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Lumbar Facet Arthropathy Workup

  • Author: Carl H Shin, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: May 26, 2016
 

Laboratory Studies

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  • No specific laboratory studies are necessary when a diagnosis of lumbar facet arthropathy is being considered.
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Imaging Studies

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  • Abnormalities on plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans[36] are not specific for patients with back pain; degenerative changes are often found in asymptomatic persons. Although some clinicians may use plain radiography and CT scanning to investigate or even diagnose facet joint pain, no radiographic findings identify lumbar facet joints as the source of low back pain and referred lower extremity pain.[37]
  • A limited number of studies have attempted to establish correlation between osteoarthritic changes and response to blocking of the joints. While some earlier studies demonstrated such a relationship, others have failed to do so. Furthermore, findings from MRI scans, CT scans, dynamic bending radiographs, and radionuclide bone scans cannot be used to reliably help predict lumbar facet joint pain.
  • Schwarzer and colleagues concluded that CT scanning has no place in the diagnosis of lumbar facet joint pain.[38] They used the stringent criteria of 80% pain relief for the duration of bupivacaine anesthesia and negative relief with saline control injection. The investigators did not observe any correlation between CT-scan findings and response to diagnostic injections.
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Procedures

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  • The use of diagnostic blocks is fundamental to a diagnosis of lumbar facet joint pain. Regardless of the symptoms, one characteristic that all patients with such pain share is the relief of pain once a local anesthetic has been injected. Fluoroscopically guided blocks of the joints constitute the only available standard to correlate with any clinical or radiographic test for facet joint pain.[39]
  • Single diagnostic blocks are a poor standard. Those employed without the provision of controls led to a false-positive rate of 38% in a lumbar study[20] and a 27% false-positive rate in a cervical study, with a 32% placebo rate in still another investigation. If an investigator relied on a single, uncontrolled block, 1 of every 3 apparently positive blocks would be a false positive. A reliable diagnosis must be accompanied by observation in relation to control subjects.
  • Control observation can be achieved either with saline injection around the joint while shielding the patient from view of the injections or through use of a confirmatory block. In a confirmatory block, relief achieved with the first local anesthetic is accompanied by relief provided by a second injection for a duration commensurate with the half-life of the second local anesthetic. A patient with genuine facet joint pain should experience relief with the first injection and feel no relief if injected with saline or, if injected with the confirmatory block, experience the same relief that he/she did with the first injection, but for a longer period of time.
  • The use of double blocks to confirm facet pain is not without limitations. When an appropriate duration of relief with a confirmatory block was required, Lord and colleagues found in cervical studies that specificity was high (88%) but that sensitivity was low (54%) in comparison with double-blinded, randomized, placebo-controlled triple blocks.[40] When diagnostic criteria for the double blocks were expanded to include all patients with reproducible relief, regardless of duration, sensitivity increased to 100% but specificity was lowered to 65%. The authors concluded that a clinician's choice of controls depends on the implications of the results. If innocuous therapy is prescribed, relief of pain, regardless of duration, with a double block may suffice. When diagnostic certainty is critical, such as in a medicolegal context or when surgical intervention is contemplated, placebo-controlled blocks are recommended.
  • The use of saline around the joint for control observation also has limitations. Of the various possible combinations of responses to 2 injections, pain relief in the same patient with local anesthetic and with saline poses a dilemma. The clinician could conclude that the patient does not have facet joint pain, having falsely responded to the local anesthetic and to the saline. However, a response to the saline injection does not necessarily negate the validity of the first injection with local anesthetic; it may instead indicate that the patient responded to a placebo. The individual may have true facet pain in addition to being a placebo responder. Because of this, some clinicians often proceed with RF neurotomy in patients who obtain 80% relief with lidocaine and with saline, depending on the clinical presentation. Studies are being conducted to report outcomes based on such an approach.
  • Facet diagnostic blocks can be performed intra-articularly and at the dorsal medial branches that supply the joint. The latter site is used if the joint is not accessible or as a means of avoiding the theoretical risk of needle damage to the joint. Barnsley and Bogduk found that local anesthetic blocks of the cervical medial branches are a specific test for the diagnosis of cervical facet joint pain. In their study, local anesthetic always reached the target nerve and did not affect any other diagnostically important structures.[41] Dreyfuss and colleagues determined that, with the use of appropriate technique, lumbar medial branch blocks are target specific.[42] The use of 0.5 mL of lidocaine adequately bathed the site of the target nerve and trivialized the spread to the dorsal root or the epidural spread to other potential pain generators.
  • With well-controlled studies reporting 7-14% prevalence rates for facet joint pain, clinicians must adopt stringent criteria for diagnosing facet joint pain. In this way, they can avoid unnecessarily subjecting a large portion of patients with chronic low back pain to various treatments aimed at facet joint pain.
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Contributor Information and Disclosures
Author

Carl H Shin, MD Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Pennsylvania

Carl H Shin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Curtis W Slipman, MD Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, North American Spine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR Senior Associate Dean, Associate Dean of Clinical Medicine, Consultant in Sports Medicine, Assistant Vice President of Program Development, Division of Health Sciences, DeBusk College of Osteopathic Medicine; Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, American Osteopathic Academy of Sports Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The editors wish to gratefully acknowledge Mark I Ellen, MD, Assistant Professor, Department of Orthopedics and Rehabilitation Medicine, The Emory Sports Medicine Center, for his previous participation in this article.

References
  1. 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].

  2. Badgley CE. The articular facet in relation to low back pain and sciatic radiation. J Bone Joint Surg. 1941. 23:481.

  3. Ghormley RK. Low-back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933. 101:1773-7.

  4. Rees WS. Multiple bilateral subcutaneous rhizolysis of segmental nerves in the treatment of intervertebral disc syndrome. Ann Gen Prac. 1972. 26:126.

  5. 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].

  6. 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].

  7. Mooney V, Robertson J. The facet syndrome. Clin Orthop Relat Res. 1976 Mar-Apr. (115):149-56. [Medline].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. Adams MA, Hutton WC. The effect of posture on the role of the apophysial joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980 Aug. 62(3):358-62. [Medline]. [Full Text].

  17. 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].

  18. 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].

  19. 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].

  20. 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].

  21. 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].

  22. Moran R, O''Connell D, Walsh MG. The diagnostic value of facet joint injections. Spine. 1988 Dec. 13(12):1407-10. [Medline].

  23. 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.

  24. 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].

  25. 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].

  26. Raymond J, Dumas JM. Intraarticular facet block: diagnostic test or therapeutic procedure?. Radiology. 1984 May. 151(2):333-6. [Medline]. [Full Text].

  27. 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].

  28. 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].

  29. Manchikanti L, Manchikanti KN, Cash KA, et al. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain Physician. 2008 Jan. 11(1):67-75. [Medline]. [Full Text].

  30. 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].

  31. 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].

  32. 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].

  33. Dory MA. Arthrography of the lumbar facet joints. Radiology. 1981 Jul. 140(1):23-7. [Medline]. [Full Text].

  34. Lippitt AB. The facet joint and its role in spine pain. Management with facet joint injections. Spine. 1984 Oct. 9(7):746-50. [Medline].

  35. 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].

  36. Carrino JA, Lurie JD, Tosteson AN, et al. Lumbar spine: reliability of MR imaging findings. Radiology. 2009 Jan. 250(1):161-70. [Medline].

  37. Maus T. Imaging the back pain patient. Phys Med Rehabil Clin N Am. 2010 Nov. 21(4):725-66. [Medline].

  38. 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].

  39. 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].

  40. 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].

  41. 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].

  42. 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].

  43. 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].

  44. 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].

  45. 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].

  46. Lynch MC, Taylor JF. Facet joint injection for low back pain. A clinical study. J Bone Joint Surg Br. 1986 Jan. 68(1):138-41. [Medline]. [Full Text].

  47. 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.

  48. 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].

  49. 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].

  50. 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].

  51. 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].

  52. Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine. 2004 Nov 1. 29(21):2471-3. [Medline].

  53. Kornick C, Kramarich SS, Lamer TJ, et al. Complications of lumbar facet radiofrequency denervation. Spine. 2004 Jun 15. 29(12):1352-4. [Medline].

  54. 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].

  55. 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].

  56. 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].

  57. Borenstein D. Does osteoarthritis of the lumbar spine cause chronic low back pain?. Curr Pain Headache Rep. 2004 Dec. 8(6):512-7. [Medline].

  58. 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].

  59. 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].

  60. Willburger RE, Wittenberg RH. Prostaglandin release from lumbar disc and facet joint tissue. Spine. 1994 Sep 15. 19(18):2068-70. [Medline].

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Anteroposterior view of right L4-5 facet intra-articular injection with contrast.
Lateral view of right L4-5 facet intra-articular injection with contrast.
Oblique view of right L4-5 facet intra-articular injection with contrast.
Anteroposterior view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala).
Lateral view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala, just below the L5-S1 facet joint).
Anteroposterior view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process).
Lateral view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process, just below L4-5 facet joint).
 
 
 
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