If your patients are having low back pain, it might be due to a number of factors, including lumbar facetogenic back pain. Facetogenic pain refers to discomfort that originates in the spine’s zygapophyseal joints.

Prevalence:

The prevalence of zygapophyseal joint pain has been estimated to be 15% of 76 (Schwarzer et al., 1994b) and 40% of 63 (Schwarzer et al., 1995b) chronic back pain patients. Another study found that 17% of 54 chronic back pain patients had their diagnosis confirmed (Moran et al., 1988). Pain from the lumbar zygapophyseal joints (ZJ) affects 15–40% of chronic low back pain patients, with an increasing frequency in older age groups (Schwarzer AC, et al., 1994; Manchikanti L, et al., 1992). The incidence of isolated ZJ-mediated back pain is predicted to be as low as 4% based on complete pain alleviation following controlled diagnostic blocks (Schwarzer AC et al. 1994).

Diagnosis: 

It is critical to distinguish between facetogenic and discogenic back pain. Discogenic pain is caused by the discs between the vertebrae, whereas facetogenic pain is caused by the tiny spinal joints. Only three patients out of 92 with chronic back pain exhibited positive discography and a favourable response to screening and confirmatory zygaphyseal joint block (Schwarzer, A., et al. 1994). The authors found that the combination of discogenic pain and zygapophyseal joint discomfort is uncommon in patients with chronic low back pain.

Noninvasive diagnosis of symptomatic ZJ joints remains challenging. Anaesthetic blockade of the LZJ affects only the LZJ; no other nerves or tissues are affected (Carragee E. and Hannibal M. 2004). However, investigations have demonstrated that blocking the actual painful site of pathology does not have to be done directly to provide subjective pain relief (Siddall P. and Cousins M. 1997; Kibler R. and Nathan P. 1960). There may also be complications with anaesthetic delivery and uptake by neighbouring structures (Saal J. 2002).

Revel M et al. (1998) discovered that a cluster of seven items (hence referred to as Revel’s criteria) were useful in predicting a 75% reduction in pain following a single intraarticular anaesthetic injection into the ZJs. Age over 65 years, discomfort well eased by recumbency, no worsening of pain with coughing and sneezing, forward flexion, extension, rising from flexion, and the extension-rotation test are the components in the cluster (Revel M. et al. 1998). These authors proposed two clinical approaches: Strategy 1 consists of at least five elements being true. Strategy 2 is the same as Strategy 1, but only one of the true claims must be ‘pain well eased by recumbency’. Sensitivities and specificities for methods 1 and 2 were estimated to be 100:92% and 66:80%, respectively. A follow-up investigation of 200 patients utilising double blocks failed to confirm these findings (Manchikanti L. et al. 2000).

According to the findings of a study conducted by Mark Laslett and his colleagues (2004), neither technique based on Revel’s criteria is adequate as a clinical screening device for selecting chronic LBP patients for initial diagnostic ZJ blocks. The latest data, in contrast to Revel’s findings, indicated low sensitivity and excellent specificity for these clinical criteria. The high specificity observed in this study is due to a single uncontrolled screening block. As a result, these criteria cannot be used to diagnose painful lumbar ZJ. Only placebo-controlled or double ZJ blocks can identify this cause of low back discomfort. However, in connection with a 75% reduction in pain following ZJ block, ‘no discomfort with cough and sneeze’ and ‘no worsening of pain increasing from flexion’ approached statistical significance.

Laslett and his colleagues (2006) conducted a study to determine clinical prediction guidelines for facetogenic back pain that can predict the outcome of screening blocks:

1. Centralization was absent following repeated movement tests.
2. The extension-external rotation test is negative.
3. Three or more of the following five clinical signs: age greater than 50, symptoms best walking, symptoms best sitting, paraspinal start pain, and positive extension or rotation test.

Clinical data can only predict positive ZJ blocks that treat the 95% pain reduction criteria. These traits are not diagnostic for zygaphyseal joint discomfort but rather suggest a patient who will respond to a zygaphyseal joint injection.

Treatment:

Back discomfort caused by ZJ can be addressed with:

 1- Intra-articular steroid injection (Bogduk N. and McGuirk B. 2002; Carette S. et al. 1991): Injections of local anaesthetic and steroids into the afflicted area can alleviate pain and inflammation.

2- Radiofrequency neurotomy (Dreyfuss P, et al. 2000; Dreyfuss PH, et al. 2003; Bogduk N, et al. 1995; Niemisto L, et al. 2003): This method employs electrical currents to heat and kill the nerve that transmits pain signals. Radiofrequency denervation (neurotomy) is an invasive procedure used to treat LZJ pain that may be more target-specific than controlled nerve blocks. 65 During this surgery, the LZJ’s nerve supply (the medial branches of the lumbar dorsal rami) is denervated, inhibiting pain generation from the LZJ for roughly 10.5 months.

Anecdotal research suggests that manual treatment has a significant effect when utilised in carefully selected cases with LZJ pain symptoms. However, there is little empirical data to back up this claim (Schofferman J. et al. 2009).

In a study including 60 patients with LBP originating from facet joints, Nedelka et al. (2014) examined the efficacy of facet joint corticosteroid injections, radiofrequency neurotomies, and extracorporeal shock wave therapy (ESWT). ESWT and radiofrequency neurotomy were found to be much more efficacious than corticosteroid injections.

Finally, I’d like to mention an uncommon condition known as “lumbar facet cysts”:

Lumbar facet cysts (LFCs) are uncommon, although they are becoming more recognised as a source of discomfort and neurologic impairment. They are known as juxtafacet cysts, cystic formations of the mobile spine, lumbar intraspinal facet cysts, synovial cysts, and pseudocysts in the spine literature.

L4-L5 (68%), L3-L4 (14%), and L5-S1 (12%) facet cysts are the most common (Bydon A. et al. 2010). The most prevalent symptom (70%) is radiculopathy, followed by low back pain (48%), sensory impairments (35%), neurogenic claudication (28%), and paresis (21%).

References

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