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Answers to Questions About Mild Curves

From time to time, the National Scoliosis Foundation receives queries from readers about how to manage pain in the spine. The pain is not caused by scoliosis, but rather can be due to problems such as facet joint syndrome. To find out more about this condition and the remedies available, we asked our Medical Update editor, Nancy Schommer, to contact Dr. James Hill, a neuroradiologist who specializes in brain and spine imaging and pain intervention at New England Baptist Hospital in Boston. What follows is an excerpt from their conversation.

Q: Dr. Hill, what is facet syndrome?
A: Facet syndrome is characterized by back pain, with or without tenderness, which can radiate from the back down to the buttocks and into the thighs. The pain is caused by inflammation of the synovial lining of the facet joints-the joints that connect the posterior elements of one vertebral level to the next and which allow the spinal column to bend forward and backward.


Q: Who is most likely to be affected by facet syndrome?
A: Facet syndrome can occur in people who have scoliosis, and in those who do not. Generally speaking, it occurs in those individuals who have some abnormal stress on the facet joints caused by disc degeneration, osteoarthritis, or an abnormal curvature. We also see facet syndrome in individuals who have had a fusion of the spine; in these cases, the fusion causes extra stress on the joints above and below it leading to inflammation and pain.

Q: If a person suspects he or she has facet syndrome, what steps should be taken?
A: If you have a neurologist or orthopedist, see them first. Otherwise see your primary care physician. Your doctor will probably perform a physical exam and ask about your pain and where it's located. The doctor may also request magnetic resonance imaging (MRI) to see if there is any abnormal disc herniation that could account for the pain.

Q: What can a physician do to alleviate the pain of facet syndrome?
A: An oral anti-inflammatory may give relief. If this fails, or is contra indicated then a facet block is used. For this treatment we inject steroids into the joint to relieve the inflammation of the synovium that lines the joint.

Q: Would you describe the procedure?
A: After reviewing the procedure with the patient, he or she lies prone on the examining table. The back is sterilized with betadyne and then numbed with a local anesthetic. Using xray monitoring to see the joints in real time, we then place a small spinal needle into the joints that the referring clinician believes are affected and inject them with steroids.

Q: What kind of steroid are you injecting into the joints?
A: It's called DepoMedrol. It's an oil-based steroid that remains in the joints for two to three weeks while slowly being absorbed by the blood stream.

Q: What happens next?
A: After the injection-which takes about 5 minutes-we pull the needle just outside the joint and inject a local anesthetic over the capsule of the joint. We do this to reduce achiness that can occur after the injection; the numbing effect lasts for about 4-5 hours. After the numbness wears off, the patient will probably experience two days of mild to moderate achiness. Following that, it can take up to two weeks for the steroids to attain their full anti-inflammatory response.

Q: How successful is the facet block for reducing pain?
A: It's variable. About 80% of our patients get good to excellent relief. Of those who do get relief, it usually lasts for months; and on rare occasions it can last for years.

Q: You mentioned that one may have a facet block three times a year but no more than that. Why not?
A: The risks of having excessive steroid injections are multifold, ranging from osteoporosis to a hormonal condition known as Cushing's syndrome. If the patient is diabetic, it will raise blood sugar. And if you're already taking steroids for other reasons, the facet block will add that much more steroid to your system.

Q: What if the patient is still in pain after three injections?
A: If pain is significant we will do another injection, but only after warning the patient of the possible downside of excessive steroids. At this point, the patient should see their physician to determine if other forms of treatment such as spinal surgery may be indicated.


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