Lumbosacral Facet Syndrome Treatment & Management
- Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD more...
The initial treatment plan for acute Z-joint pain is focused on education, relative rest, pain relief, maintenance of positions that provide comfort, exercises, and some modalities. Physical therapy includes instruction on proper posture and body mechanics in activities of daily living that protect the injured joints, reduce symptoms, and prevent further injury. Positions that cause pain (eg, extension, oblique extension) should be avoided. Bed rest beyond 2 days is not recommended because this can have detrimental effects on bone, connective tissue, muscle, and the cardiovascular system. Thus, activity modification, rather than bed rest, is strongly recommended.
Modalities such as superficial heat and cryotherapy may also help relax the muscles and reduce pain. In addition, medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) may also be administered. Spinal manipulation and mobilization may also be attempted to reduce pain.
Surgical intervention is not the first-line treatment for the management of LBP, including Z-joint–mediated pain, and the vast majority of patients with LBP improve without surgery. Some circumstances, however, dictate that surgical evaluation is indicated. For example, loss of bowel or bladder function or saddle anesthesia (ie, decreased sensation of the perineal region, such as loss of the ability to feel toilet paper touching the skin) are particularly concerning and require emergent surgical evaluation.
Other red flags that may necessitate surgical evaluation include signs and symptoms of malignancy (eg, rapid, unintended weight loss; cancer history; night pain; radiologic findings), unexplained fever, or rapidly progressing neurologic deficits. Importantly, the practitioner must be alert to these ominous signs (red flags) because they can manifest even later in the course of managing a patient’s LBP.
Spinal manipulation may be useful for both short- and long-term pain relief. Some evidence supports the use of spinal manipulative therapy combined with a trunk-strengthening program, which, over the course of a year, may actually reduce the need for pain medication.
While radiofrequency ablation for the treatment of general low back pain is controversial, one area that it seems to have better outcomes is lumbar facet syndrome. A study that investigated function, pain, and medication use outcomes of radiofrequency ablation for lumbar facet syndrome demonstrated a durable treatment effect of radiofrequency ablation for lumbar facet syndrome at long-term follow-up, as measured by improvement in function, pain, and analgesic use.
Once the painful symptoms are controlled during the acute phase of treatment, stretching and strengthening exercises of the lumbar spine and associated muscles can be initiated.
Because Z-joint–mediated pain tends to be worse with extension, strengthening and conditioning exercises should typically be performed with a flexed trunk. Strengthening maneuvers must emphasize flexion, neutral postures, and pelvic tilt, all in an effort to reduce compression of the Z-joints.
Another therapeutic goal is to reduce the lumbar lordosis because excessive lordosis increases the loading on the posterior elements, including the Z-joints. Therefore, the patient should be taught pelvic tilt maneuvers to reduce the degree of lumbar lordosis. Pelvic tilt maneuvers can be taught in multiple positions (with knees bent while standing, legs straight while standing, and while sitting) to emphasize proper posture in multiple planes. Flexion-based exercises should be avoided in the presence of hypermobility or instability or if the maneuvers increase LBP.
Similarly, stretching exercises should be focused on restoring proper pelvic tilt; therefore, special emphasis should be placed on stretching those muscles that cause excessive anterior pelvic tilt (eg, the hip flexors and lumbar extensors). Stretching should be not limited to just these muscles because all the muscles attaching to the lumbar spine and pelvic girdle may be in imbalance, and regular stretching can help restore normal motion to the lumbar spine and pelvis. Therefore, stretching programs should also include stretches of the hamstrings, quadriceps, hip abductors, gluteals, and abdominals. Stretching through dynamic postural motions (eg, yoga postures) can be especially helpful because the motions can restore balance to the muscles of the lumbar spine and pelvic girdle.
These exercises are eventually incorporated into a more comprehensive rehabilitation program, which includes spine stabilization exercises. The goal with these exercises is to teach the patient how to find and maintain a neutral spine during everyday activities. The neutral spine position is specific to the individual and is determined by the pelvic and spine posture that places the least stress on the elements of the spine and supporting structures.
Dynamic lumbar control is also incorporated to protect the spine from biomechanical stresses, including tension, compression, torsion, and shear. Spinal stabilization emphasizes synergistic activation of the trunk and spinal musculature in the midrange position by strengthening the abdominal and gluteal muscles and enables the patient to develop the muscles that support the trunk and spine and, ultimately, diminish the overall stress on the spine.
Not all patients have the same flexibility and strength imbalances. Individual, detailed assessment by an experienced physical therapist may allow for a tailored therapeutic program.
Other Treatment (Injection, manipulation, etc.)
Three fluoroscopically guided spinal injections are often used in the diagnosis and management of Z-joint pain, although their efficacy remains in question. The goal of Z-joint injections is to facilitate a physical therapy program; therefore, their utility is primarily to verify the diagnosis and perhaps reduce pain to make the patient’s physical therapy program more successful. If previous injections were helpful and pain recurs, injections can be repeated; however, they should be limited.
Single injections with a local anesthetic have high false-positive rates (38%). Therefore, when performing any interventional injection, the criterion standard is to use a double- or triple-block paradigm. In a double-block protocol, the patient is given an injection with a short-acting anesthetic (eg, lidocaine) and records the duration of pain relief in a diary. On a follow-up visit (typically 1-2 wk later), a second injection is performed, using an anesthetic with a different duration of action (eg, bupivacaine, which has a longer half-life than lidocaine), and the patient again should chart pain relief in a diary. A patient is diagnosed as having a positive block if they receive pain relief (typically >80%) for both injections for a length of time corresponding to the duration of action of the medication.
For additional diagnostic accuracy, a third block can be performed with saline, although this is rarely performed in clinical practice. The diagnostic reliability of double- and triple-block protocols is clearly superior to that of a single-block protocol; therefore, these should be used before performing an ablation procedure or surgery.
Intra-articular Z-joint injection with corticosteroids and a local anesthetic can also be performed.[22, 23, 24, 25, 26, 27] Typically, this is performed under fluoroscopic guidance with contrast medium. Intra-articular anesthetic injections are considered the most accurate method for diagnosing Z-joint–mediated pain, particularly when performed with a double- or triple-block protocol.
Some have questioned, however, whether intra-articular corticosteroids are as effective in relieving Z-joint–mediated pain as other options, namely RFA of the medial branch of the dorsal ramus.[28, 29, 30] Additionally, injections into the Z-joint are often technically difficult because of joint degeneration and bony overgrowth. The main advantage of intra-articular injections, then, is not so much in its efficacy, but rather that it allows the practitioner to offer a potentially therapeutic injection at the same time as the diagnostic injection (as opposed to RFA, which is preferably performed after a double- or triple-block diagnostic protocol, and thus requires at least 3 separate injections).
Proietti et al aimed to evaluate the effectiveness of facet joints injections in lumbar facet syndrome correlating clinical results to the sagittal contour of the spine. Only patients with thoracolumbar kyphosis and short hyperlordosis (Type I Rossouly classification) showed significant improvement in pain at 3 month follow-up. For other classifications, facet joint injections provided only a temporary pain relief and should be reserved for diagnostic use.
The long-term benefit of intra-articular injection remains controversial, and some studies have reported similar results with either steroids or saline injection.
Complications are rare, although tenderness at the injection site is reported. A few reports have noted spinal block, vasovagal episodes, and chemical meningitis due to puncturing of the dural cuff, but these reports are rare. Recommend that patients withhold medications that promote bleeding, such as NSAIDs, warfarin (Coumadin), and aspirin. Contraindications include bacterial infection, possible pregnancy, bleeding diathesis, and local anesthetic allergy.
Medial branch block for diagnostic purposes has already been described (see Workup, Procedures), and studies have shown it to be effective in this regard; however, controversy remains regarding its use as a therapeutic intervention. Note that such a block also eliminates pain that may be emanating from other structures that are innervated by the medial branch, such as the multifidus or interspinous muscles or the interspinous ligaments.
An alternative to medial branch block denervation was studied by Iwatsuki et al in 21 patients with lumbosacral facet syndrome. These investigators evaluated the use of laser denervation to the dorsal surface of the facet capsule. At 1-year postprocedure, 17 patients (81%) experienced complete or greater than 70% pain reduction, whereas 4 patients (19%) had unsuccessful therapy. Iwatsuki et al suggested that the dorsal surface of the facet capsule might be a more preferable target for facet denervation.
A third intervention involves a medial branch neurotomy through RFA, chemical neurolysis, or cryoneurolysis. Percutaneous radiofrequency neurotomy is a method of denaturing the nerves that innervate the Z-joint through coagulation, thus resulting in more prolonged pain relief.[33, 34] Medial branch neurotomy through RFA has emerged as the standard therapy for facet-mediated low back pain. When performing these procedures, remember that the radiofrequency signal spreads circumferentially from the shaft and not linearly from the tip of the transducer; therefore, the shaft of the transducer must be placed parallel to the medial branch (as opposed to when performing a medial branch block, in which the tip should be aimed at the medial branch because the anesthetic leaves the tip of the needle and not the shaft). Once the axons regenerate, pain often returns.
The therapeutic benefit of this procedure likewise remains controversial[28, 35, 36] ; however, success rates range from 17-90% for periods of 6-12 months. Many of the studies have poor selection criteria, inconsistent techniques, poor outcome measures, and small sample sizes.
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The maintenance phase represents the final phase of the rehabilitation process for lumbosacral facet syndrome. Eccentric muscle-strengthening exercises, including more dynamic conditioning exercises (eg, with a large gym ball) are added to the program. Exercises are to be performed in a functional manner and in functional planes (eg, standing in multiple planes). For patients involved in sporting activities, sports-specific training is incorporated so that a neutral spine can be maintained. The goals of a comprehensive spine rehabilitation program have been met when pain is controlled, near-full range of motion of the spine is achieved, symmetrical flexibility is attained, and trunk control can be maintained in sport or recreational activities.
Spinal manipulation is being used for both short- and long-term pain relief. Some evidence supports the use of spinal manipulative therapy combined with a trunk-strengthening program, which, over the course of a year, may actually reduce the need for pain medication.
Goldwaith JE. The lumbosacral articulation: an explanation of many cases of "lumbago," "sciatica" and "paraplegia". Boston Med Surg J. 1911. 164:365-72.
Putti V. New conceptions in the pathogenesis of sciatic pain. Lancet. 1927. 2:53-60.
Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933. 101:1773-7.
McRae DL. Asymptomatic intervertebral disc protrusions. Acta radiol. 1956 Jul-Aug. 46(1-2):9-27. [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].
Kayser R, Mahlfeld K, Heyde CE. [Concepts of in-patient gradual diagnostics for patients with lumbar back-pain] [German]. Orthopade. 2008 Apr. 37(4):285-99. [Medline].
Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007 Mar. 106(3):591-614. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine. 1994 Apr 1. 19(7):801-6. [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].
Schwarzer AC, Derby R, Aprill CN, et al. Pain from the lumbar zygapophysial joints: a test of two models. J Spinal Disord. 1994 Aug. 7(4):331-6. [Medline].
Schwarzer AC, Derby R, Aprill CN, et al. The value of the provocation response in lumbar zygapophyseal joint injections. Clin J Pain. 1994 Dec. 10(4):309-13. [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].
Ray CD. Percutaneous Radiofrequency Facet Nerve Blocks: Treatment of the Mechanical Low Back Syndrome. Radionics Procedure Technique Series. Burlington, Mass: Radionics Inc; 1982.
Van Zundert J, Vanelderen P, Kessels A, van Kleef M. Radiofrequency Treatment of Facet-related Pain: Evidence and Controversies. Curr Pain Headache Rep. 2011 Nov 18. [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].
Kawu AA, Olawepo A, Salami AO. Facet joints infiltration: a viable alternative treatment to physiotherapy in patients with low back pain due to facet joint arthropathy. Niger J Clin Pract. 2011 Apr-Jun. 14(2):219-22. [Medline].
D'Aprile P, Tarantino A, Jinkins JR, Brindicci D. The value of fat saturation sequences and contrast medium administration in MRI of degenerative disease of the posterior/perispinal elements of the lumbosacral spine. Eur Radiol. 2007 Feb. 17(2):523-31. [Medline].
Cohen SP, Williams KA, Kurihara C, et al. Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology. 2010 Aug. 113(2):395-405. [Medline].
McCormick ZL, Marshall B, Walker J, McCarthy R, Walega DR. Long-Term Function, Pain and Medication Use Outcomes of Radiofrequency Ablation for Lumbar Facet Syndrome. Int J Anesth Anesth. 2015. 2 (2):[Medline].
Schulte TL, Pietilä TA, Heidenreich J, Brock M, Stendel R. Injection therapy of lumbar facet syndrome: a prospective study. Acta Neurochir (Wien). 2006 Nov. 148(11):1165-72; discussion 1172. [Medline].
Ständer M, März U, Steude U, Tonn JC. [The facet syndrome: frequent cause of chronic backaches] [German]. MMW Fortschr Med. 2006 Oct 26. 148(43):33-4. [Medline].
Shih C, Lin GY, Yueh KC, Lin JJ. Lumbar zygapophyseal joint injections in patients with chronic lower back pain. J Chin Med Assoc. 2005 Feb. 68(2):59-64. [Medline].
Maldjian C, Mesgarzadeh M, Tehranzadeh J. Diagnostic and therapeutic features of facet and sacroiliac joint injection. Anatomy, pathophysiology, and technique. Radiol Clin North Am. 1998 May. 36(3):497-508. [Medline].
Falco FJ. Lumbar spine injection procedures in the management of low back pain. Occup Med. 1998 Jan-Mar. 13(1):121-49. [Medline].
Kinard RE. Diagnostic spinal injection procedures. Neurosurg Clin N Am. 1996 Jan. 7(1):151-65. [Medline].
Slipman CW, Bhat AL, Gilchrist RV, et al. A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain. Spine J. 2003 Jul-Aug. 3(4):310-6. [Medline].
Manchikanti L. Facet joint pain and the role of neural blockade in its management. Curr Rev Pain. 1999. 3(5):348-58. [Medline].
Marks RC, Houston T, Thulbourne T. Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain. Pain. 1992 Jun. 49(3):325-8. [Medline].
Proietti L, Schirò GR, Sessa S, Scaramuzzo L. The impact of sagittal balance on low back pain in patients treated with zygoapophysial facet joint injection. Eur Spine J. 2014 Oct. 23 Suppl 6:628-33. [Medline].
Iwatsuki K, Yoshimine T, Awazu K. Alternative denervation using laser irradiation in lumbar facet syndrome. Lasers Surg Med. 2007 Mar. 39(3):225-9. [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].
Dreyfuss P, Halbrook B, Pauza K, et al. Lumbar radiofrequency neurotomy for chronic zygapophysial joint pain: a pilot study using dual medial branch blocks. ISIS Sci Newsl. 1999. 3(2):13-33.
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].
Hooten WM, Martin DP, Huntoon MA. Radiofrequency neurotomy for low back pain: evidence-based procedural guidelines. Pain Med. 2005 Mar-Apr. 6(2):129-38. [Medline].
Adams MA, Hutton WC. The mechanical function of the lumbar apophyseal joints. Spine. 1983 Apr. 8(3):327-30. [Medline].
Anderson R, Meeker WC, Wirick BE, et al. A meta-analysis of clinical trials of spinal manipulation. J Manipulative Physiol Ther. 1992 Mar-Apr. 15(3):181-94. [Medline].
Bogduk N. International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophysial joint blocks. Clin J Pain. 1997 Dec. 13(4):285-302. [Medline].
Bogduk N. The innervation of the lumbar spine. Spine. 1983 Apr. 8(3):286-93. [Medline].
Bogduk N. The lumbar mamillo-accessory ligament. Its anatomical and neurosurgical significance. Spine. 1981 Mar-Apr. 6(2):162-7. [Medline].
Bogduk N, Long DM. The anatomy of the so-called "articular nerves" and their relationship to facet denervation in the treatment of low-back pain. J Neurosurg. 1979 Aug. 51(2):172-7. [Medline].
Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV. Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial. J Manipulative Physiol Ther. 1996 Nov-Dec. 19(9):570-82. [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].
Cavanaugh JM, Ozaktay AC, Yamashita T, et al. Mechanisms of low back pain: a neurophysiologic and neuroanatomic study. Clin Orthop Relat Res. 1997 Feb. 335:166-80. [Medline].
Cho J, Park YG, Chung SS. Percutaneous radiofrequency lumbar facet rhizotomy in mechanical low back pain syndrome. Stereotact Funct Neurosurg. 1997. 68(1-4 pt 1):212-7. [Medline].
Derby R, Bogduk N, Anat D, Schwarzer A. Precision percutaneous blocking procedures for localizing spinal pain. Part 1. The posterior lumbar compartment. Pain Digest. 1993. 3:89-100.
Dreyfuss PH, Dreyer SJ, Herring SA. Lumbar zygapophysial (facet) joint injections. Spine. 1995 Sep 15. 20(18):2040-7. [Medline].
Fujiwara A, Tamai K, Yamato M, et al. The relationship between facet joint osteoarthritis and disc degeneration of the lumbar spine: an MRI study. Eur Spine J. 1999. 8(5):396-401. [Medline].
Gries NC, Berlemann U, Moore RJ, Vernon-Roberts B. Early histologic changes in lower lumbar discs and facet joints and their correlation. Eur Spine J. 2000 Feb. 9(1):23-9. [Medline].
Jerosch J, Castro WH, Liljenqvist U. Percutaneous facet coagulation: indication, technique, results, and complications. Neurosurg Clin N Am. 1996 Jan. 7(1):119-34. [Medline].
Kaul MP, Herring SA. Rehabilitation of lumbar spine injuries in sports. Phys Med Rehabil Clin N Am. 1994. 5(1):133-56.
Krishna M, Pollock RD, Bhatia C. Incidence, etiology, classification, and management of neuralgia after posterior lumbar interbody fusion surgery in 226 patients. Spine J. 2008 Mar-Apr. 8(2):374-9. [Medline].
Lorenz M, Patwardhan A, Vanderby R Jr. Load-bearing characteristics of lumbar facets in normal and surgically altered spinal segments. Spine. 1983 Mar. 8(2):122-30. [Medline].
Malanga GA, Nadler SF. Nonoperative treatment of low back pain. Mayo Clin Proc. 1999 Nov. 74(11):1135-48. [Medline].
Manchikanti L, Pampati V, Fellows B, Bakhit CE. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain. 2000. 4(5):337-44. [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].
McLain RF, Pickar JG. Mechanoreceptor endings in human thoracic and lumbar facet joints. Spine. 1998 Jan 15. 23(2):168-73. [Medline].
Moore RJ, Crotti TN, Osti OL, et al. Osteoarthrosis of the facet joints resulting from anular rim lesions in sheep lumbar discs. Spine. 1999 Mar 15. 24(6):519-25. [Medline].
Nade S, Bell E, Wyke BD. The innervation of the lumbar spinal joints and its significance. J Bone Joint Surg Br. 1980. 62-B:253-61.
Pauza KJ. Nomenclature and terminology for spine specialists (appropriate words meant to replace the most commonly misused words of the spine specialists). Updated 2005. Physiatric Association of Spine, Sports and Occupational Rehabilitation. [Full Text].
Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine. 2002 Nov 15. 27(22):2538-45; discussion 2546. [Medline].
Sabers SR, Ross SR, Grogg BE, Lauder TD. Procedure-based nonsurgical management of lumbar zygapophyseal joint cyst-induced radicular pain. Arch Phys Med Rehabil. 2005 Sep. 86(9):1767-71. [Medline].
Shealy CN. Facet denervation in the management of back and sciatic pain. Clin Orthop Relat Res. 1976 Mar-Apr. 115:157-64. [Medline].
Yang KH, King AI. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine. 1984 Sep. 9(6):557-65. [Medline].