The small vertebral joints are often mentioned only in passing in a report — “spondylarthrosis”, “facet joint osteoarthritis” — and yet in many people with low back or neck pain they are at the centre of things. What is difficult is less the treatment than the question of whether the osteoarthritis on the image really is the reason for the pain. This page explains how we test that and what helps then.
Worn vertebral joints are almost the rule on imaging from middle age onwards. Whether they hurt is decided by the examination, not by the MRI — and in facet joint osteoarthritis an operation is the exception.
What is it?
Every motion segment of the spine has two small joints at the back, the facet joints or zygapophysial joints. They guide the movement, limit twisting and bending backwards, and carry part of the load. Like the knee or the hip, they can wear: the cartilage becomes thinner, the joint capsule thickens, bony outgrowths form at the edge, sometimes cysts. That is the osteoarthritis. One speaks of facet joint syndrome when these joints are regarded as the source of the pain — and it is precisely this attribution that is difficult, because the imaging finding and the pain are only loosely connected.
In the lumbar spine the lower levels are most often affected, in the cervical spine the middle and lower ones. Usually facet joint osteoarthritis is part of a general wear of the segment, together with loss of height of the disc, sometimes with spondylolisthesis or a narrowing of the spinal canal.
What symptoms occur?
In the lumbar spine it is a deep, dull low back pain, often on both sides next to the spine, which appears in the morning and after longer periods of sitting as a start-up pain and increases on bending backwards, twisting and standing for a long time. It can radiate into the buttock and into the back of the thighs, as a rule not below the knee. Numbness and weakness are not part of it. In the cervical spine it is a neck pain that becomes stronger on turning the head and on looking upwards and pulls to the back of the head, into the shoulder or between the shoulder blades; often mobility is restricted.
If, on the other hand, the pain runs along a strip into the foot or into the fingers, accompanied by tingling or loss of strength, a nerve root is usually irritated — by a herniated disc or by a narrowing of the nerve exit opening, which can also arise from bony outgrowths of the facet joints. The distinction matters, because the treatment differs.
Causes
Facet joint osteoarthritis is first and foremost a consequence of age and load. If the disc loses height, the joint surfaces move closer together and carry more load than intended; a pronounced hollow back, excess weight, years of physical work with twisting movements and earlier injuries speed the process up. A displaced vertebra or a fusion of the neighbouring segment also loads the joints more heavily. In some people a predisposition plays a part. A single trigger usually cannot be named.
How is it diagnosed?
In the consultation we ask about the site of the pain, how it changes over the day and what brings it on. At the examination we test whether bending backwards and twisting trigger the pain, whether the joints are tender on pressure and — above all — whether nerve function is unremarkable: strength, reflexes, sensation, stretch signs. None of these tests on its own proves that the facet joints are hurting; taken together they make it likely or unlikely.
X-ray, MRI and CT show the osteoarthritis, but not whether it hurts; in older people, signs of osteoarthritis are present on imaging almost without exception. Imaging is therefore needed in order to rule out other causes and to clarify whether the joints are constricting nerves — not in order to “see” the facet joint syndrome. What the terms in your report mean is explained on the page Understanding your MRI report. The most informative test is regarded to be a diagnostic anaesthetic block: under image guidance, a local anaesthetic is injected at the joint or at the small nerve branches that supply it. If the pain clearly eases for the duration of its effect, that speaks for the joint. This test too has an error rate, which is why it is often repeated or carried out with two agents of differing duration of action.
Warning signs
Facet joint osteoarthritis is not an emergency. Low back or neck pain does, however, need prompt assessment if fever, unintended weight loss, a cancer in the past history, a fall with known osteoporosis or pain at rest at night are added — and immediately in the case of numbness in the perineal area, a new bladder or bowel problem or an increasing paralysis. More on this on the page Warning signs.
Conservative treatment
In facet joint osteoarthritis, treatment without an operation is not the first step before something else, but the actual treatment. Its core is movement: the joints need it, and strong trunk muscles take load off them.
- Physiotherapy and your own training — strengthening the deep back and abdominal muscles, mobility, posture training; in the cervical spine additionally the neck and shoulder blade muscles. Warmth, if it does you good. Bed rest does not help.
- Painkillers — anti-inflammatory medicines for a limited time at the lowest effective dose, so that movement remains possible; not as a permanent solution.
- Injection at the joint — an anti-inflammatory medicine at or into the joint under image guidance can ease the pain for a few weeks; a longer-term benefit is not established. This treatment may come into consideration if the diagnostic anaesthetic block has made the joint likely as the cause.
- Switching off the joint nerves (radiofrequency denervation) — the small nerve branches that supply the joint are switched off with a probe using heat. This may come into consideration if an anaesthetic block of these branches has clearly eased the pain beforehand. The evidence is inconsistent: a large Dutch study found no meaningful additional effect compared with an exercise programme alone; the nerves also grow back, so that the effect is limited in time.
- Multimodal pain therapy — for symptoms lasting months, a combined treatment of exercise, pain medicine and psychological support.
When an operation is considered
Nobody is operated on because of the joint pain alone — there is no procedure for it with a proven benefit that would justify the risks. An operation is considered if the worn joints are causing something else: a narrowing around a nerve root or of the spinal canal with leg pain, loss of strength or a shortened walking distance, a joint cyst pressing on a nerve, or a demonstrated instability of the segment. And even then only once treatment without an operation has not helped sufficiently over weeks to months, the picture matches the symptoms, and you want the procedure. An operation is urgent only in the case of warning signs.
Surgical options
The procedure depends on what the joints have brought about. If bony outgrowths or a cyst are pressing on a nerve, microsurgical decompression is the right procedure; we offer it. Its aim is a limited one: to create room for the nerve and in doing so to preserve the joint as far as possible. The osteoarthritis itself is not removed by it.
- ProcedureUnder general anaesthetic and lying face down, a small window is made in the vertebral arch through a short skin incision under the operating microscope. The constricting parts of bone and ligament, or the cyst, are removed and the nerve is exposed. The procedure takes one to two hours as a rule, the hospital stay usually a few days.
- RisksAs with any operation, infection, bleeding, thrombosis and the risks of anaesthesia. Specific to this procedure: an injury to the membrane around the nerves with leakage of spinal fluid; rarely damage to the nerve root with sensory disturbance or weakness; an instability, if a great deal of joint has to be removed for the decompression; and a recurrence of the narrowing or of the cyst. The back pain coming from the joint can remain despite a successful decompression of the nerve. Which of these is to the fore in your situation, we discuss before the procedure.
- AftercareGetting up on the day of the operation or the day after. For a few weeks no heavy lifting and no twisting movements under load, physiotherapy once the wound has healed, then your own training. How long you are unfit for work depends on your occupation. A follow-up check with us is part of it.
A fusion of the segment with screws and rods, which we offer, is indicated in facet joint osteoarthritis only if an instability has been demonstrated or if so much joint would have to be removed for the decompression that the segment loses its hold — not because of the joint pain itself. In the cervical spine, the decompression of a constricted nerve root is usually carried out from the front; the procedures are described on the page about the herniated disc of the cervical spine.
Alternatives
Treatment without an operation is not the alternative here, but the normal case: training, pain treatment, injections if needed, and multimodal pain therapy for persisting symptoms. If a decompression of a nerve is under discussion, supported waiting with checks of nerve function is part of it. If you have been advised elsewhere to have an operation or a fusion, you can obtain a second opinion from us.
What to expect
The osteoarthritis stays; the pain comes and goes in phases. With regular training and occasional pain treatment, many people reach a state in which the back is admittedly not young, but is dependable. What you can do yourself: train the trunk muscles for the long term, break up long periods of sitting, avoid bending backwards and twisting under load, keep an eye on your weight, and answer flare-ups not with rest but with adapted movement. If a pain appears that pulls into the leg or into the arm, or a weakness, that is a reason to come back and be seen.
Frequently asked questions
My MRI says “spondylarthrosis” — is that the reason for my pain?
Perhaps, but not for certain. Worn vertebral joints are very common on imaging from middle age onwards, including in people without symptoms. Whether they are hurting in your case is clarified by the examination and, where appropriate, by a diagnostic anaesthetic block.
Does an injection help permanently?
No. Injections at the joint ease pain for weeks, sometimes months. They make sense in order to bridge a phase in which you get moving again — not as a permanent treatment.
Can the joints not simply be fused?
Technically yes, but a benefit for pure joint pain is not established, and a fusion loads the neighbouring segments. It comes into consideration only where instability has been demonstrated.
Is facet joint osteoarthritis the same as facet joint syndrome?
Not quite. Osteoarthritis describes the wear on the image; facet joint syndrome means that the joints are regarded as the source of the pain. The one can occur without the other.
Which sports are suitable?
Walking, cycling, swimming on your back or front crawl and strength training with clean technique are usually well tolerated. Sports with repeated bending backwards, twisting under load or hard impacts you should only do if they do not trigger pain.