What is multilevel joint facet degeneration?

Multilevel Joint Facet Degeneration

Multilevel joint facet degeneration refers to degenerative changes affecting the facet joints at multiple levels of the spine, characterized by cartilage deterioration, joint space narrowing, and bony remodeling that can contribute to pain, reduced mobility, and neurological symptoms. 1, 2

Anatomy and Pathophysiology

Facet joints (zygapophyseal joints) are diarthrodial joints formed by the articulation between the superior and inferior articular processes of adjacent vertebrae. These joints:

• Provide stability to the spine
• Guide and constrain spinal motion
• Work with intervertebral discs to transfer loads through the spine
• Contain articular cartilage surfaces and a ligamentous capsule 3

The degenerative process typically involves:

• Cartilage thinning and erosion
• Joint space narrowing
• Subchondral bone sclerosis
• Osteophyte formation
• Synovial inflammation
• Capsular hypertrophy

Diagnostic Imaging

Different imaging modalities can be used to evaluate facet joint degeneration:

• CT scanning: Provides excellent visualization of facet joint degeneration with 94-100% sensitivity 2

  • Best for evaluating bony changes
  • Can assess facets and neural foramina
  • Delineates osseous margins for surgical planning 1

• MRI: Preferred for evaluating soft tissue involvement 1, 2

  • Shows disc degeneration and neural structures
  • Evaluates thecal sac compression
  • The Fujiwara MRI grading system can be used to assess facet joint degeneration 4

• Radiographs: Initial imaging for cervical/lumbar pain without "red flags" 1, 2

  • Assess vertebral alignment
  • Evaluate loss of normal lordosis
  • Sensitivity ranges from 49-82% 2

• SPECT/CT: May help identify the source of pain related to facet arthropathy 1

  • A prospective study showed >40% of scintigraphically active facet joints did not correlate to the degree of facet joint degeneration on CT 1

Distribution and Patterns

Facet joint degeneration can occur throughout the spine but shows specific patterns:

• Cervical spine:

  • Highest at C4-C5 level in cervical spondylotic myelopathy patients 5
  • Progressive increase from C3-C7 in patients with ossification of the posterior longitudinal ligament 5

• Lumbar spine:

  • Often affects L4-L5 and L5-S1 levels 4, 6
  • Lumbosacral junction is particularly vulnerable 6

Clinical Manifestations

Multilevel facet joint degeneration can cause:

• Axial pain (neck or back pain)
• Reduced range of motion
• Myofascial tenderness
• Radicular symptoms if neural foraminal narrowing occurs
• Myelopathic symptoms if spinal cord compression develops 2

Patients with severe cervical facet joint degeneration often present with:

• Pronounced cervical lordosis
• Increased T1 slope
• Elevated cervical sagittal vertical axis
• Heightened neck pain 5

Risk Factors

Several factors can contribute to facet joint degeneration:

• Advanced age (>65 years) 2
• Previous trauma 2
• Poor posture 2
• Biomechanical stress from activities like horseback riding 1
• Genetic predisposition 7
• Segmental instability 5

Relationship to Other Spinal Conditions

Facet joint degeneration often coexists with:

• Disc degeneration
• Spinal stenosis
• Spondylolisthesis
• Ossification of posterior longitudinal ligament 5

Research suggests facet joint tropism (asymmetry in orientation of bilateral facets) may be developmental in origin or a combination with secondary changes due to degenerative effects 7.

Management Approaches

Treatment depends on severity and associated symptoms:

Conservative Management

• Activity modification
• Physical therapy with isometric exercises
• Postural correction
• Pharmacotherapy:
  • NSAIDs at lowest effective dose for shortest duration 2
  • Muscle relaxants
  • Analgesics

Interventional Procedures

• Image-guided facet joint injections 2
• Medial branch blocks for diagnostic confirmation 2
• Radiofrequency denervation for confirmed facet-mediated pain 2
  • Requires two positive diagnostic blocks with ≥80% pain relief

Surgical Options

For patients with:

• Progressive neurological deficits
• Development of myelopathic signs
• Failure of conservative management after 6-8 weeks
• Significant impact on quality of life 2

Surgical approaches include:

• Decompression procedures
• Fusion for instability
• Dynamic stabilization systems (may delay facet joint degeneration in adjacent segments) 4

Clinical Implications

Multilevel facet joint degeneration has important clinical implications:

• Can lead to adjacent segment degeneration following spinal fusion or disc replacement 6
• May influence surgical planning and approach selection
• Affects postoperative outcomes and recovery
• Requires monitoring for progression over time

Pitfalls and Caveats

Important considerations when evaluating facet joint degeneration:

• MRI abnormalities are common in asymptomatic individuals 1
• Imaging findings may not correlate with clinical symptoms
• Facet joint tropism should be noted in imaging assessments as it may have implications for treatment decisions 7
• Lower segmental mobility following treatment may indicate inferior compatibility with the segment's biomechanics 6