Facet
syndrome
Facet joints connect the vertebrae at the back of the spine. When they become worn or inflamed, they can become the main source of chronic low back pain. When properly diagnosed, facet syndrome can be treated.
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Each level of the spine rests on a three-point support: the intervertebral disc at the front and two facet joints at the back. These small joints guide and limit spinal movement. Like any joint, they can wear out (facet osteoarthritis), become inflamed or become unstable.
Facet syndrome occurs when these joints become the source of pain. Studies suggest that they may be responsible for 15 to 45% of chronic low back pain [1][1] Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A, Heck O, Boubagra K, Grand S, Krainik A. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018 Oct;9(5):773-789. doi: 10.1007/s13244-018-0638-x. Epub 2018 Aug 8. PMID: 30090998; PMCID: PMC6206372.[2][2] Manchikanti L, Manchikanti KN, Cash KA, Singh V, Giordano J. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain Physician. 2008 Jan;11(1):67-75. PMID: 18196171.. Yet facet syndrome has long been underdiagnosed for a simple reason: it is not always visible on standard imaging, and osteoarthritis seen on imaging is not always painful. Diagnosis therefore requires a specific approach.
No single symptom is specific on its own, but certain signs suggest a facet origin for low back pain:
- low back pain, on one or both sides, sometimes radiating to the buttock or thigh (rarely below the knee);
- pain worsened by extending the back (arching backwards, standing for long periods) and by rotation;
- morning stiffness on getting started, improving with movement;
- pain relieved by sitting while leaning forward or by lying down;
- absence of clear neurological signs (no true sciatica caused by nerve-root involvement).
Diagnosing facet syndrome cannot be reduced to either a clinical examination or imaging alone. It relies on the convergence of three elements:
- the clinical examination, which looks for suggestive signs and rules out other causes of low back pain;
- imaging (MRI, CT and, in some cases, bone scintigraphy combined with CT, known as SPECT-CT), which can reveal osteoarthritis or inflammation of the facet joints;
- the reference test: an anesthetic medial branch block, targeting the small nerves that transmit facet-joint pain. If temporarily anesthetizing these nerves makes the pain disappear, a facet origin is confirmed.
This step-by-step approach ensures that targeted treatment is offered only to patients in whom a facet origin of the pain has actually been demonstrated.
Treatment of facet syndrome follows a stepwise approach, from the simplest to the most comprehensive:
- Conservative treatment: rehabilitation, muscle strengthening, activity modification and pain medication. This is always the first step.
- Facet injections: anti-inflammatory medication injected around the painful joints for both diagnostic and therapeutic purposes.
- Radiofrequency ablation (thermocoagulation) of the medial branches: temporary interruption of the nerves that transmit pain. It can be effective, but the benefit is often time-limited because these nerves regrow.
- Surgery: reserved for disabling pain that has not responded to previous treatments, when a facet origin has been formally demonstrated.
When surgery becomes necessary, the standard treatment has long been pedicle-screw arthrodesis: fusion of the vertebrae using screws and rods, an effective but invasive procedure.
In 2015, I designed, and later patented, a facet arthrodesis device based on a different principle: directly fusing the painful facet joints using small devices of about 1 cm, called facet cages, implanted within the joint itself. This approach enables a less invasive procedure, with nearly 20 times less implanted metal volume compared with pedicle screw fixation.
This device has been evaluated in several clinical studies published in international peer-reviewed journals. At one year, a prospective multicenter study showed a significant improvement in symptoms in operated patients [3][3] Srour R, Gdoura Y, Delaitre M, Mortada J, Benali MA, Millot F, Hritcu D, Timofeev A, Sellal F. Facet Arthrodesis with the FFX Device: One-Year Results from a Prospective Multicenter Study. Int J Spine Surg. 2020 Dec;14(6):996-1002. doi: 10.14444/7149. Epub 2020 Dec 29. PMID: 33560260; PMCID: PMC7872413.. Compared with pedicle-screw fixation, its use significantly reduces operating time and blood loss [4][4] Srour R. Comparison of Operative Time and Blood Loss With the FFX® Device Versus Pedicle Screw Fixation During Surgery for Lumbar Spinal Stenosis: A Retrospective Cohort Study. Cureus. 2022 Mar 7;14(3):e22931. doi: 10.7759/cureus.22931. PMID: 35399487; PMCID: PMC8986517.. Finally, a long-term comparative study in patients with lumbar stenosis found a 91% facet-fusion rate, with no difference from pedicle screws in the primary fusion outcome or complications, and fewer reoperations at two years: 3.6% versus 10.7% [5][5] Houari O, Douanla A, Ben Ammar M, Benmekhbi M, Mortada J, Lungu G, Magheru C, Voirin J, Lebedinsky PA, Musacchio M, Bolognini F, Srour R. Evaluation of the Efficacy and Safety of FFX Facet Cages Compared With Pedicle Screw Fixation in Patients With Lumbar Spinal Stenosis: A Long-Term Study. Clin Spine Surg. 2025 Jun 1;38(5):E269-E276. doi: 10.1097/BSD.0000000000001704. Epub 2024 Oct 15. PMID: 39404118..
Full references for these studies, with links to the publications, are available on the Scientific Articles page.
For transparency: I am a co-inventor of this device (“FFX”), whose industrial development is carried out by SC MEDICA, a company in which a member of my family holds a senior position.
Surgery is appropriate for only a minority of patients: those whose facet pain has been demonstrated by diagnostic blocks, is disabling in daily life, and has not responded to well-conducted conservative treatment. In all other cases, non-surgical treatment remains the rule. Each situation is assessed individually during consultation, and the benefits and risks of every option are explained before any decision is made together.
Frequently asked questions
Not always. MRI can show facet osteoarthritis, but it is not always painful, and a painful joint may appear normal. This is why diagnosis relies on anesthetic medial branch blocks rather than imaging alone.
For many patients, yes. Injections and radiofrequency treatment, combined with rehabilitation, can provide lasting pain control. Surgery is considered only if these treatments fail.
Conventional arthrodesis fuses the vertebrae using pedicle screws and rods, sometimes combined with an implant placed inside the intervertebral disc, called an interbody cage. Facet arthrodesis directly fuses the facet joints using small devices of about 1 cm, called facet cages, implanted within the joint itself. This approach enables a less invasive procedure, with nearly 20 times less implanted metal volume compared with pedicle screw fixation.
As with any spinal surgery, there are risks (infection, bleeding, neurological complications, lack of improvement), which are explained during consultation. In approximately 4% of cases, facet arthrodesis surgery may lead to symptomatic non-fusion of the facet joint (pseudarthrosis), requiring revision surgery with pedicle screws. Rigorous patient selection is specifically intended to offer surgery only when the expected benefit justifies those risks.
Recovery varies from one patient to another and according to the extent of the procedure. The minimally invasive nature of facet arthrodesis generally allows early mobilization and a short hospital stay. The specific recovery plan is explained during the preoperative consultation.