Anatomy & Background
The thoracic spine, or mid-back, is the largest section of the back and includes 12 vertebrae, with an intervertebral disc in-between each. The vertebrae are the bony building blocks of the back and spine. They are designed to protect the spinal cord, provide support and structure to the spine, and carry the head, neck, and trunk weight. The vertebrae of each section of the spine are slightly different and specific to the function of that area.
Spinal and Facet Joints
Each thoracic vertebral level has three joints. There is only one joint made up of intervertebral discs that connect the vertebral bodies. There are also two posterior and lateral joints called facet joints, one on each side. The facet joints support, stabilize, and allow movement of the thoracic spine.
Facet joints are synovial joints, meaning they have smooth, gleaming contact surfaces known as articular cartilage. The articular cartilage allows the bones to move freely over one another, reducing friction and stress. Each joint is also protected by a sleeve called a capsule and is lubricated by synovial fluid. Facet joints can become inflamed and irritated, resulting in pain and dysfunction.
Each thoracic vertebra contains two ribs, one on each side. The thoracic cage is made up of twelve ribs that protect the body’s vital organs (lungs, heart, liver, kidneys, etc.) The thoracic spine nerves innervate the trunk and a portion of each arm with sensory and muscle innervation. Furthermore, these nerves are supplied by the body’s internal organs.
The thoracic spine moves more slowly than the cervical and lumbar spines. Forward bending requires the most movement. The ribs limit mid-back side bending, rotational, and turning motions.
Degenerative joint disease
Arthritis is a non-infectious, progressive disorder of the joints. The normal articular joint cartilage is smooth, white, and translucent. In early arthritis or joint degeneration, the cartilage becomes yellow and opaque with localized areas of softening and roughening of the surfaces. As degeneration progresses, the soft areas become cracked and worn, exposing bone under the cartilage. Eventually, osteophytes (spurs of new bone) covered by cartilage, form at the edge of the joint. As mechanical wear increases, the cartilage cells are unable to repair themselves.
Back pain is usually caused by degenerative joint disease. The spinal facet joints, like the rest of the body’s synovial joints, the spinal facet joints are prone to wear and tear degeneration, inflammation, and arthritic changes. Facet joint inflammation and degeneration can cause pain, loss of motion, and severe encroachment or pinching of the nerve exiting the spinal column. The following are some of the most common causes of facet joint irritation:
- Degeneration, arthritic changes, or general joint wear and tear;
- Disc degeneration that results in a loss of height between the vertebrae, which places a greater compression force on the posterior facet joints, increasing and intensifying wear and tear on these joints;
- Backward motions that cause facet joint compression, leading to degenerative and eventually arthritic changes;
- A sudden fall or trauma, such as a car accident, that causes facet joint irritation, increasing and intensifying joint wear and tear;
- Ligament damage resulting in joint instability and increased wear and stress on the spinal joints;
- Genetic predisposition;
- Lifting or carrying heavy weights that causes facet joint irritation and degenerative joint disease due to repetitive stress injuries;
- Long-term scoliosis causes severe wear on the spinal facet joints.
Open and honest communication with your doctor is essential to determine the exact cause of your back pain and the most effective degenerative disc disease treatment.
The symptoms of the degenerative joint disease vary depending on where the joint is located and which structures are affected. Symptoms range from mild to severe and may resemble those of a disc problem:
- Back pain or radicular symptoms to the trunk or rib cage;
- Localized pain and tenderness at the level of the involved facet joint;
- Muscle spasms and posture changes as a result of the injury;
- Limited range of motion, such as the inability to bend backward, move sideways to the affected side, or stand upright;
- Difficulty standing and walking due to severe irritation;
- Difficulty sitting;
- Joint stiffness after rest;
- Pain due to strenuous activity that relieves with rest;
- Swelling at the joint level.
If your pain worsens for no apparent reason and rest and over-the-counter medication are ineffective, consult your doctor. If the numbness and tingling persist or you are unable to move a part of your body, make an appointment. If you begin to lose control of your bowels or bladder, seek medical attention immediately.
Treating Degenerative Joint Disease
Treatment of degenerative joint disease or injury will depend on the severity of the condition. When treating acute back problems:
- Rest. Avoid the activities that produce the pain (bending, lifting, twisting, turning, bending backward, etc.);
- Anti-inflammatory drugs and other pain medication;
- Apply ice in acute cases to the thoracic spine to help reduce pain and associated muscle spasms. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin;
- Moist heat may be helpful to reduce pain and improve any feelings of stiffness;
- An exercise regimen designed specifically to address the cause of the symptoms associated with the degenerative joint disease and improve joint mobility, spinal alignment, posture, and range of motion;
- The use of a brace or other supports may be necessary to reduce stress on the facet joints, muscles, and thoracic spine;
- Steroidal medication to reduce inflammation in moderate to severe conditions;
- Facet joint injections directly to the involved joint;
- Physical therapy to reduce inflammation, restore joint mobility, improve motion, and help the return of full function.
The main goal is to alleviate your pain and avoid further injury. These pain management techniques are usually intended to be used for a long time as long as your condition is manageable.
In mild cases, patients found that rest, ice, and medication may be enough to reduce the pain. Pain specialist doctor in NJ Dr. Freeman, recommends physical therapy to develop a series of stretching and strengthening exercises to prevent the re-occurrence of the injury. Return to activity should be gradual to prevent a flare-up of symptoms.
Moderate to Severe Cases
If the problem persists, visit one of our New Jersey pain management clinics to consult with your pain management specialist. Your physician should perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination, your local pain care doctor or Dr. Freeman, the best pain specialist doctor in NJ may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors, or infection present;
- MRI to determine any soft tissue involvement, including visualization of the discs, spinal cord, and nerve roots;
- CT scans, which can give a cross-section view of the spinal structures.
Medications to consider
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation, and muscle spasm that may be associated with facet joint injuries.
- Over-the-counter medications for mild to moderate pain;
- If over-the-counter medications are not effective, your physician may prescribe stronger pain medication;
- Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury;
- Muscle relaxers to reduce acute muscle spasms;
- Injections like facet injections, nerve blocks, or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Conditions
In the case of conditions that do not respond to conservative care, surgery may be indicated. If you continue to experience some of the following symptoms:
- Increase in radiating or radicular pain;
- Pain or nerve irritation that gets worse;
- Associated disc involvement.
The majority of patients return to normal function within a few weeks of surgery, and the results are usually excellent.
Medical Procedures to Consider
Injections like facet injections, nerve blocks, or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
- Caudal Epidural Injections;
- Facet Joint Injections;
- Interlaminar Caudal Epidural Steroid Injections;
- Medial Branch Blocks;
- Selective Nerve Root Blocks.
The procedures mentioned above are used to isolate the source of pain, provide temporary pain relief, and improve the effectiveness of physical therapy in patients with severe pain.
Procedures your doctor can perform to reduce the effects of degeneration on pain-producing structures of the spine include:
- Endoscopic Decompression;
- Endoscopic Foraminotomy;
- Laser Facet Rhizotomy;
- Facet Thermal Ablation;
- Radiofrequency Ablation.
Your doctor will use different surgical procedures depending on the condition and its severity. Sometimes, they can surgically repair a herniated disc to restore the normal anatomic structure. In other cases, the specialist must remove the painful disc or a bone pressing against the spinal cord. Only surgery to relieve pressure on the spinal cord can provide long-term relief in patients with spinal stenosis.