Acute Phase
Rehabilitation Program
Physical Therapy
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
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.
Other Treatment
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. [22] A systematic review by Bernardes et al found most of the 12 studies included in their analysis showed that radiofrequency ablation was effective in relieving chronic low back pain caused by lumbar facet syndrome after conservative treatments had failed. [23]
A study by Juch et al reviewed three randomized clinical trials that evaluated the effectiveness of radiofrequency denervation in 681 total patients with chronic low back pain and who were unresponsive to standard treatment (251 patients in the facet joint trial, 228 in the sacroiliac joint trial and 202 patients in a combination of facet joints, sacroiliac joints, or intervertebral disks trial). The study reported no clinically important improvements in patients from radiofrequency denervation combined with a standardized exercise program compared with a standardized exercise program alone. [24]
A retrospective study by Manchikanti et al that compared radiofrequency neurotomy with therapeutic lumbar facet joint nerve blocks demonstrated similar outcomes for the two treatments. From baseline to 12 months, patients in both treatment groups experienced significant improvement, which was defined as at least a 50% improvement in relief from pain. [25]
Recovery Phase
Rehabilitation Program
Physical Therapy
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. Bridges and planks are ideal exercises for this as they can be done in the neutral spine position with high muscle activation and relatively low spinal loads. McGill recommends work up to 1 rep at 60 sec holds to build the necessary endurance for optimum spine function. [26]
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. [27, 28, 29, 30, 31, 32] 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. [33, 34, 35] 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. [36]
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. However, recent guidelines from the NASS have noted that the risk of MI or stroke in stopping these medications is much greater than the risk of bleeding in the soft tissues of the lumbar spine. 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. [37] 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. [37] 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. [38, 39] Medial branch neurotomy through RFA has emerged as the standard therapy for facet-mediated low back pain. [21] 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 [33, 40, 41] ; 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.
Related Medscape Reference topics:
Maintenance Phase
Rehabilitation Program
Physical Therapy
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.
Other Treatment
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.
Return to Play and Prevention
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.
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.
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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.
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Mamillary process anatomy.
