What are facet hypertrophic changes and how are they treated in older adults with a history of osteoarthritis?

What Are Facet Hypertrophic Changes?

Facet hypertrophic changes are a form of arthritis in the small joints of your spine where the joints become enlarged, thickened, and develop bone spurs due to wear and tear over time. 1, 2

Understanding the Basics

The facet joints are the only true movable joints between the bones of your spine, located in the back portion of your vertebral column. 2 Think of them like hinges that allow your spine to bend and twist. When these joints develop osteoarthritis (the "wear and tear" type of arthritis), several changes occur:

• Hypertrophy means the joint tissues become enlarged and thickened 1, 3
• Osteophytes (bone spurs) develop around the joint edges 1
• Sclerosis occurs, where the bone becomes denser and harder 1
• The joint surfaces become rough instead of smooth 2

These changes are extremely common with aging—approximately 40% of women aged 55 and 85% of those over age 75 will have spine osteoarthritis affecting these facet joints. 1

Why This Happens

Facet joint degeneration can start surprisingly early (as young as 15 years of age in some cases) and progresses with age. 4 The condition is more common in:

• Older adults (rarely occurs before age 40) 5
• Women (particularly at certain spine levels) 5
• Males for cervical (neck) spine facet hypertrophy 3

The mid-levels of the spine (L4/5 in the lower back, C4/5 in the neck) are most frequently affected. 4, 3

How It Affects You

Pain Pattern: The enlarged facet joints can cause referred pain (pain that spreads to other areas) and local tenderness. 6 In the neck, 78% of patients with facet hypertrophy experience neck pain. 3 Facet-mediated pain becomes increasingly common with age. 2

Nerve Compression: When the joints become significantly enlarged, they can press on nearby nerves, causing:

• Radiating pain down your arms or legs 6
• Neurogenic claudication (leg pain with walking that improves with rest) 5
• Numbness or weakness in severe cases 5

Spinal Stenosis: The hypertrophic changes narrow the spaces where nerves exit the spine, a condition called lateral stenosis. 5

Treatment Approach for Older Adults with Osteoarthritis

Core Non-Pharmacological Treatments (Start Here First)

Exercise therapy is essential and must be the foundation of treatment. 1, 7 This includes:

• Strengthening exercises for muscles supporting the spine, performed 2-3 times weekly 1, 7
• Aerobic fitness training such as walking or swimming 1, 7
• Flexibility exercises performed daily when pain is minimal, holding stretches for 10-30 seconds 1
• Each exercise session should include: 5-10 minute warm-up, training period, and 5-minute cool-down with stretching 1

Weight loss if overweight or obese reduces mechanical stress on the spine. 1, 7

Patient education is crucial to counter the misconception that osteoarthritis is inevitably progressive and untreatable. 1, 7

Medication Management Algorithm

Step 1: Start with Acetaminophen (Paracetamol)

• First-line pharmacologic treatment: regular dosing up to 4000 mg daily 1, 8, 9
• Use regular dosing rather than "as needed" for better sustained pain control 1, 8
• In elderly patients, consider staying at or below 3000 mg daily for enhanced safety 8, 9

Step 2: Add Topical NSAIDs if Acetaminophen Insufficient

• Apply topical diclofenac gel or similar topical NSAIDs before considering oral NSAIDs 1, 8, 9
• These have minimal systemic absorption and substantially lower risk of complications 8, 9
• Topical capsaicin is an alternative localized option 1, 8

Step 3: Oral NSAIDs Only When Topical Treatments Fail

• Use at the lowest effective dose for the shortest possible duration 1, 8
• Always co-prescribe a proton pump inhibitor for gastroprotection 1, 8
• Choose the PPI with the lowest acquisition cost 1, 8
• Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing, particularly in patients over 50 years 8, 9, 7

Step 4: Consider Intra-articular Corticosteroid Injections

• For moderate to severe pain relief when other measures are insufficient 1
• Can be injected directly into the facet joint or as nerve blocks 6

Critical Safety Warnings

Never exceed 4000 mg daily of acetaminophen to prevent liver toxicity. 8

Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor). 8, 9

Elderly patients face substantially higher risks of GI bleeding, renal insufficiency, and cardiovascular complications with NSAIDs. 8, 9, 7

Avoid prolonged NSAID use at high doses, particularly in elderly patients who are at highest risk for serious adverse events. 8

Adjunctive Treatments

• Local heat or cold applications for temporary pain relief 1, 7
• Shock-absorbing shoes or insoles 1
• Assistive devices as needed 1
• Manual therapy (manipulation and stretching) 1

When Conservative Treatment Fails

Surgical referral should be considered when joint symptoms substantially affect quality of life and are refractory to non-surgical treatment, but only after core treatment options have been offered. 1 Treatment options may include decompression if the hypertrophied facet joints are compressing nerves and causing radicular pain. 6

Common Pitfalls to Avoid

Do not use glucosamine or chondroitin products—current evidence does not support their efficacy. 8, 7

Do not overlook facet joint degeneration when assessing causes of back or neck pain, as it can occur early and progress independently. 4

Joint pain lasting more than 1 hour after exercise indicates excessive activity and requires modification of the exercise program. 1