Lumbosacral Facet Syndrome Follow-up: Return to Play, Complications, Prevention

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Follow-up

Return to Play

Athletes who demonstrate lumbosacral Z-joint pathology should remain out of their sport until they regain full, pain-free range of motion and are able to complete sport-specific training without discomfort. They should also have symmetrical flexibility and be able to maintain trunk control throughout sporting activities to prevent recurrence.

Complications

In some cases, lumbosacral facet syndrome can lead to chronic pain, time lost from employment or sports, and disability. Interventional procedures, such as Z-joint injections with anesthetics and corticosteroids, can lead to transient lower-extremity weakness, insomnia, headache, fluid and electrolyte disorders (especially in patients with congestive heart failure), GI upset, bone demineralization, and impaired glucose tolerance (patients with diabetes). Less common effects are mood swings, increased appetite, and, the most serious, adrenocortical insufficiency. Dural puncture can lead to infection and an increased incidence of headaches.

Prevention

Instruction should be provided to the patient on proper posture, activity modification, and body mechanics in activities of daily living and sports. This helps protect the injured joints, reduce symptoms, and prevent further injury. Positions that cause pain should be avoided.

Prognosis

With an active and focused spine rehabilitation program, the prognosis for these patients to achieve pain-free activity is good; however, the definitive diagnosis of Z-joint pathology is often difficult to make and challenging to confirm. For some patients, LBP may persist, and more aggressive interventions beyond conservative rehabilitation should be considered. Interventions such as medial branch blocks or neurolysis remain controversial, but they should be given consideration in the event conservative treatment remains inadequate and all other sources of LBP have been investigated.

Education

Patient education is important for the recovery and rehabilitation of the spine in patients with lumbosacral facet syndrome. In the acute stage, patients must have a good understanding of their condition and of the possible detrimental effects of prolonged bed rest (ie, >2 d). Instruction in proper posture and body mechanics with activities of daily living is very important for these individuals. As pain becomes more controlled, the patient must be active in a progressive spine rehabilitation program, which later should be incorporated into a home exercise program for continued functional strengthening. Back safety and joint protection strategies should be incorporated throughout the rehabilitation process.

Questions

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].
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.
Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br. 1954 May. 36-B(2):304-22. [Medline]. [Full Text].
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].
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].
Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA. 2017 Jul 4. 318 (1):68-81. [Medline].
McGill SM. Low back disorders: Evidence based prevention and rehabilitation. Third. Champaign, IL: Human Kinetics Publishers; 2002, 2016.
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. Management of chronic low back pain. Med J Aust. 2004 Jan 19. 180(2):79-83. [Medline]. [Full Text].
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].
Dunlop RB, Adams MA, Hutton WC. Disc space narrowing and the lumbar facet joints. J Bone Joint Surg Br. 1984 Nov. 66(5):706-10. [Medline]. [Full Text].
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].
Lilius G, Laasonen EM, Myllynen P, Harilainen A, Grönlund G. Lumbar facet joint syndrome. A randomised clinical trial. J Bone Joint Surg Br. 1989 Aug. 71(4):681-4. [Medline]. [Full Text].
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].
Schellinger D, Wener L, Ragsdale BD, Patronas NJ. Facet joint disorders and their role in the production of back pain and sciatica. Radiographics. 1987 Sep. 7(5):923-44. [Medline]. [Full Text].
Shealy CN. Facet denervation in the management of back and sciatic pain. Clin Orthop Relat Res. 1976 Mar-Apr. 115:157-64. [Medline].
Yamashita T, Cavanaugh JM, el-Bohy AA, Getchell TV, King AI. Mechanosensitive afferent units in the lumbar facet joint. J Bone Joint Surg Am. 1990 Jul. 72(6):865-70. [Medline]. [Full Text].
Yang KH, King AI. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine. 1984 Sep. 9(6):557-65. [Medline].
Alexander CE, Varacallo M. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan. [Full Text].

Media Gallery

Dorsal ramus innervation (medial and lateral branches). MAL23 = mamillo-accessory ligament bridging the mamillary and accessory processes of L2 and L3; Z-joint = zygapophyseal joint.
Mamillary process anatomy.

of 2

Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Coauthor(s)

Gary P Chimes, MD, PhD Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute of Rehabilitation, University of Medicine and Dentistry of New Jersey

Gary P Chimes, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Pietro Memmo, MD Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey

Pietro Memmo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American Medical Association

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.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lumbosacral Facet Syndrome Follow-up

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