In case of significant arthritic changes of the facet joints with hypertrophy of the capsule, hypertrophied facet osteophytes, incomplete spontaneous fusion of the facet joints, and air inclusion, the patients may profit from a facet joint infiltration. If a temporary pain release can be reached, a direct fusion or screw fixation of the arthritic joint may be quite helpful. The so-called “facet joint syndrome” which is radiologically difficult to identify, even with MRI, is a diagnosis which rarely goes along with long-lasting periods of pain relief after surgical treatment. Even if the facet joint infiltration may be suggestive for a facet joint syndrome, the pain relief through fusion may only be temporarily.
In a recent study it has been demonstrated that cases where there is fluid in the lumbar facet joints, detected on MRI, as well as instability in flexion lumbar radiographs, in patients with L4/5 degenerative disease, pain correlates well with the morphological findings. Therefore, fluid on MRI in the facet joints should raise suspicion of lumbar instability and qualifies for fusion
The X-rays, respectively the MRI, of significant facet arthritis should be done supine as well as standing to demonstrate the fluid in the joint. When standing, the fluid is pressed out and the facet joints are almost locked. When the patient is supine, the joints may open and air inclusion can be demonstrated on the conventional X-rays as well as fluid in the joints.
These patients often indicate typical pain in the night when turning in bed which wakes them up and pain in the morning while getting up until the facet joints have “settled” under the axial load. True facet joint arthritis, as the relevant pain source, can usually be stabilized with simple translaminar or transfacetal screws. In case of a still significantly good disk, a combination with an anterior interbody fusion through a TLIF or PLIF may be mandatory to get the patient pain-free.
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