Facet Arthropathy

Facet arthropathy usually causes lower back pain that is worse when you lean backwards, twist, or stand for a while, and tends to ease when you sit or lean forwards. The pain is usually felt locally, or spreads into the buttock or thigh, rather than travelling down the leg past the knee the way sciatica does. Many people notice it most as stiffness in the morning or after sitting still.

No single symptom, and no scan on its own, reliably confirms that the facet joints are the cause. Wear on the facet joints appears on the scans of many people who have no pain, and examination and imaging correlate poorly with the pain itself, so the diagnosis usually requires targeted injections to identify the facet joints as the ‘pain generator’.

Imaging (X-ray, CT, or MRI) can show wear on the facet joints, but studies have consistently found that examination and imaging correlate poorly with the pain, and that joint wear is common on the scans of people without symptoms. A scan cannot confirm on its own that the joints are the pain source.

The most reliable test is a medial branch block: local anaesthetic is placed on the small nerves that carry pain from a specific facet joint. If it removes a high proportion of the pain, usually 80% or more, it points to that joint as the pain source. Because a single block has a high false-positive rate, it is often repeated on a second occasion to confirm before any surgery is considered.

Most facet arthropathy is managed without surgery. Treatment usually works up a ladder, starting with the simplest options and moving on only if pain persists.

1. Conservative care (first line). Staying active within comfortable limits, targeted physiotherapy to strengthen the muscles that support the spine, avoiding the movements that flare it up, and anti-inflammatory medication where appropriate. Many people need nothing more than this.
2. Injections and radiofrequency ablation. If the pain is confirmed to come from the facet joints, radiofrequency ablation, also called neurotomy, uses heat to interrupt the small nerves carrying pain from the joint. In carefully selected patients, confirmed by diagnostic blocks, it can give months of relief, and it is regarded as the mainstay interventional treatment for confirmed facet pain. The evidence here is mixed, though: some trials show clear benefit and others little advantage over a sham procedure, so careful patient selection matters. Steroid injections into the joint itself have a weaker and more variable record.
3. Regenerative treatment. Stem cell & Exosome injections into the joint is considered experimental, with limited long-term evidence. Some patients may try this before considering surgery, and some achieve positive results. This is an emerging field in medicine.
4. Surgery. Surgery is considered only when conservative options are exhausted and there is a clear structural cause, particularly where there is nerve compression, instability, or associated stenosis. What kind of surgery is appropriate depends on why the joint is painful.

Ryan, from Medicine Hat in Canada, had lived with lower back pain for close to three decades after a hockey injury in his teens. Over the last two years it worsened sharply, culminating in a severe episode that ended in an ambulance. He first heard about the ONZ centre from three men at his gym who had each travelled to Germany for spine surgery. Within two weeks of making contact he had his evaluation back, and shortly afterwards he underwent a multi-level dynamic stabilisation with the HPS 2.0 system, across three levels from L2 to L5, with facet joint deterioration at L4/L5 part of the picture.

He checked in the day before surgery and was operated on by Dr. Bierstedt the next morning. By day four or five he was managing stairs, which he said he would not have believed possible so soon. Towards the end of his second week, at the Medicos Aufschalke rehabilitation centre, he was walking for around 45 minutes after a full day of therapy sessions, and largely pain-free.

By the time he recorded this, Ryan described the back pain he had arrived with as gone, with only the expected post-surgical soreness remaining, and, having had the height between his vertebrae restored, he said he is “a little bit taller now.”

If you have been offered a fusion for facet arthropathy, or you are stuck on a waiting list, or facing a cost you cannot meet at home, it is worth seeking a second opinion before committing to a procedure that permanently removes movement. Our specialists in Germany and Thailand can review your imaging and tell you honestly whether disc replacement or another option fits your case, or whether a fusion is the better choice for you.