Thoracic Facet Joint Pain

What is thoracic facet joint pain?

The thoracic facet joints are small joints at the posterolateral aspect of the thoracic spinal column. Their primary role is to help bear load through the thoracic spine. Similar to a hip, knee, or shoulder joint, the thoracic facet joints can be a source of pain.

What causes thoracic facet joint pain?

The two most common causes of thoracic facet joint pain are degenerative/arthritic changes or trauma. Similar to when people begin to feel knee pain as the joint degenerates and becomes arthritic, the thoracic facet joints can become painful with time as they degenerate and become arthritic. Alternatively, the thoracic facet joints may become a source of pain after a traumatic event such as a motor vehicle collision, sports injury, or any other forceful impact.

How is thoracic facet joint pain diagnosed?

A diagnosis of thoracic facet joint pain is primarily based on a patient’s symptoms and physical examination findings. Typical symptoms and signs of thoracic facet joint pain include mid back pain. While imaging such as x-ray, magnetic resonance imaging (MRI), or computed tomography (CT) may be useful to evaluate for other potential sources of mid back pain, rule out more serious issues such as fractures, tumors, or infections, and help plan procedural approach, there is actually very limited data to suggest that imaging plays a role in being able to more conclusively rule in or rule out the facet joints as a source of pain. Consequently, the gold standard method for diagnosis of thoracic facet joint pain is patient response to diagnostic medial branch nerve blocks.

How is thoracic facet joint pain treated?

Initial treatment options for management of thoracic facet joint pain may include medications, physical therapy, and/or chiropractic. In many cases, these conservative measures will allow for good recovery. If a patient is still experiencing significant pain despite the aforementioned treatment options, thoracic medial branch blocks can be considered to more precisely identify the facet joints as the primary source of pain. This can also provide information about patients who may be good candidates for treatment of the facet joint pain with radiofrequency ablation (RFA). Alternative interventional options may include facet joint injections with corticosteroids or platelet-rich plasma (PRP).

Thoracic Medial Branch Blocks and Radiofrequency Ablation

When a person’s facet (zygapophysial) joints are emanating pain, the medial branch nerves will sense this pain signal and transmit it along a pathway to the spinal cord and up to the brain where we interpret and “feel” that painful sensation. As such, medial branch nerve blocks can be used as a diagnostic injection to help determine whether or not the facet joints are the primary source of pain. Using x-ray (fluoroscopic) guidance, needles are safely guided to and placed near the medial branch nerves which are then anesthetized, thus temporarily blocking the pain coming from the facet joints. Patients are then asked to monitor their pain during the time period that the local anesthetic is blocking the facet joint pain. In patients who experience a significant improvement in their pain, it increases the likelihood that the facet joints are the main source of pain and radiofrequency ablation (RFA) can be performed as a treatment to provide long lasting improvement in the pain. In patients who do not experience much improvement in their pain during the anesthetic phase, it can be determined with much more certainty that the facet joints are not the main source of the pain and the focus can shift to other potential pain generating structures.

After a patient has undergone medial branch nerve blocks to more precisely determine that the facet joints are the primary source of pain, radiofrequency ablation (RFA) can then be performed. With RFA, the needle tip is placed in close proximity to the medial branch nerves (the nerves that supply sensation to the painful facet joints). The needle tips are then warmed up to a temperature that causes coagulation or “cauterization” of the medial branch nerves. This disrupts the nerves that sense the pain coming from the facet joint and, consequently, disrupts the pathway for that pain to be sensed and transmitted to the brain to be interpreted. In the end, RFA can provide long lasting improvement in facet joint pain, typically 9-18 months at a time, and repeat RFA procedures can be performed time and again to allow for ongoing pain relief for patients.

Platelet Rich Plasma (PRP) injection