of the Topic

Patricia W. Nance, MD and Elise M Adcock, MD. Facet Mediated Pain. 3/24/2017

Patricia W. Nance, MD, Peter Lee, DO, Karim Fahmy, DO, Michael Beckman, MD. Facet Mediated Pain. 2/9/2022

Author Disclosure

Dylan Banks, MD
Nothing to Disclose

Erica Kwong, MD
Nothing to Disclose

Margaret Martinez, DO
Nothing to Disclose

Salvador Portugal, DO, MBA
Nothing to Disclose