The acute phase
The high-pitched crisis of acute facet inflammation usually follows a wrenching of the spine which provokes a slower brewing problem. A dormant stiff facet sets itself up for being hurt by not accepting shock as readily as its neighbours above and below—or even its facet partner on the other side.
The cause of the flare-up can be hard to pinpoint but in a matter of hours the injury can be literally crippling. It is usually something awkward but not disastrous, such as moving a pot plant which was heavier than you thought. You often hear a small sound, like a click or a small tear in your back, which may give you fleeting pain at the time but then passes off. But by nightfall or next morning, when the heat of the exertion has gone, a nasty frightening back pain comes on.
At the height of the crisis, the symptoms are a stabbing pain in the side of the back which often goes with searing waves of pain down your leg. Your back feels hard and sore with muscle spasm on one side but the leg pain can be almost unbearable. The pain is often associated with intense pins and needles and a burning sensation which floods downwards as your leg takes weight.
Leg pain of this type is called sciatica, but it is different from the sciatica of a bulging disc (see Chapter 5). Although it is hard for you to know the difference, as a rule, acute facet inflammation gives a hot surging tide of prickling pain down the leg, whereas disc prolapse sciatica is more like intense cramp locking up the leg muscles.
Locating the swollen joint with the thumbs usually confirms the facet as the source of trouble. Probing in beside the spine with the thumbs, the inflamed capsule can be felt welling up from below, like the dome of a cathedral rising up through low-lying cloud. It has the typically tense feel of an over-filled hot-water bottle and rebuffs the pressure of probing thumbs.
Apart from the joint feeling hard under the skin, direct pressure usually gives a sudden slice of pain through the back which may then flood down the leg. Unlike this direct evidence of facet involvement, it is impossible to be so sure if the disc is causing sciatica. The disc is around at the front of the spine, out of reach of the hands and, I believe, can only be assumed to be the culprit if there is nothing wrong with the facets. I mention this because there was a time, not too long ago, when all forms of sciatica were deemed to come from herniated or prolapsed discs. I believe discogenic sciatica is infinitely rarer than facet-based sciatica, though much harder to fix.
Typical facet joint sciatica is easily set off by changes in position. Any posture which compresses the swollen joint can exacerbate the pain. Even small positional adjustments can cause a corresponding reaction down the leg, as if the new contortion increases the swelling on the nerve. The pain then fades as the swelling oozes to other parts of the joint capsule and drains away.
In the acute stage of facet arthropathy there is usually armour-plated spasm of the muscles protecting the back. Unfortunately the spasm often makes matters worse by obliterating too much movement and letting the swelling accumulate. At this point, the best course of action is to take anti-inflammatory drugs to reduce the heat, and then muscle relaxants to break the cycle of muscle holding.
This treatment is especially indicated if your spine is listing over, with the hips protruding one side and shoulders the other. This 'windswept' deformity is known as sciatic scoliosis and is caused by the muscles on one side of the spine contracting more than the other. Even though its purpose is to spare the joint, the resulting discord often makes the spine more susceptible to other injury, and makes the current problem harder to fix. At this stage, the best thing to do is take your medication and do gentle knees-rocking exercises in bed to 'milk' the joint.
With severe facet inflammation, the recovery from the acute stage is usually quite rapid—as long as the muscle spasm does not hang on for too long. Fear at this stage is usually the greatest impediment and can slow recovery significantly, sometimes completely. Excessive anxiety or anger (even if it is subconscious) will also lower the pain threshold and create a 'volitional' tension in the muscles on top of the automatic protective one.
All going well, the back is not excessively plagued by anxieties and the muscle spasm releases the joint to get going. As soon as normal movement returns, the joint will be well on the way to recovery; and the sooner the better. Normal movement 'works' the joint properly and disperses the inflammation, and everything assumes normality again. Normality begets normality.
What causes the acute pain?
The facet's response to injury is the same as any other of the body's synovial joints. When a knee or ankle is twisted there is a sudden jerk of pain the moment you do it, and just after it feels wonky but still workable. Within a few hours it becomes more painful as the joint swells. It may reach a peak after a period of inactivity when you suddenly sense the pain stubbornly roosting there and you cannot work it away.
An injured facet joint behaves in exactly the same way. But because of the closer quarters inside the back, with many moving parts of spinal machinery packed cheek by jowl into a tightly confined space, a minor injury can have devastating effects. With so many sensitive structures (not least the spinal nerve) and so little room for anything to swell, a relatively small mishap can cause a crisis.
When a facet joint is wrenched, the synovial lining of the capsule weeps clear fluid into the joint space. It is similar to the way tears well up in the eyes, except the tension of the fluid trapped inside the joint is much more problematic. The engorgement makes the joint semirigid from its own bloatedness and it has difficulty sliding and gapping open. The lack of movement makes it less competent at pumping out the fluid, which consequently accumulates even faster. Eventually, pressure from the swelling trapped in the joint causes pain.
As with all joints, special 'mechano-receptors' in the capsular wall are stimulated by the pressure of the fluid, and messages relayed to the brain are interpreted as pain. Pain is also registered by the leakage of inflammatory fluids from the torn tissue of the original joint injury. As their chemical concentration rises, free nerve endings in the joint capsule are stimulated. These are called 'chemo-receptors' and they send off more messages to the brain about pain.
The typical searing pain down the leg is caused by irritation of the nerve root when it becomes embroiled in the joint's inflammation, simply by being so close. As it makes its way past the joint on its way out of the spine it is both physically squashed by the swollen capsule and chemically irritated by the cocktail of toxins coming from its inflamed wall. Things hot up apace when the nerve starts to chafe where it threads past both the capsule and other swollen structures. Eventually it too becomes inflamed and leaks inflammatory fluid.
When I palpate an acute facet problem I cannot feel much at all because the superficial muscle spasm is too unyielding to allow the hands to penetrate. Before proceeding, I induce muscle relaxation by getting the patient to rock the knees to the chest and then roll back and forth over the facet. (Reverse curl-up exercises do it faster if they are not too uncomfortable to do.) The physical movement 'pumps'
the joint clear by providing artificial activity to evacuate the fluid. This lowers the tension in the tissues and interrupts the cycle of pain. In the same way that a twisted ankle becomes more comfortable when the swelling subsides and movement ekes back, the pain of an acute facet problem dramatically reduces as the engorged joint empties.
The pain also fades as fresh blood passes through the joint, cleansing away toxins liberated by the damaged tissues. As the stale blood is dispersed it lowers the concentration of metabolites and reduces the potency of the pain messages to the brain.
Chronic inflammation of a facet joint causes a local patch of pain beside the spine. It typically welcomes the piercing pressure from your own fist or fingers on the spot. Although the joint is several centimetres below the skin it can be felt quite easily, like a brick under a mattress, and you can often elicit a half-relieving sweet pain through your own digging. It usually feels about the size of a squash ball.
Lessening the pain
Figure 3.14 Inflamed and bloated facet joints yearn for the piercing pressure of hands.
Depending on the nature of the inflammation, a facet problem may be relieved by stretching or compressing the joint. If there is established tightness and inelasticity of the capsule, you may gain relief by leaning away from the pain and pulling the joint apart. Although the stretching discomfort hurts at the time, the back feels freer and looser afterwards, with less pain. If the problem is more acute, with trapped engorgement in the facet capsule, it can be eased by leaning towards the pain and closing the joint down. This gives a sharper, more piercing pain which can be almost unbearable for a moment but again feels better afterwards. If you arch backwards while still leaning over to the painful side, you can create an even shriller pain, like a knife going in. Alarming as it sounds, compressing the joint like this helps evacuate it and takes some of its bursting discomfort away.
You will see in the self-help section that 'milking' an engorged joint is an integral part of treatment. You can use a Ma Roller on the floor to do this (the purchasing details for which are at the back of the book). By lying on your back on the floor and rolling back and forth over the roller with the knees bent, you get the familiar sweet pain as the pressure empties the joint. Take care, however, not to inflame the facet. The Ma Roller is tough medicine when a facet is very irritable and it is easy to stir things up. Do not remain on it more than a few seconds.
It is safer to use a tennis ball when the condition is very severe, because it is safer and kinder on the joint. Its pressure is the nearest thing to the direct contact from human thumbs. But remember it too can make the joint sore and should never be continued for longer than 60 seconds, three times per week.
What causes the chronic pain?
Most of the pain from a chronically inflamed facet joint comes from the stretching of the stiff soft tissues around the joint. As a sequel to disc thinning and overriding of facet surfaces, there is adaptive shortening of the capsule and the soft tissues which reinforce it.
Mechano-receptors situated in the capsule wall detect the tension in the soft tissues as they are pulled. As small spherical structures between the tissue fibres, they are squashed like tiny ping-pong balls under guitar strings as the tension in the capsular wall mounts. The messages are again relayed to the brain and interpreted as pain.
As an isolated joint becomes tighter and more crimped in the chain it becomes chronically painful. Its capsule is less able to pay out and stretch with the other links in the spine as your body bends and sways about. At a certain point the tightness becomes so unforgiving that every movement elicits a response from the pain receptors embedded in the over-tight fibres.
At this stage, the crimped link is extremely susceptible to additional injury. Its lack of stretch causes fibres of the tight capsule to be tweaked by any chance movement. As each shock racks through the spine, all the mobile segments ride out the force, like a row of corks dancing on the water as a wave passes underneath, except the stiff one which is wrenched anew. Insult is added to injury. Chemo-receptors in the joint capsule are activated by substances released from the torn tissue and their constant bathing of the free nerve endings means the joint emits a barrage of pain signals.
With micro-trauma heaped upon a pre-existing stiffness the familiar old pain becomes a different sort of pain. There is low-grade tenderness in your back and a newer pain in the leg. Pain in the buttock and thigh comes and goes with activities which increase the tension of the facets, such as slumped sitting or prolonged bending activities like gardening. This is called referred pain. The mechanism for this pain is not the same as the direct inflammation of the nerve root which we saw in the acute disorder. Referred pain is a complex phenomenon where structures sharing the same nerve supply as the inflamed joint 'mistakenly' feel pain too. In the same way that the pain of a heart attack is felt in the neck and left arm, nowhere near the heart, the referred pain from an irritable facet joint can be felt quite far away from the point of trouble.
Referred pain rarely extends below the knee although other symptoms can. These can be diffuse, sometimes indefinable sensations which are difficult to put a name to. One leg may not work as well as the other; it is the typical 'gammy' leg and may feel heavier as you walk. The back of the thigh may feel sensitive when you sit, as if the skin and subcutaneous fat is thinner. One foot may feel colder, or as if you have a pebble in your shoe. Sometimes the heel feels numb, or ants seem to be crawling up your calf. Sometimes it feels as if a cobweb is brushing your skin or the leg hairs prickle uncomfortably against your trousers. The buttock of your bad side may feel bonier when you sit, or the hamstring muscle of the problem side tighter. When you bend forward, there may be a tension beside the spine, down through the buttock and into your leg which makes the knee bend automatically as you go over.
Almost all of these signs vary from day to day, sometimes from hour to hour, and almost from one position to the next. They can be explained as the effect of variable swelling within the facet joint capsule. Another explanation points to the build-up of pressure around the nerve root, impinging upon different sensory pathways in the nerve which brings about a wide variety of symptoms.
If there is protective muscle spasm guarding the stiff link, there will be some discomfort coming from the chronically stiffened muscles. This pain is typically a tired cramping feeling, made much worse by emotional tension. Being 'uptight' increases the spinal symptoms by adding to the compression of the spine and congesting of the problem inside.
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