Lumbar Facet Arthropathy Clinical Presentation
- Author: Carl H Shin, MD; Chief Editor: Stephen Kishner, MD, MHA more...
Little controversy surrounds the facet joint as a possible source of chronic low back pain (LBP). Innervation and possible inflammatory mediators of the joint have been elucidated. Pain upon provocation of the joint, relief upon anesthetization of the same joint in healthy volunteers, and chronic LBP in patients have been documented. Although initially described as a syndrome, investigators now prefer to term it facet joint pain. By definition, a syndrome is a group of signs and symptoms that occur together and characterize a particular abnormality; however, no signs or symptoms have been identified as unique to facet-mediated pain.
A major source of frustration for clinicians has been the fact that no reliable means exist to document a clinical diagnosis of lumbar facet joint pain without the use of invasive techniques. If the true prevalence of facet joint pain was 40-75%, as initially reported, a clinical profile might not be crucial, because all chronic LBP patients would warrant investigation for this disorder. However, a prevalence of 10-15% would indicate that a clinical profile would be important in preventing the indiscriminate use of diagnostic and/or therapeutic blocks.
Biomechanical studies of the facet joint during extension and of facet capsular ligaments strained during rotation initially provided the belief that facet joint pain is worse with extension and rotation. Early studies by Helbig and Lee provided initial credence to this belief, but later studies by Revel and coauthors and by Schwarzer and colleagues did not support it.
Revel's investigation found that an increase in pain during hyperextension and extension-rotation was, in fact, less frequent in the group that responded to the facet joint injection than in the group that did not.
The characteristics of lumbar facet joint pain include the following:
Location of pain.
- Lumbar facet joint pains are lateralized and can radiate below the knee. They rarely, if ever, cause axial or central back pain.
- In their study of 26 patients selected by way of differential diagnostic blocks, Schwarzer and colleagues observed that no patients with central pain responded to diagnostic blocks of the facet joints.[20, 21] This study also refuted the commonly held notion that pain below the knee is unlikely to be referred from the facet joint.
Clinical features of facet joint pain.
- In their large 1988 study, Jackson and coauthors could not identify clinically specific facet syndromes or predict with any degree of accuracy which patients were more likely to respond to facet diagnostic blocks. They concluded that facet syndrome is not a reliable clinical diagnosis.
- Studies addressing the pattern of referred pain have been unable to distinguish pain from different levels. However, a generally held belief is that facet joint pain is more prevalent among the older population, is more lateralized, and is a more likely diagnosis when radiographic findings show severe facet arthritis.
The cause of most lumbar facet pain is unknown. On occasion, the lumbar facet joints are affected by systemic inflammatory arthritides, such as rheumatoid arthritis and ankylosing spondylitis. The following is a more specific look at sources of low back pain (LBP).
Microtrauma of the facet joints can produce pain. Small fractures, capsular tears, splits in the articular cartilage, and hemorrhage have been documented on postmortem studies of trauma victims who had normal radiographic findings. Whether these abnormalities were painful was not recorded.
Osteoarthritis is another cause of lumbar facet joint pain. However, not all cases of facet arthritis are painful; the radiographic changes of osteoarthritis are as common in patients with LBP as in those without it. Some studies report that severely degenerated joints are more likely to cause symptoms. In a 2008 report, multidetector computed tomography (CT) scanning in 188 individuals revealed lumbar facet osteoarthritis in 59.6% of males and 66.7% of females. In this study population, however, the report found no association between osteoarthritis at any level of the lumbar spine and the development of LBP.
Reports indicate that the orientation of the facet joints is associated with the development of spinal osteoarthritis. In a study of 150 patients, Linov et al found that a particularly sagittal orientation of the L4 and L5 facet joints appeared to be linked to the disease.
Synovial capsule distention and inflammation
Dory attributed LBP from facet syndrome to distention and inflammation of the synovial capsule, with resultant stimulation of the nociceptive nerve endings. Expanded synovial recesses may also compress nerve roots in the spinal canal and neural foramina, which may explain the presence of radicular pain in patients with facet syndrome. Lippitt attributed pain in facet syndrome to a combination of synovitis, segmental instability, and degenerative arthritis.
Using magnetic resonance imaging (MRI) scans, a study by Yamada et al of 201 patients with rheumatoid arthritis found erosion of the lumbar facets and endplates in 76.6% and 70.6% of patients, respectively, with the erosion occurring at 38.7% and 33.8% of intervertebral levels, respectively. Facet and endplate erosion both occurred most commonly at the midlumbar and lower-lumbar areas. A correlation was seen between facet erosion and the presence of spondylolisthesis.
Other theories regarding the causes of LBP include meniscoid entrapment, synovial impingement, joint subluxation, chondromalacia facette, capsular and synovial inflammation, mechanical injury to the joint capsule, and the restriction of normal articular motion from soft or articular causes.
Manchikanti L, Kaye AD, Boswell MV, et al. A Systematic Review and Best Evidence Synthesis of the Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. Pain Physician. 2015 Jul-Aug. 18 (4):E535-82. [Medline]. [Full Text].
Badgley CE. The articular facet in relation to low back pain and sciatic radiation. J Bone Joint Surg. 1941. 23:481.
Ghormley RK. Low-back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933. 101:1773-7.
Rees WS. Multiple bilateral subcutaneous rhizolysis of segmental nerves in the treatment of intervertebral disc syndrome. Ann Gen Prac. 1972. 26:126.
Shealy CN. Facets in back and sciatic pain. A new approach to a major pain syndrome. Minn Med. 1974 Mar. 57(3):199-203. [Medline].
Hirsch C, Ingelmark BE, Miller M. The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand. 1963. 33:1-17. [Medline].
Mooney V, Robertson J. The facet syndrome. Clin Orthop Relat Res. 1976 Mar-Apr. (115):149-56. [Medline].
McCall IW, Park WM, O''Brien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine. 1979 Sep-Oct. 4(5):441-6. [Medline].
Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain. 1989 Oct. 39(1):37-40. [Medline].
Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am. 1991 Apr. 22(2):181-7. [Medline].
Bokov A, Isrelov A, Skorodumov A, Aleynik A, Simonov A, Mlyavykh S. An analysis of reasons for failed back surgery syndrome and partial results after different types of surgical lumbar nerve root decompression. Pain Physician. 2011 Nov-Dec. 14(6):545-57. [Medline].
Ashton IK, Ashton BA, Gibson SJ, et al. Morphological basis for back pain: the demonstration of nerve fibers and neuropeptides in the lumbar facet joint capsule but not in ligamentum flavum. J Orthop Res. 1992 Jan. 10(1):72-8. [Medline].
Giles LG, Harvey AR. Immunohistochemical demonstration of nociceptors in the capsule and synovial folds of human zygapophyseal joints. Br J Rheumatol. 1987 Oct. 26(5):362-4. [Medline].
Grönblad M, Korkala O, Konttinen YT, et al. Silver impregnation and immunohistochemical study of nerves in lumbar facet joint plical tissue. Spine. 1991 Jan. 16(1):34-8. [Medline].
Netzer C, Urech K, Hugle T, Benz RM, Geurts J, Scharen S. Characterization of subchondral bone histopathology of facet joint osteoarthritis in lumbar spinal stenosis. J Orthop Res. 2016 May 4. [Medline].
Schmidt H, Heuer F, Wilke HJ. Interaction between finite helical axes and facet joint forces under combined loading. Spine. 2008 Dec 1. 33(25):2741-8. [Medline].
Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine. 1988 Sep. 13(9):966-71. [Medline].
Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med. 1991 Oct 3. 325(14):1002-7. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994 Aug. 58(2):195-200. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?. Spine. 1994 May 15. 19(10):1132-7. [Medline].
Moran R, O''Connell D, Walsh MG. The diagnostic value of facet joint injections. Spine. 1988 Dec. 13(12):1407-10. [Medline].
Schwarzer AC, Wang S, Laurent R, et al. The role of the zygapophysial joint in chronic low back pain [abstract]. Aust NZ J Med. 1992. 22:185.
Schwarzer AC, Wang SC, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis. 1995 Feb. 54(2):100-6. [Medline]. [Full Text].
Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004 May 28. 5:15. [Medline]. [Full Text].
Revel ME, Listrat VM, Chevalier XJ, et al. Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil. 1992 Sep. 73(9):824-8. [Medline].
Ko S, Vaccaro AR, Lee S, Lee J, Chang H. The prevalence of lumbar spine facet joint osteoarthritis and its association with low back pain in selected Korean populations. Clin Orthop Surg. 2014 Dec. 6 (4):385-91. [Medline]. [Full Text].
Varlotta GP, Lefkowitz TR, Schweitzer M, Errico TJ, Spivak J, Bendo JA, et al. The lumbar facet joint: a review of current knowledge: Part II: diagnosis and management. Skeletal Radiol. 2011 Feb. 40(2):149-57. [Medline].
Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine. 2008 Nov 1. 33(23):2560-5. [Medline].
Linov L, Klindukhov A, Li L, et al. Lumbar facet joint orientation and osteoarthritis: a cross-sectional study. J Back Musculoskelet Rehabil. 2013. 26(4):421-6. [Medline].
Lippitt AB. The facet joint and its role in spine pain. Management with facet joint injections. Spine. 1984 Oct. 9(7):746-50. [Medline].
Yamada K, Suzuki A, Takahashi S, et al. MRI evaluation of lumbar endplate and facet erosion in rheumatoid arthritis. J Spinal Disord Tech. 2014 Jun. 27(4):E128-35. [Medline].
Carrino JA, Lurie JD, Tosteson AN, et al. Lumbar spine: reliability of MR imaging findings. Radiology. 2009 Jan. 250(1):161-70. [Medline].
Maus T. Imaging the back pain patient. Phys Med Rehabil Clin N Am. 2010 Nov. 21(4):725-66. [Medline].
Schwarzer AC, Wang SC, O'Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. 1995 Apr 15. 20(8):907-12. [Medline].
Cohen SP, Hurley RW. The ability of diagnostic spinal injections to predict surgical outcomes. Anesth Analg. 2007 Dec. 105(6):1756-75, table of contents. [Medline].
Lord SM, Barnsley L, Wallis BJ, et al. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996 Aug 1. 21(15):1737-44; discussion 1744-5. [Medline].
Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. Reg Anesth. 1993 Nov-Dec. 18(6):343-50. [Medline].
Dreyfuss P, Schwarzer AC, Lau P, et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. A computed tomography study. Spine. 1997 Apr 15. 22(8):895-902. [Medline].
Kroll HR, Kim D, Danic MJ, et al. A randomized, double-blind, prospective study comparing the efficacy of continuous versus pulsed radiofrequency in the treatment of lumbar facet syndrome. J Clin Anesth. 2008 Nov. 20(7):534-7. [Medline].
Cohen SP, Moon JY, Brummett CM, White RL, Larkin TM. Medial Branch Blocks or Intra-Articular Injections as a Prognostic Tool Before Lumbar Facet Radiofrequency Denervation: A Multicenter, Case-Control Study. Reg Anesth Pain Med. 2015 Jul-Aug. 40 (4):376-83. [Medline].
Nedelka T, Nedelka J, Schlenker J, et al. Mechano-transduction effect of shockwaves in the treatment of lumbar facet joint pain: comparative effectiveness evaluation of shockwave therapy, steroid injections and radiofrequency medial branch neurotomy. Neuro Endocrinol Lett. 2014. 35(5):393-7. [Medline].
Gallagher J, Petriccioone di Vadi PL, Wedley JR. Radiofrequency facet joint denervation in the treatment of low back pain: a prospective controlled double-blind study to assess its efficacy. Pain Clin. 1994. 7(3):193-8.
van Kleef M, Barendse GA, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine. 1999 Sep 15. 24(18):1937-42. [Medline].
Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000 May 15. 25(10):1270-7. [Medline].
Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine. 2001 Jul 1. 26(13):1411-6; discussion 1417. [Medline].
van Wijk RM, Geurts JW, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain. 2005 Jul-Aug. 21(4):335-44. [Medline].
Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine. 2004 Nov 1. 29(21):2471-3. [Medline].
Kornick C, Kramarich SS, Lamer TJ, et al. Complications of lumbar facet radiofrequency denervation. Spine. 2004 Jun 15. 29(12):1352-4. [Medline].
Manchikanti L, Falco FJ, Singh V, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part I: introduction and general considerations. Pain Physician. 2013 Apr. 16(2 Suppl):S1-48. [Medline].
Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr. 16(2 Suppl):S49-283. [Medline].
Beaman DN, Graziano GP, Glover RA, et al. Substance P innervation of lumbar spine facet joints. Spine. 1993 Jun 15. 18(8):1044-9. [Medline].
Borenstein D. Does osteoarthritis of the lumbar spine cause chronic low back pain?. Curr Pain Headache Rep. 2004 Dec. 8(6):512-7. [Medline].
Eubanks JD, Lee MJ, Cassinelli E, et al. Prevalence of lumbar facet arthrosis and its relationship to age, sex, and race: an anatomic study of cadaveric specimens. Spine. 2007 Sep 1. 32(19):2058-62. [Medline].
Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique. Phys Ther. 2007 Oct. 87(10):1348-61. [Medline].
Willburger RE, Wittenberg RH. Prostaglandin release from lumbar disc and facet joint tissue. Spine. 1994 Sep 15. 19(18):2068-70. [Medline].