Lumbar Facet Syndrome

Lumbar Facet Syndrome
Nikolai Bogduk
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There is no lumbar facet syndrome. A syndrome is a clinical
entity dened, and recognized, by a specic constellation of
clinical features. Reiters syndrome is dened by the combi-
nation of urethritis, uveitis, and spondylarthropathy. Tolosa-
Hunt syndrome is headache combined with palsy of one or
more of the third, fourth, and sixth cranial nerves.
No combination of clinical features denes lumbar facet
syndrome. Although some proponents had submitted that
aggravation of pain by certain movements of the back is
indicative of facet syndrome,
1,2
this has been refuted by
studies using controlled diagnostic blocks.
3-5
Even the most
recent study of Revel and associates
6
does not dene a facet
syndrome. Rather, the clinical tests used by these investiga-
tors serve to identify patients who do not have facet pain.
There is no syndrome. What patients have is lumbar
zygapophyseal joint pain. This is an entity dened, not by
clinical features, but by a specic source of pain. In many
circles it is a diagnosis that is rejected or disdained, but iron-
ically it is one of the best studied, and most strongly validated,
entities in the specialty of pain medicine. Those who deny
it either simply do not want to know or are unaware of the
literature and its strength.
Few, if any, other conditions in pain medicine satisfy the
following theoretical and practical criteria:
The pain has an anatomic basis.
The pain has been produced experimentally in normal
volunteers.
The pain can be diagnosed by a test that has been validated.
The test used to diagnose the condition protects normal
volunteers from experimentally induced versions of the
condition.
When tested, patients with the condition obtain complete
relief of their pain.
When diagnosed with the condition, patients can be treated.
When treated, patients obtain complete relief of pain.
When pain recurs, it can again be completely relieved.
ANATOMY
The lumbar zygapophyseal joints are formed by the superior
and inferior articular processes of consecutive lumbar verte-
bra (Fig. 841). Each joint is named according to the
segmental numbers of the vertebrae that form it. The joint
between L5 and the sacrum is known as the lumbosacral or
L5-S1 zygapophyseal joint. Each has the typical structure of
a synovial joint.
The joints are innervated by the medial branches of the
lumbar dorsal rami. Each joint receives articular branches
from the ipsisegmental medial branch and from the medial
branch above (see Fig. 841).
7,8
The joints, therefore, are
endowed with the necessary neurologic apparatus potentially
to be a source of pain.
A source of confusion arises in naming the nerves that
innervate each joint. The segmental numbers of the nerves are
one segment less than the name of the joint. Thus, the L4-5
joint is innervated by the L3,4 medial branches, and the
L5-S1 joint is innervated by the L4,5 nerves. As a matter of
discipline, for clarity in communication, practitioners should
take care, when referring to a segment, whether they are refer-
ring to the joint or to the nerves that innervate it. One device
is to use a hyphen (L4-5) when naming a joint, but a comma
(L4,5) when naming its nerves. A hyphen indicates conjunc-
tion and, therefore, a joint; a comma indicates consecutive
and, therefore, a pair of nerves.
EXPERIMENTALLY STIMULATED PAIN
IN NORMAL VOLUNTEERS
When lumbar zygapophyseal joints are stimulated experi-
mentally with a noxious stimulus, normal volunteers suffer
and describe pain that resembles that reported in patients with
low back pain. The experimental stimuli that have been used
include injections of hypertonic saline into the joints,
9,10
injec-
tions of contrast medium to distend the capsules of the joints,
11
and electrical stimulation of the nerves that innervate the
joints.
11,12
In all studies that have been conducted, noxious stimula-
tion of the zygapophyseal joints has produced low back pain
and some degree of referred pain. Studies have differed on
with respect to the distribution of referred pain (Fig. 842).
As a rule, the referred pain tends to radiate inferolaterally
from the site of stimulation. Pain from upper lumbar
zygapophyseal joints extends into the loin or toward the pos-
terior iliac crest from above. Pain from lower lumbar joints
extends across the iliac crest into the buttock.
The pattern of referred pain is segmental in nature, in so
far as pain from higher levels tends to be perceived in more
cephalad regions than is pain from lower levels, but the
pattern is not distinctive. Within and between studies, the
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zygapophyseal joint pain. This is an entity dened, not by zygapophyseal joint pain. This is an entity dened, not by
clinical features, but by a specic source of pain. In many clinical features, but by a specic source of pain. In many
circles it is a diagnosis that is rejected or disdained, but iron- circles it is a diagnosis that is rejected or disdained, but iron-
ically it is one of the best studied, and most strongly validated, ically it is one of the best studied, and most strongly validated,
entities in the specialty of pain medicine. Those who deny entities in the specialty of pain medicine. Those who deny
it either simply do not want to know or are unaware of the it either simply do not want to know or are unaware of the
Few, if any, other conditions in pain medicine satisfy the Few, if any, other conditions in pain medicine satisfy the
following theoretical and practical criteria: following theoretical and practical criteria:
The pain has an anatomic basis. The pain has an anatomic basis.
The pain has been produced experimentally in normal The pain has been produced experimentally in normal
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syndrome. Rather, the clinical tests used by these investiga- syndrome. Rather, the clinical tests used by these investiga-
tors serve to identify patients who do not have facet pain. tors serve to identify patients who do not have facet pain.
There is no syndrome. What patients have is lumbar There is no syndrome. What patients have is lumbar
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Even the most Even the most
does not dene a facet does not dene a facet
syndrome. Rather, the clinical tests used by these investiga- syndrome. Rather, the clinical tests used by these investiga-
from the ipsisegmental medial branch and from the medial from the ipsisegmental medial branch and from the medial
branch above (see Fig. 841). branch above (see Fig. 841).
endowed with the necessary neurologic apparatus potentially endowed with the necessary neurologic apparatus potentially
to be a source of pain. to be a source of pain.
A source of confusion arises in naming the nerves that A source of confusion arises in naming the nerves that
innervate each joint. The segmental numbers of the nerves are innervate each joint. The segmental numbers of the nerves are
one segment less than the name of the joint. Thus, the L4-5 one segment less than the name of the joint. Thus, the L4-5
joint is innervated by the L3,4 medial branches, and the joint is innervated by the L3,4 medial branches, and the
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Few, if any, other conditions in pain medicine satisfy the Few, if any, other conditions in pain medicine satisfy the
following theoretical and practical criteria: following theoretical and practical criteria:
The pain has an anatomic basis. The pain has an anatomic basis.
The pain has been produced experimentally in normal The pain has been produced experimentally in normal
The pain can be diagnosed by a test that has been validated. The pain can be diagnosed by a test that has been validated.
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There is no syndrome. What patients have is lumbar There is no syndrome. What patients have is lumbar
circles it is a diagnosis that is rejected or disdained, but iron- circles it is a diagnosis that is rejected or disdained, but iron-
ically it is one of the best studied, and most strongly validated, ically it is one of the best studied, and most strongly validated,
L5-S1 joint is innervated by the L4,5 nerves. As a matter of L5-S1 joint is innervated by the L4,5 nerves. As a matter of
discipline, for clarity in communication, practitioners should discipline, for clarity in communication, practitioners should
take care, when referring to a segment, whether they are refer- take care, when referring to a segment, whether they are refer-
ring to the joint or to the nerves that innervate it. One device ring to the joint or to the nerves that innervate it. One device
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L5-S1 joint is innervated by the L4,5 nerves. As a matter of L5-S1 joint is innervated by the L4,5 nerves. As a matter of
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A source of confusion arises in naming the nerves that A source of confusion arises in naming the nerves that
innervate each joint. The segmental numbers of the nerves are innervate each joint. The segmental numbers of the nerves are
one segment less than the name of the joint. Thus, the L4-5 one segment less than the name of the joint. Thus, the L4-5
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The joints are innervated by the medial branches of the The joints are innervated by the medial branches of the
lumbar dorsal rami. Each joint receives articular branches lumbar dorsal rami. Each joint receives articular branches
from the ipsisegmental medial branch and from the medial from the ipsisegmental medial branch and from the medial
branch above (see Fig. 841). branch above (see Fig. 841).
L1-2
L4-5
L2
L3
L4
L5
A B C
FIGURE 842 Maps of referred
pain patterns elicited from the lumbar
zygapophyseal joints in normal volun-
teers. A, After injection of hypertonic
saline into the lower lumbar joints,
segments not specied. B, After injec-
tion of hypertonic saline into the L1-2
and L4-5 joints. C, After electrical
stimulation of the medial branches at
the segments indicated.
Medial branch of
dorsal ramus
Superior
articular process
Zygapophysial joint
Inferior articular process
FIGURE 841 Diagram of posterior view of lumbar segment showing
the structure and innervation of the zygapophyseal joints. The zygapophy-
seal joint is formed by the adjacent superior articular process and inferior
articular process. Each is innervated by articular branches from the medial
branch (mb) of the same segment and the one above.
distribution of pain from particular segments overlaps with
the distribution of pain from adjacent and lower segments.
Consequently, the location of referred pain cannot be used
reliably to infer the exact location of its source. Although not
quantied, it has been noted qualitatively that the distance of
referral appears to be proportional to the intensity of stimula-
tion. When stronger, noxious stimuli are applied the referred
pain spreads further.
9
Also not rigorously studied, but noted in one study,
experimentally induced referred pain from the lumbar
zygapophyseal joints can be associated with increased elec-
tromyographic activity in the hamstring muscles.
9
This is in
accord with the more general observation that pain from struc-
tures innervated by the lumbar dorsal rami can be accompa-
nied by involuntary activity in muscles of the lower limb.
13
DIAGNOSTIC BLOCKS
Pain from a lumbar zygapophyseal joint can be relieved
temporarily by anesthetizing the joint. This can be done by
injecting local anesthetic into the cavity of the joint or by
anesthetizing the medial branches that innervate the joint.
Intraarticular blocks constitute a direct test of zygapo-
physeal joint pain and were originally promoted in ortho-
pedic and radiologic circles.
14-30
Intraarticular blocks have
face validity, in that it can be shown, by injecting contrast
medium into the joint, that the local anesthetic accurately and
exclusively targets the joint. However, although still used,
intraarticular blocks have not been validated further. In par-
ticular, they have not been subjected to controls and have not
been shown to have predictive validity or therapeutic utility.
Provocation of pain during injection of a joint is not diag-
nostic of the joint being painful. Provocation is not associated
with subsequent relief when the joint is anesthetized.
31
In contrast, medial branch blocks have been extensively
tested. They involve injecting a tiny amount of local anes-
thetic (0.3 mL), under uoroscopic control, onto each of the
medial branches that innervate the target joint. The blocks
require a preliminary test dose of contrast medium, because
in about 8% of cases the injection can be into the vena comi-
tans of the medial branch. Venous uptake is not a complica-
tion, given the small volume of local anesthetic injected, but
it risks obtaining a false-negative response.
The face-validity of lumbar medial branch blocks has
been established. Provided that correct target points are used,
770 Section 4 REGIONAL PAIN SYNDROMES
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seal joint is formed by the adjacent superior articular process and inferior seal joint is formed by the adjacent superior articular process and inferior
articular process. Each is innervated by articular branches from the medial articular process. Each is innervated by articular branches from the medial
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Diagram of posterior view of lumbar segment showing Diagram of posterior view of lumbar segment showing Diagram of posterior view of lumbar segment showing
the structure and innervation of the zygapophyseal joints. The zygapophy- the structure and innervation of the zygapophyseal joints. The zygapophy-
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Inferior articular process
Provocation of pain during injection of a joint is not diag- Provocation of pain during injection of a joint is not diag-
nostic of the joint being painful. Provocation is not associated nostic of the joint being painful. Provocation is not associated
with subsequent relief when the joint is anesthetized. with subsequent relief when the joint is anesthetized.
In contrast, medial branch blocks have been extensively In contrast, medial branch blocks have been extensively
tested. They involve injecting a tiny amount of local anes- tested. They involve injecting a tiny amount of local anes-
thetic (0.3 mL), under uoroscopic control, onto each of the thetic (0.3 mL), under uoroscopic control, onto each of the
medial branches that innervate the target joint. The blocks medial branches that innervate the target joint. The blocks
require a preliminary test dose of contrast medium, because require a preliminary test dose of contrast medium, because
in about 8% of cases the injection can be into the vena comi- in about 8% of cases the injection can be into the vena comi-
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tans of the medial branch. Venous uptake is not a complica- tans of the medial branch. Venous uptake is not a complica-
tion, given the small volume of local anesthetic injected, but tion, given the small volume of local anesthetic injected, but
it risks obtaining a false-negative response. it risks obtaining a false-negative response.
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tested. They involve injecting a tiny amount of local anes- tested. They involve injecting a tiny amount of local anes-
thetic (0.3 mL), under uoroscopic control, onto each of the thetic (0.3 mL), under uoroscopic control, onto each of the
medial branches that innervate the target joint. The blocks medial branches that innervate the target joint. The blocks
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ticular, they have not been subjected to controls and have not ticular, they have not been subjected to controls and have not
been shown to have predictive validity or therapeutic utility. been shown to have predictive validity or therapeutic utility.
Provocation of pain during injection of a joint is not diag- Provocation of pain during injection of a joint is not diag-
nostic of the joint being painful. Provocation is not associated nostic of the joint being painful. Provocation is not associated
with subsequent relief when the joint is anesthetized. with subsequent relief when the joint is anesthetized.
the local anesthetic covers the target nerve and does not
spread to affect other structures that might be alternative
sources of pain. The correct target point lies midway between
two points
32
: the notch between the superior articular process
and the transverse process, where the medial branch enters the
posterior compartment of the spine, and the mammilloacces-
sory notch, where it hooks medially beneath the mammil-
loaccessory ligament (Fig. 843).
33
If deposited here, local
anesthetic surrounds the nerve reliably. It may spread dorsally
into the cleavage plane between the multidus and longis-
simus lumborum or between fascicles of the multidus at
lower lumbar levels, but it does not indiscriminately anes-
thetize the back muscles. Target points more rostral on the
transverse process risk some of the local anesthetic spreading
to the intervertebral foramen where, theoretically, it might
affect the spinal nerve and compromise the specicity of the
block. Pointing the bevel of the needle caudad guards against
this direction of spread.
The L5 medial branch cannot be selectively anesthetized.
At this segmental level the target nerve is the L5 dorsal ramus
itself, which runs over the ala of the sacrum. The target point
is nevertheless analogous to that at typical lumbar levels. It
lies opposite the middle of the base of the superior articular
process of S1. Placing the needle further rostrad risks ow of
injectate to the L5-S1 intervertebral foramen. Placing it more
caudad risks ow to the S1 posterior foramen.
The face validity of medial branch blocks was established
by stimulating the lumbar zygapophyseal joints, in normal
volunteers, with injections of hypertonic saline, before and after
medial branch blocks of the target joint. Medial branch blocks
protect volunteers from experimentally induced zygapo-
physeal joint pain.
34
Single, uncontrolled blocks of lumbar medial branches
are not valid. They have a false-positive rate of between 25%
and 41%.
35-37
This means that if the prevalence of lumbar
zygapophyseal joint pain is 15% (see later), for every three
blocks that appear to be positive, two will be false positive.
If the prevalence is 40%, three of every ve blocks will be
false positive. Such yields of false-positive results are unac-
ceptable and underscore the necessity for every block to
be subjected to controls. Two types of controls are available:
placebo controls and comparative blocks.
Placebo controls provide the highest order of validity, but
they are difcult to implement in practice. Blocks would need
to be performed on three separate occasions. A rst block is
required to establish that the target joint is, indeed, sympto-
matic. Thereafter, the second block cannot automatically be a
placebo, because mischievous patients would know that the
second agent is the sham. For the second block, the patient
must randomly receive either an active agent or a placebo. For
the third block, the patient receives the complementary agent.
Less discriminating, but more practical are comparative
local anesthetic blocks.
38,39
On each of two occasions the
patient receives an active agent, but the agents are varied.
When a short-acting agent is used, the patient should obtain
short-lasting relief. When a long-acting agent is used, the
patient should obtain longer-lasting relief. When tested
against placebo, this protocol has a sensitivity of 54% and
a specicity of 88%.
39
That means that when comparative
blocks are positive, the patient is very likely to have genuine
zygapophyseal joint pain but the protocol fails to detect all
genuine patients. If the criteria are relaxed to count as posi-
tive all patients who obtain complete relief of their pain, irre-
spective of duration of relief, the sensitivity rises to 80% but
the specicity drops to 55%. This means that more patients
who have zygapophyseal joint pain will be detected but not
all positive responses will be truly positive.
Some practitioners, and some insurers, object to con-
trolled blocks. Mistaken, or misguided, they believe that they
can diagnose zygapophyseal joint pain with a single block and
that controlled blocks simply increase costs. This attitude
overlooks the cost of false-positive responses. If only single
Chapter 84 Lumbar Facet Syndrome 771
FIGURE 843 Lumbar medial branch blocks. A, At typical segmental levels (L1-L5), the target point lies on the nerve midway between the notch between
the superior articular process (sap) and the transverse process (tp), and where the nerve hooks medially under the mammilloaccessory ligament. At L5, a homol-
ogous point applies lateral to the superior articular process. The numbering of the nerves (white) is one less than their respective vertebrae (black). B, Oblique
view of a needle in position on for an L4 medial branch block. C, Anteroposterior view of a needle in position for an L5 dorsal ramus block.
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sory notch, where it hooks medially beneath the mammil- sory notch, where it hooks medially beneath the mammil-
If deposited here, local If deposited here, local
anesthetic surrounds the nerve reliably. It may spread dorsally anesthetic surrounds the nerve reliably. It may spread dorsally
into the cleavage plane between the multidus and longis- into the cleavage plane between the multidus and longis-
simus lumborum or between fascicles of the multidus at simus lumborum or between fascicles of the multidus at
lower lumbar levels, but it does not indiscriminately anes- lower lumbar levels, but it does not indiscriminately anes-
thetize the back muscles. Target points more rostral on the thetize the back muscles. Target points more rostral on the
transverse process risk some of the local anesthetic spreading transverse process risk some of the local anesthetic spreading
to the intervertebral foramen where, theoretically, it might to the intervertebral foramen where, theoretically, it might
affect the spinal nerve and compromise the specicity of the affect the spinal nerve and compromise the specicity of the
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: the notch between the superior articular process : the notch between the superior articular process
and the transverse process, where the medial branch enters the and the transverse process, where the medial branch enters the
posterior compartment of the spine, and the mammilloacces- posterior compartment of the spine, and the mammilloacces-
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spread to affect other structures that might be alternative spread to affect other structures that might be alternative
sources of pain. The correct target point lies midway between sources of pain. The correct target point lies midway between
: the notch between the superior articular process : the notch between the superior articular process
blocks that appear to be positive, two will be false positive. blocks that appear to be positive, two will be false positive.
If the prevalence is 40%, three of every ve blocks will be If the prevalence is 40%, three of every ve blocks will be
the superior articular process (sap) and the transverse process (tp), and where the nerve hooks medially under the mammilloaccessory ligament. At L5, a homol- the superior articular process (sap) and the transverse process (tp), and where the nerve hooks medially under the mammilloaccessory ligament. At L5, a homol-
(white) (white) is one less than their respective vertebrae is one less than their respective vertebrae
Anteroposterior view of a needle in position for an L5 dorsal ramus block. Anteroposterior view of a needle in position for an L5 dorsal ramus block.
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lower lumbar levels, but it does not indiscriminately anes- lower lumbar levels, but it does not indiscriminately anes-
thetize the back muscles. Target points more rostral on the thetize the back muscles. Target points more rostral on the
transverse process risk some of the local anesthetic spreading transverse process risk some of the local anesthetic spreading
to the intervertebral foramen where, theoretically, it might to the intervertebral foramen where, theoretically, it might
affect the spinal nerve and compromise the specicity of the affect the spinal nerve and compromise the specicity of the
block. Pointing the bevel of the needle caudad guards against block. Pointing the bevel of the needle caudad guards against
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posterior compartment of the spine, and the mammilloacces- posterior compartment of the spine, and the mammilloacces-
If deposited here, local If deposited here, local
anesthetic surrounds the nerve reliably. It may spread dorsally anesthetic surrounds the nerve reliably. It may spread dorsally
into the cleavage plane between the multidus and longis- into the cleavage plane between the multidus and longis-
false positive. Such yields of false-positive results are unac- false positive. Such yields of false-positive results are unac-
ceptable and underscore the necessity for every block to ceptable and underscore the necessity for every block to
be subjected to controls. Two types of controls are available: be subjected to controls. Two types of controls are available:
placebo controls and comparative blocks. placebo controls and comparative blocks.
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false positive. Such yields of false-positive results are unac- false positive. Such yields of false-positive results are unac-
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blocks that appear to be positive, two will be false positive. blocks that appear to be positive, two will be false positive.
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At typical segmental levels (L1-L5), the target point lies on the nerve midway between the notch between At typical segmental levels (L1-L5), the target point lies on the nerve midway between the notch between
the superior articular process (sap) and the transverse process (tp), and where the nerve hooks medially under the mammilloaccessory ligament. At L5, a homol- the superior articular process (sap) and the transverse process (tp), and where the nerve hooks medially under the mammilloaccessory ligament. At L5, a homol-
is one less than their respective vertebrae is one less than their respective vertebrae
Anteroposterior view of a needle in position for an L5 dorsal ramus block. Anteroposterior view of a needle in position for an L5 dorsal ramus block.
blocks are used, the diagnosis will be false in over 60% of
cases and all subsequent decisions about these patients will
be founded on a false premise. Cost-saving pays for diagnos-
tic noise and therapeutic failure. Meanwhile an economics
study has shown that, even at modest rates of reimbursement,
controlled blocks are cost effective.
40
CLINICAL PRESENTATION
There are no diagnostic clinical features of lumbar zygapo-
physeal joint pain. The patient has lumbar spinal pain and
may have somatic referred pain into the lower limb. Most
often the pain is referred only to the region of the buttock or
proximal thigh, but it can extend beyond the knee and even
into the foot. It is not true that pain below the knee is always
sciatica. Pain distal to the knee has successfully been relieved,
in some patients, by anesthetizing lower lumbar zygapophy-
seal joints.
9,21
No associated features, however, are unique to lumbar
zygapophyseal joint pain. Aggravation of pain by any move-
ments or by any applied, clinical maneuver does not distin-
guish lumbar zygapophyseal joint pain from pain stemming
from other sources.
3-5,41
This should not be surprising. All the elements of the
lumbar spine share a similar segmental innervation. There-
fore, the symptoms that they produce should be similar. No
movement selectively stresses just the zygapophyseal joints.
The disk will also be stressed by movement, along with liga-
ments and muscles. Therefore, all sources of pain should be
aggravated in a similar manner by movement.
Yet, this lack of distinctive clinical features is not an
indictment of the condition. Demands for there to be a dis-
tinctive clinical syndrome are based on the cynical and arti-
cial expectation that all disorders in the specialty of pain
medicine must have distinctive features and that if they do not
they cannot exist. Elsewhere in other medicine specialties
conditions abound that do not constitute distinctive clinical
syndromes. Most causes of chest pain cannot be diagnosed
unless and until investigations such as radiography are per-
formed. Most causes of abdominal pain are not distinctive
until imaging, laboratory tests, ultrasound, or endoscopy is
performed. For lumbar zygapophyseal joint pain, the deni-
tive test is the use of controlled, diagnostic blocks.
Revel and colleagues
6
identied ve features that were
signicantly associated with zygapophyseal joint pain: (1)
pain not worsened when rising from forward exion; (2) pain
well relieved by recumbency; (3) pain not exacerbated by
coughing; (4) pain not worsened by extension-rotation; and
(5) pain not worsened by hyperextension. Four of these ve
features are negative in nature. They refer to pain not being
aggravated. In practice, these features serve more to identify
patients who do not have zygapophyseal joint pain than to
diagnose those who do.
Patients with zygapophyseal joint pain are typically pos-
itive to all ve of the features that Revel and colleagues
describe,
6
but so, too, are 34% of patients who do not have
zygapophyseal joint pain. As long as patients who do not have
zygapophyseal joint pain outnumber those who do, the diag-
nostic value of Revels tests is limited.
42
If the pretest preva-
lence of zygapophyseal joint pain is 10%, the posttest
diagnostic condence rises only 25%.
42
If the pretest preva-
lence is 40%, the posttest diagnostic condence increases to
only 66%. Thus, Revels features do not provide for a de-
nite diagnosis. By eliminating those patients who are unlikely
to have zygapophyseal joint pain, they serve to increase the
chances that those who remain do have zygapophyseal joint
pain, but the low prevalence of zygapophyseal joint pain
means that many or most of those who are positive to the tests
will, nevertheless, still not have zygapophyseal joint pain.
PREVALENCE
By using controlled diagnostic blocks, multiple studies have
established that lumbar zygapophyseal joint pain is common.
Its actual prevalence varies according to the population
studied but is not negligible.
Among injured workers, with a median age of 38 years,
the prevalence was found to be 15% (95% condence inter-
val [CI]: 10% to 20%).
4
In an older population, without a
history of trauma, it was found to be 40% (CI: 27% to 53%).
5
A similar prevalence (45%; CI: 39% to 54%) was found in a
heterogeneous population attending a pain clinic.
36
These gures, however, may constitute an overestimate,
because the studies often used a generous criterion for a pos-
itive response to blocks. They considered positive anyone
who had greater than 50% relief of pain. This falls short
of 100% relief, which would be more compelling evidence
that the zygapophyseal joint tested was the sole source of
pain. Nevertheless, one study did provide data in this regard.
When the criterion was 50% relief of pain, the prevalence of
zygapophyseal joint pain was 40%. When the criterion was
90% relief, the prevalence decreased to 32%.
5
Thus, although
the prevalence decreases when the diagnostic criteria are
more stringent, the prevalence does not evaporate. It remains
substantial.
PATHOLOGY
The pathology that causes lumbar zygapophyseal joints to be
painful is not known. Lumbar zygapophyseal joint pain is an
entity whose source can be established but whose pathology
remains elusive.
Although evident as a pathology of the lumbar zyga-
pophyseal joints,
43,44
osteoarthrosis cannot be blamed. The
radiologic features of osteoarthrosis, as seen radiographi-
cally,
45,46
or on computed tomography,
47
do not correlate with
whether the affected joint is painful or not. Osteoarthrosis is
a normal age change and does not constitute a basis for
zygapophyseal joint pain.
At post-mortem examination, it has been shown that the
lumbar zygapophyseal joints can sustain small fractures that
are not evident in radiographs.
48,49
In principle, such lesions
could be construed as likely causes of pain. Such lesions have
been detected in living individuals, using stereoradiography,
50
but they have not been pursued with CT or other imaging tests
and have not been correlated with zygapophyseal joint pain.
Rare disorders that can affect the lumbar zygapophyseal
joints are rheumatoid arthritis,
51
infection,
52-55
and pigmented
villonodular synovitis.
56,57
These conditions, however, do not
explain the large numbers of patients whose pain is relieved
when their zygapophyseal joints are anesthetized.
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indictment of the condition. Demands for there to be a dis- indictment of the condition. Demands for there to be a dis-
tinctive clinical syndrome are based on the cynical and arti- tinctive clinical syndrome are based on the cynical and arti-
cial expectation that all disorders in the specialty of pain cial expectation that all disorders in the specialty of pain
medicine must have distinctive features and that if they do not medicine must have distinctive features and that if they do not
they cannot exist. Elsewhere in other medicine specialties they cannot exist. Elsewhere in other medicine specialties
conditions abound that do not constitute distinctive clinical conditions abound that do not constitute distinctive clinical
syndromes. Most causes of chest pain cannot be diagnosed syndromes. Most causes of chest pain cannot be diagnosed
unless and until investigations such as radiography are per- unless and until investigations such as radiography are per-
formed. Most causes of abdominal pain are not distinctive formed. Most causes of abdominal pain are not distinctive
until imaging, laboratory tests, ultrasound, or endoscopy is until imaging, laboratory tests, ultrasound, or endoscopy is
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ments and muscles. Therefore, all sources of pain should be ments and muscles. Therefore, all sources of pain should be
Yet, this lack of distinctive clinical features is not an Yet, this lack of distinctive clinical features is not an
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The disk will also be stressed by movement, along with liga- The disk will also be stressed by movement, along with liga-
ments and muscles. Therefore, all sources of pain should be ments and muscles. Therefore, all sources of pain should be
A similar prevalence (45%; CI: 39% to 54%) was found in a A similar prevalence (45%; CI: 39% to 54%) was found in a
heterogeneous population attending a pain clinic. heterogeneous population attending a pain clinic.
These gures, however, may constitute an overestimate, These gures, however, may constitute an overestimate,
because the studies often used a generous criterion for a pos- because the studies often used a generous criterion for a pos-
itive response to blocks. They considered positive anyone itive response to blocks. They considered positive anyone
who had greater than 50% relief of pain. This falls short who had greater than 50% relief of pain. This falls short
of 100% relief, which would be more compelling evidence of 100% relief, which would be more compelling evidence
that the zygapophyseal joint tested was the sole source of that the zygapophyseal joint tested was the sole source of
pain. Nevertheless, one study did provide data in this regard. pain. Nevertheless, one study did provide data in this regard.
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conditions abound that do not constitute distinctive clinical conditions abound that do not constitute distinctive clinical
syndromes. Most causes of chest pain cannot be diagnosed syndromes. Most causes of chest pain cannot be diagnosed
unless and until investigations such as radiography are per- unless and until investigations such as radiography are per-
formed. Most causes of abdominal pain are not distinctive formed. Most causes of abdominal pain are not distinctive
until imaging, laboratory tests, ultrasound, or endoscopy is until imaging, laboratory tests, ultrasound, or endoscopy is
performed. For lumbar zygapophyseal joint pain, the deni- performed. For lumbar zygapophyseal joint pain, the deni-
tive test is the use of controlled, diagnostic blocks. tive test is the use of controlled, diagnostic blocks.
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tinctive clinical syndrome are based on the cynical and arti- tinctive clinical syndrome are based on the cynical and arti-
cial expectation that all disorders in the specialty of pain cial expectation that all disorders in the specialty of pain
medicine must have distinctive features and that if they do not medicine must have distinctive features and that if they do not
When the criterion was 50% relief of pain, the prevalence of When the criterion was 50% relief of pain, the prevalence of
zygapophyseal joint pain was 40%. When the criterion was zygapophyseal joint pain was 40%. When the criterion was
90% relief, the prevalence decreased to 32%. 90% relief, the prevalence decreased to 32%.
the prevalence decreases when the diagnostic criteria are the prevalence decreases when the diagnostic criteria are
-

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itive response to blocks. They considered positive anyone itive response to blocks. They considered positive anyone
who had greater than 50% relief of pain. This falls short who had greater than 50% relief of pain. This falls short
of 100% relief, which would be more compelling evidence of 100% relief, which would be more compelling evidence
F
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In an older population, without a In an older population, without a
history of trauma, it was found to be 40% (CI: 27% to 53%). history of trauma, it was found to be 40% (CI: 27% to 53%).
A similar prevalence (45%; CI: 39% to 54%) was found in a A similar prevalence (45%; CI: 39% to 54%) was found in a
heterogeneous population attending a pain clinic. heterogeneous population attending a pain clinic.
These gures, however, may constitute an overestimate, These gures, however, may constitute an overestimate,
TREATMENT
Although readily diagnosed, lumbar zygapophyseal joint pain
is not easily treated. Few treatments explicitly for diagnosed
lumbar zygapophyseal joint pain have been tested let alone
validated. There is no evidence that conservative therapies of
any kind relieve zygapophyseal joint pain. There is no evi-
dence that fusing a segment relieves zygapophyseal joint
pain. The tested treatments are limited to minimally invasive
procedures.
Intraarticular Corticosteroids
Perhaps the most prolic treatment for lumbar zygapophyseal
joint is intraarticular injection of corticosteroids.
14-18,23-30
This
treatment has a chequered past and a vexatious future.
There is no rationale for the intraarticular use of corti-
costeroids. There is no evidence that lumbar zygapophyseal
joint pain is caused by inammation. Corticosteroids were
adopted for zygapophyseal joint pain simply on the strength
that they appeared to be effective when used for osteoarthri-
tis in joints of the limbs.
An abundance of descriptive and observational studies
underlies the use of intraarticular corticosteroids for lumbar
zygapophyseal joint pain.
14-18,23-30
In none of these studies was
injection of corticosteroids tested in patients with proven
zygapophyseal joint pain. Corticosteroids were injected pre-
sumptively and without controls. The reported success rates
are, therefore, meaningless.
If a diagnosis of zygapophyseal joint pain has not been
made, the injection of corticosteroids into a joint is indis-
criminate. If corticosteroids do have a specic therapeutic
effect, they will work, under those circumstances, only in
those patients who happen to have zygapophyseal joint pain
and in whom the correct joint was fortuitously injected. Thus,
the success rate would be a measure of the prevalence of
zygapophyseal joint pain in the sample studied. If this is low,
the success rate will appear to be low. Conversely, given the
low prevalence of zygapophyseal joint pain, success rates of
80% are patently absurd, for they mean that patients had a
therapeutic response when they were treated for a source of
pain that they did not have.
Both of these arguments are confounded by the lack of
controls. Without controls, consumers cannot know if the
reported efcacy of intraarticular corticosteroids represents a
genuine attributable effect or a placebo effect.
Lumbar intraarticular corticosteroids have not been sub-
jected to a proper controlled trial. All trials, to date, that have
used controls have carried fatal aws.
Laudably, the studies of Lilius and associates
58-60
com-
pared the efcacy of corticosteroids with that of normal
saline. Those studies, however, treated unselected patients.
Diagnostic blocks were not performed. No steps were taken
to ensure that the patients had zygapophyseal joint pain.
Therefore, the studies are not a test of the efcacy of intra-
articular corticosteroids for zygapophyseal joint pain. What
they do prove, however, is that indiscriminate injection of cor-
ticosteroids in patients with back pain is patently ineffective.
The most rigorous study to date has been that of Carette
and colleagues,
61
who found that corticosteroids had no
attributable effect beyond that of injection of normal saline.
They did preselect their patients, but they used liberal diag-
nostic criteria. They enrolled patients who obtained at least
50% relief of pain after a single diagnostic block. Under these
conditions, it is highly likely that patients were enrolled who
did not have zygapophyseal joint pain or whose pain did not
exclusively arise in their zygapophyseal joints.
Proponents of intraarticular corticosteroids have seized
on this aw and have argued that the Carette and colleagues
study did not discredit intraarticular corticosteroids, that in
patients who really do have zygapophyseal joint pain, corti-
costeroids work better than demonstrated by Carette and col-
leagues.
61
Indeed, this study does not disprove this contention,
but critics have not revealed whether their practice is more
disciplined than that of Carette and colleagues.
61
No advo-
cates of intraarticular corticosteroids have demonstrated that
patients were selected by controlled diagnostic blocks and
thereafter obtained good outcomes when corticosteroids were
injected.
18,23-26
They simply proselytize that corticosteroids
work. Unless diagnostic blocks are used, the results of Lilius
and associates apply.
58-60
When injected simply for back pain,
intraarticular corticosteroids do not work.
Radiofrequency Neurotomy
Radiofrequency neurotomy is a procedure in which pain from
a zygapophyseal joint can be relieved by coagulating, percu-
taneously, the nerves that innervate the joint. It, too, is a
treatment with a checkered past.
It was originally described as facet denervation,
62-66
and
astounding results were claimed for it.
67-82
But anatomic
studies showed that there were no nerves where the electrode
was placed.
83,84
Yet, this did not dissuade some operators who
continued to use the discredited technique,
85,86
even in con-
trolled trials.
87
Anatomic studies showed that the articular branches to
the zygapophyseal joints could not be selectively coagulated,
but their parent nerves, the medial branches of the dorsal
rami, could be.
83,84
Because these nerves ran a constant course
across the root of the transverse process at each segmental
level, electrodes placed on that bony landmark could be relied
on to incur the target nerve. These realizations converted the
procedure from facet denervation to lumbar medial branch
neurotomy.
83,84
By using the modied surgical anatomy, some studies
claimed good success.
88,89
But even that technique was awed.
A laboratory study showed that electrodes do not coagulate
distally from their tip.
90
Therefore, an electrode placed per-
pendicular to the course of the nerve would not reliably co-
agulate it. The electrodes coagulate circumferentially, that is,
sideways. Therefore, to coagulate the nerve, the electrode
must be placed parallel to it.
This explanation has not been heeded. Operators
still insist on placing electrodes perpendicular or semi-
perpendicular to the target nerve, in the manner in which
block needles are introduced onto the nerve.
91-94
Doing so
limits the chances of coagulating the nerve thoroughly. If
the nerve is incompletely coagulated, relief of pain may not
occur. If only a short length of nerve is coagulated, relief of
pain may be only brief in duration. Accurate technique is
paramount.
One controlled study used an invalid technique.
91
It found
that active treatment was not more effective than sham treat-
ment. Indeed, the results of active treatment were worse than
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effect, they will work, under those circumstances, only in effect, they will work, under those circumstances, only in
those patients who happen to have zygapophyseal joint pain those patients who happen to have zygapophyseal joint pain
and in whom the correct joint was fortuitously injected. Thus, and in whom the correct joint was fortuitously injected. Thus,
the success rate would be a measure of the prevalence of the success rate would be a measure of the prevalence of
zygapophyseal joint pain in the sample studied. If this is low, zygapophyseal joint pain in the sample studied. If this is low,
the success rate will appear to be low. Conversely, given the the success rate will appear to be low. Conversely, given the
low prevalence of zygapophyseal joint pain, success rates of low prevalence of zygapophyseal joint pain, success rates of
80% are patently absurd, for they mean that patients had a 80% are patently absurd, for they mean that patients had a
therapeutic response when they were treated for a source of therapeutic response when they were treated for a source of
pain that they did not have. pain that they did not have.
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If a diagnosis of zygapophyseal joint pain has not been If a diagnosis of zygapophyseal joint pain has not been
made, the injection of corticosteroids into a joint is indis- made, the injection of corticosteroids into a joint is indis-
criminate. If corticosteroids do have a specic therapeutic criminate. If corticosteroids do have a specic therapeutic
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sumptively and without controls. The reported success rates sumptively and without controls. The reported success rates
If a diagnosis of zygapophyseal joint pain has not been If a diagnosis of zygapophyseal joint pain has not been
Radiofrequency Neurotomy Radiofrequency Neurotomy
Radiofrequency neurotomy is a procedure in which pain from Radiofrequency neurotomy is a procedure in which pain from
a zygapophyseal joint can be relieved by coagulating, percu- a zygapophyseal joint can be relieved by coagulating, percu-
taneously, the nerves that innervate the joint. It, too, is a taneously, the nerves that innervate the joint. It, too, is a
treatment with a checkered past. treatment with a checkered past.
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the success rate will appear to be low. Conversely, given the the success rate will appear to be low. Conversely, given the
low prevalence of zygapophyseal joint pain, success rates of low prevalence of zygapophyseal joint pain, success rates of
80% are patently absurd, for they mean that patients had a 80% are patently absurd, for they mean that patients had a
therapeutic response when they were treated for a source of therapeutic response when they were treated for a source of
Both of these arguments are confounded by the lack of Both of these arguments are confounded by the lack of
controls. Without controls, consumers cannot know if the controls. Without controls, consumers cannot know if the
C
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E
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criminate. If corticosteroids do have a specic therapeutic criminate. If corticosteroids do have a specic therapeutic
those patients who happen to have zygapophyseal joint pain those patients who happen to have zygapophyseal joint pain
and in whom the correct joint was fortuitously injected. Thus, and in whom the correct joint was fortuitously injected. Thus,
the success rate would be a measure of the prevalence of the success rate would be a measure of the prevalence of
astounding results were claimed for it. astounding results were claimed for it.
studies showed that there were no nerves where the electrode studies showed that there were no nerves where the electrode
was placed. was placed.
continued to use the discredited technique, continued to use the discredited technique,
-

It was originally described as facet denervation, It was originally described as facet denervation,
astounding results were claimed for it. astounding results were claimed for it.
N
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a zygapophyseal joint can be relieved by coagulating, percu- a zygapophyseal joint can be relieved by coagulating, percu-
taneously, the nerves that innervate the joint. It, too, is a taneously, the nerves that innervate the joint. It, too, is a
treatment with a checkered past. treatment with a checkered past.
It was originally described as facet denervation, It was originally described as facet denervation,
F
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When injected simply for back pain, When injected simply for back pain,
intraarticular corticosteroids do not work. intraarticular corticosteroids do not work.
Radiofrequency Neurotomy Radiofrequency Neurotomy
those of sham treatment. More signicantly, however, no
patient obtained any appreciable relief. This result is not sur-
prising given the operative technique used. In effect, this
study compared one sham against another and did not consti-
tute a valid test of lumbar medial branch neurotomy.
Another controlled study used a suboptimal technique but
fortuitously was able to obtain short-lasting results.
95
It was
not a proper test of how well medial branch neurotomy works
or can work, but it did show convincingly that the effects were
not due to placebo.
Only one published study has used an anatomically
correct technique in correctly selected patients (Fig. 844).
96
It establishes the benchmark of how effective lumbar medial
branch neurotomy can be. All patients had to have near-com-
plete relief of pain after diagnostic blocks on two occasions.
All were treated with the electrode placed parallel to the target
nerve. Postoperative electromyography proved that the nerves
had been coagulated. At 12 months follow-up some 80% of
patients still had at least 60% relief of their pain and some
60% of patients still had 80% relief.
For lumbar medial branch neurotomy to work, the
patients must have zygapophyseal joint pain. The procedure
is not indicated simply for undiagnosed back pain. Patients
must obtain complete, or near complete, relief of their pain
when the medial branches of the target joint are anesthetized.
Moreover, the diagnostic blocks must be controlled.
For lumbar medial branch neurotomy to work, correct
technique must be used. Placing electrodes perpendicular to
the target nerves risks not coagulating the nerve or coagulat-
ing it only partially. If the nerve is missed, no relief will occur.
If the nerve is only partially coagulated, partial relief will
occur. If only a limited length of nerve is coagulated, the dura-
tion of relief will be limited. For optimal and lasting results,
the electrode must be placed parallel to the nerve.
Medial branch neurotomy is not a permanent cure. The
nerve coagulated will regenerate. Pain will recur. In that
event, however, the procedure can be repeated and relief
restored. A study reported in 2004 by Schoffrman and Kine
97
shows that, in patients whose pain recurs after an initially suc-
cessful neurotomy, repeating the treatment restores relief and
that two, three, and even four repetitions continue to provide
relief. The median duration of relief after each repetition is
just short of a calendar year.
CONCLUSION
An irony applies. Lumbar zygapophyseal joint pain is one of
the best-studied and best-validated entities in the specialty of
pain medicine. At the same time it is one of the most abused.
Few other conditions have an established anatomic basis,
have a validated diagnostic test, and have a treatment that can
abolish the pain. Yet, so few practitioners practice according
to the evidence. They do not use diagnostic blocks. They do
not use controlled blocks to ensure that their diagnosis is
valid. They use treatments that do not work, yet ignore treat-
ments that do. They claim to use a procedure that has been
proven to work but use the wrong technique. It is hard to nd
another realm of medicine in which there is so much disso-
nance between science and practice.
It is no wonder, therefore, that insurers and others are so
opposed to lumbar facet syndrome and its management. They
are justied in being opposed to what is practiced, but they
are not justied in opposing the science. Unfortunately, those
who follow the science responsibly are compromised by those
who ignore it. Lack of recognition of lumbar facet syndrome
is not a scientic issue; it is a social one, in which the lack
of responsibility and discipline by medical practitioners is to
blame.
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1. Helbig T, Lee CK: The lumbar facet syndrome. Spine 13:61, 1988.
2. Revel ME, Listrat VM, Chevalier XJ, et al: Facet joint block for low
back pain: Identifying prediction of a good response. Arch Phys Med
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3. Schwarzer AC, Derby R, Aprill CN, et al: Pain from the lumbar
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4. Schwarzer AC, Aprill CN, Derby R, et al: Clinical features of patients
with pain stemming from the lumbar zygapophyseal joints. Is the lumbar
facet syndrome a clinical entity? Spine 19:1132-1137, 1994.
FIGURE 844 Lumbar radiofrequency neurotomy. A, Lateral view of the target zone, on which the course of the medial branch has been depicted.
B, Lateral view of the electrode in place, parallel to and on the nerve. C, Anteroposterior view of the electrode, inserted obliquely from below, in order to lie
parallel to the nerve.
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Only one published study has used an anatomically Only one published study has used an anatomically
correct technique in correctly selected patients (Fig. 844). correct technique in correctly selected patients (Fig. 844).
It establishes the benchmark of how effective lumbar medial It establishes the benchmark of how effective lumbar medial
branch neurotomy can be. All patients had to have near-com- branch neurotomy can be. All patients had to have near-com-
plete relief of pain after diagnostic blocks on two occasions. plete relief of pain after diagnostic blocks on two occasions.
All were treated with the electrode placed parallel to the target All were treated with the electrode placed parallel to the target
nerve. Postoperative electromyography proved that the nerves nerve. Postoperative electromyography proved that the nerves
had been coagulated. At 12 months follow-up some 80% of had been coagulated. At 12 months follow-up some 80% of
patients still had at least 60% relief of their pain and some patients still had at least 60% relief of their pain and some
60% of patients still had 80% relief. 60% of patients still had 80% relief.
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not a proper test of how well medial branch neurotomy works not a proper test of how well medial branch neurotomy works
or can work, but it did show convincingly that the effects were or can work, but it did show convincingly that the effects were
E
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It was It was
not a proper test of how well medial branch neurotomy works not a proper test of how well medial branch neurotomy works
that two, three, and even four repetitions continue to provide that two, three, and even four repetitions continue to provide
relief. The median duration of relief after each repetition is relief. The median duration of relief after each repetition is
just short of a calendar year. just short of a calendar year.
CONCLUSION CONCLUSION
S
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L
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All were treated with the electrode placed parallel to the target All were treated with the electrode placed parallel to the target
nerve. Postoperative electromyography proved that the nerves nerve. Postoperative electromyography proved that the nerves
had been coagulated. At 12 months follow-up some 80% of had been coagulated. At 12 months follow-up some 80% of
patients still had at least 60% relief of their pain and some patients still had at least 60% relief of their pain and some
60% of patients still had 80% relief. 60% of patients still had 80% relief.
For lumbar medial branch neurotomy to work, the For lumbar medial branch neurotomy to work, the
patients must have zygapophyseal joint pain. The procedure patients must have zygapophyseal joint pain. The procedure
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correct technique in correctly selected patients (Fig. 844). correct technique in correctly selected patients (Fig. 844).
96 96
It establishes the benchmark of how effective lumbar medial It establishes the benchmark of how effective lumbar medial
branch neurotomy can be. All patients had to have near-com- branch neurotomy can be. All patients had to have near-com-
An irony applies. Lumbar zygapophyseal joint pain is one of An irony applies. Lumbar zygapophyseal joint pain is one of
the best-studied and best-validated entities in the specialty of the best-studied and best-validated entities in the specialty of
pain medicine. At the same time it is one of the most abused. pain medicine. At the same time it is one of the most abused.
Few other conditions have an established anatomic basis, Few other conditions have an established anatomic basis,
-

N
O
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just short of a calendar year. just short of a calendar year.
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L
that two, three, and even four repetitions continue to provide that two, three, and even four repetitions continue to provide
Anteroposterior view of the electrode, inserted obliquely from below, in order to lie Anteroposterior view of the electrode, inserted obliquely from below, in order to lie
5. Schwarzer AC, Wang S, Bogduk N, et al: Prevalence and clinical
features of lumbar zygapophyseal joint pain: A study in an Australian
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picture to characterize low back pain relieved by facet joint anesthesia:
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the lumbar zygapophyseal joints and dorsal rami. Clin J Pain 13:303,
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15. Carrera GF: Lumbar facet joint injection in low back pain and sciatica:
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facet joints. CRC Crit Rev Diagn Imag 21:85, 1984.
18. Destouet JM, Gilula LA, Murphy WA, Monsees B: Lumbar facet joint
injection: Indication, technique, clinical correlation, and preliminary
results. Radiology 145:321, 1982.
19. Dory MA: Arthrography of the lumbar facet joints. Radiology 140:23,
1981.
20. Drevet JG, Chirossel JP, Phelip X: Lombalgies-lomboradiculalgies et
articulations vertebrales posterieures. Lyon Med 245:781, 1981.
21. Fairbank JCT, Park WM, McCall IW, OBrien JP: Apophyseal injection
of local anesthetic as a diagnostic aid in primary low-back pain syn-
dromes. Spine 6:598, 1981.
22. Glover JR: Arthrography of the joints of the lumbar vertebral arches.
Orthop Clin North Am 8:37, 1977.
23. Lau LSW, Littlejohn GO, Miller MH: Clinical evaluation of intra-artic-
ular injections for lumbar facet joint pain. Med J Aust 143:563, 1985.
24. Lewinnek GE, Wareld CA: Facet joint degeneration as a cause of low
back pain. Clin Orthop 213:216, 1986.
25. Lippit AB: The facet joint and its role in spine pain: Management with
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26. Lynch MC, Taylor JF: Facet joint injection for low back pain. J Bone
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27. Moran R, OConnell D, Walsh MG: The diagnostic value of facet joint
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