Lumbar Facet Syndrome

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Search Strategy

To gather information on this subject I consulted Google using following search items: “common lower back pain”. Here I found the term: “Lumbar facet syndrome”. Then I searched in the library of the Vrije Universiteit Brussel for books. Further I searched for scientific articles on PubMed and Web of knowledge using following key words: “Lumbar facet syndrome” and “zygopophysial joint pain”.

Definition/Description

Lumbar facet syndrome means: A dysfunction at the level of the posterior facet joints of the spine. These joints together with the disc form the intervertebral joint. Changes at the level of the posterior facet joints can influence the disc and vice versa.
The term ‘dysfunction’ implies that at a certain level (mostly L4-L5 or L5-S1) these 3 components do not function normally.

The lumbar facet syndrome is a painful irritation of the posterior part of the lumbar spine. Swelling from the surrounding structures, can cause pain due to an irritation of the nerve roots.

Little capsular tears can originate at the level of the posterior facet joints due to a trauma. This can lead to a subluxation of the joint. The synovia that surrounds the joint is damaged and leads to a synovitis. Secondly a hypertonic contraction of the surrounding muscles present itself. This is a protection mechanism that increases the pain. These changes lead to a fibrosis and osteophyte formation.

The most common cause is repetitive micro trauma and as positive result of this chronic degeneration. In daily living this may occur with repetitive extension of the back. So mostly all movements with the arms above the head.

These recurring injuries can happen in sports were it is necessary to make repetitive powerful hyperextensions of the lumbar spine.
An irritation can also occur when the intervertebral disc is damaged and the biomechanics of the joint have changed. In this case the facet joints are exposed to a higher loading.

Clinically Relevant Anatomy

For relevant anatomy I refer to Cohen S. P. et Al. [4] and Facet joint syndrome clinically relevant Anatomy

Epidemiology /Etiology

LBP is the most common musculoskeletal disorder of industrialized society and the most common cause of disability in persons younger than 45 years. Given that 90% of adults experience LBP sometime in their lives, the fact that it is the second leading cause for visits to primary care physicians and the most frequent reason for visits to orthopedic surgeons or neurosurgeons is not surprising. As the primary cause of work-related injuries, LBP is the most costly of all medical diagnoses when time off from work, long-term disability, and medical and legal expenses are taken into account.

The lumbosacral facet joint is reported to be the source of pain in 15-40% of patients with chronic LBP. Ray believed that facet joint–mediated pain is the etiology for most cases of mechanical LBP, whereas other authors have argued that it may contribute to nearly 80% of cases. Thus, the diagnosis and treatment of this entity may help alleviate LBP in a significant number of patients.

Characteristics/Clinical Presentation

• Local pressure pain at the level of the affected joint
• Local pressure pain of the M. Multifidi and M. Erector Spinae (when palpating very stiff due to hypertonia)
• Decreased extension and painful
• Unilateral abnormal lateroflexion
• Antalgia
• can occur when rising up with a flexed torso
• Sometimes a functional scoliosis in anteflexion
• sensibility/pain local and ipsilateral
• pain in hyperextension
• pain in hip, bottom and back when lifting a extended leg
• referred pain not further than the knee
• local stiffness
• Kemp’s test positive
• Springing test positive
  Pain: mild – severe, different between patients and within patient.Pain variat during different positions
  

Increase pain.

- Extension
- Rotation
- Prolonged standing
- Sudden movements
- After rest
- Lateral flexion towards affected side
- Returning from flexed position
- Movements in general

- Sitting, flexion, using a clutch (in a vehicle), coughing and/or sneezing, and walking for a long time

Decrease pain

- Walking
- Lying with knees bent
- Medication
- Supported flexion, sitting, standing with weight on hands and elbows
- Rest
- Lateral bending towards healthy side
- Varying activity

Diagnostic Procedures

Lumbar Facet syndrome can not be reliably clinically diagnosed (Jackson RP2 1992). The most used systems to diagnose this syndrome are an X-ray, a computed tomography (CT) scan of the spine or a magnetic resonance imaging (MRI) scan. Plain radiography does not provide information in establishing the diagnosis of the facet joint syndrome. But it may help with the evaluation of the degree of degeneration. Only, once the degeneration is visible on plain radiography, it has already reached an advanced stage.
The working diagnosis of facet pain, based on history and clinical examination, may be confirmed by performing a diagnostic block. This is considered positive when the patient experiences a 50% pain reduction. It involves injecting a medicine into or near the nerves that supply the facet joint. If the pain is not relieved by the injection, it is unlikely that the facet joint is the source of the pain. If these injections help and reduce the pain, we can suggest that the pain comes from the facet joint.Although no single sign or symptom is diagnostic, Jackson et al demonstrated that the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular facet joint injection:

• Older age
• Previous history of LBP
• Normal gait
• Maximal pain with extension from a fully flexed position
• The absence of leg pain
• The absence of muscle spasm
• The absence of exacerbation with a Valsalva maneuver

Differential Diagnosis

• Lumbosacral Disc Injuries
• Lumbosacral Discogenic Pain Syndrome
• Lumbosacral Radiculopathy
• Lumbosacral Spine Acute Bony Injuries
• Lumbosacral Spine Sprain/Strain Injuries
• Lumbosacral Spondylolisthesis
• Lumbosacral Spondylolysis
• Piriformis Syndrome
• Sacroiliac Joint Injury
• Inflammatory arthritidies (ex. rheumatoid arthritis)
• Spondylarthropathies (ex. osteoarthrosis, synovitis)

Examination

Inspection
Inspection should include an evaluation of paraspinal muscle fullness or asymmetry, increase or decrease in lumbar lordosis, muscle atrophy, or posture asymmetry.
Patients with chronic facet syndrome may have flattening of the lumbar lordosis and rotation or lateral bending at the sacroiliac joint or thoracolumbar area.
Palpation
The examiner should palpate along the paravertebral regions and directly over the transverse processes because the facet joints are not truly palpable. This is performed in an attempt to localize and reproduce any point tenderness, which is usually present with facet joint–mediated pain.
In some cases, facet joint–mediated pain may radiate to the gluteal or posterior thigh regions.
Range of motion
Range of motion should be assessed through flexion, extension, lateral bending, and rotation.
With facet joint–mediated LBP, pain is often increased with hyperextension or rotation of the lumbar spine, and it might be either focal or radiating.
Flexibility
Inflexibility of the pelvic musculature can directly impact the mechanics of the lumbosacral spine.
With facet joint pathology, the clinician may find an abnormal pelvic tilt and rotation of the hip secondary to tight hamstrings, hip rotators, and the quadratus, but these findings are nonspecific and can be found in patients with other causes of LBP.
Sensory examination
Sensory examination (ie, light touch and pinprick in a dermatomal distribution) findings are usually normal in persons with facet joint pathology.
Muscle stretch reflexes
Patients with facet joint–mediated LBP usually have normal muscle stretch reflexes. Radicular findings are usually absent unless the patient has nerve root impingement from bony overgrowth or a synovial cyst.
Side-to-side asymmetry should lead one to consider possible nerve root impingement.
Muscle strength
Manual muscle testing is important to determine whether weakness is present and whether the distribution of weakness corresponds to a single root, multiple roots, or a peripheral nerve or plexus.
Typically, manual muscle testing results are normal in persons with facet joint pathology; however, subtle weakness of the muscles of the pelvic girdle may contribute to pelvic tilt abnormalities. This subtle weakness may be appreciated with trunk, pelvic, and lower-extremity extension asymmetry.
Straight leg – raise test
This maneuver is usually normal for facet joint–mediated pain. However, if facet joint hypertrophy or a synovial cyst encroaches on the intervertebral foramen, causing nerve root impingement, this maneuver may elicit a positive response.

Special test for LBA due to facet joint

Kemp’s test positive
Springing test positive

• The pharmacological therapy used by doctors for acute back pains caused by facet joint syndrome is based on administrating muscle relaxants.
• In medicine they also use nonsteroidal anti-inflammatory drugs and acetaminophen as first line drugs for the treatment of LBP, with little evidence to support one particular drug over another.
• Standard treatment modalities for facet joint syndrome pain include intraarticular steroid injections and radiofrequency denervation of the medial branches innervating the joints. Yet there is much controversy in scientific articles related to this standard treatment.

Cohen S. P. et al. (2007) investigated several publications about the effectiveness of intraarticulair steroid injections and radiofrequency denervation of the medial branches. In uncontrolled studies of people that have never been diagnosed for facet joint syndrome, the long-term relief of back pain after intraarticular steroid injection varies from 18% to 63%.In controlled trials, the results are disputable. In the largest study, the investigators reported no significant difference in outcome between the patients who received large-volume (8 ml) LA and steroids injected into facet joints or around facet joints or intraarticular saline injections. Cohen S. P. et al. (2007) also verified that radiofrequency denervation of the medial branches innervating the joints, is an effective treatment for facet joint syndrome. Unfortunately, there aren’t enough studies that follow the same protocol, to make a conclusion about it. For example the placement of the electrodes plays a very crucial role in processing the results.
There is also controversy about the long term effect of radiofrequency denervation. Further research should confirm whether radiofrequency means an effective treatment in people with facet joint syndrome.

Physical Therapy Management

When acute signals have disappeared, the underlying cause is treated by physiotherapy:

The first thing you need to do is to inform your patient. He needs to understand the problems he is having. You may not make him anxious, so a diplomatic approach is necessary to prevent him from catastrophizing. When he is anxious when he needs to move, you cannot do exercises. So the kinesiophobia needs to be banned.

Now you can start with the exercises. When your patient is having an antalgic posture, this needs to be treated by giving instructions how he has to keep his back in the right position/straight. He has to keep all physiological curves in his back (cervical lordosis, thoracal kyphosis, lumbar lordosis). These instructions are not only important for passive activities, like sitting and standing, but also for active movements. So when he does a certain movement, he can take a certain posture to which will not provoke his symptoms.

As therapist you can do passive modalities. You can mobilize the lower back of your patient. In a later stage of the therapy, you can manipulate the lower back.

Reinforcing the muscles of the torso and the pelvis it is also necessary for increase core stability (e.g. by using exercises for pelvis, back and bottom)

Resources

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Recent Related Research (from Pubmed)

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