Anesthesiology 2007; 106:591614 Copyright 2007, the American ociety o!

Anesthesiologists, "nc# $ippincott %illiams & %il'ins,

"nc#
Pathogenesis, Diagnosis, and Treatment of
Lumbar
Zygapophysial (Facet) Joint Pain
Steven P. Cohen, M.D.,* Srinivasa N. Raja, M.D.
This article has been selected for the Anesthesiology
CME Program. After reading the article, go to http://
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the CME section at the bac$ of this iss"e.
Lumbar zygapophysial joint arthropathy is a
challenging condition afecting up to 15% of patients
with chronic low back pain. The onset of lumbar facet
joint pain is usually insidious with predisposing
factors including spondylolisthesis degener!ati"e disc
pathology and old age. #espite pre"ious reports of a
$facet syndrome% the e&isting literature does not
support the use of historic or physical e&amination
'ndings to diagnose lumbar zygapophysial joint pain.
The most accepted method for diagnosing pain arising
from the lumbar facet joints is with low!"olume
intraarticular or medial branch blocks both of which
are associated with high false!positi"e rates. (tandard
treatment modalities for lumbar zygapophysial joint
pain in!clude intraarticular steroid injections and
radiofre)uency de!ner"ation of the medial branches
inner"ating the joints but the e"idence supporting
both of these is con*icting. +n this article the authors
pro"ide a comprehensi"e re"iew of the anatomy
biomechanics and function of the lumbar
zygapophysial joints along with a systematic analysis
of the diagnosis and treatment of facet joint pain.
"(C) its original *escription almost 100 yr
ago, tho+,san*s o! scienti-c articles ha.e /een
p+/lishe* on l+m,/ar 0ygapophysial 1l,02 3oint
pain, an* !acet inter.entions represent the
secon* most common type o! proce*+re
per!orme* in pain management centers
thro+gho+t the 4nite* tates#
1
5+t *espite the
plethora o! research an* clinical emphasis on
this *isor*er, almost e.ery aspect o! l,0 3oint
pain, !rom *iagnosis to treatment, remains
mire* in contro.ersy# ).en among pain
specialists, l+m/ar !acet 3oint pain remains a
mis+n*erstoo*, mis*iagnose*, an* improperly
treate* me*ical con*ition# "n this article,
* Associate 6ro!essor, 7epartment o! Anesthesiology an* Critical
Care 8e*i,cine, 9ohns :op'ins chool o! 8e*icine, 5altimore,
8arylan*, an* %alter ;ee* Army 8e*ical Center, %ashington, 7#C#
6ro!essor, 7epartment o! Anesthe,siology an* Critical Care 8e*icine
an* 7epartment o! (e+rology, 9ohns :op'ins chool o! 8e*icine#
;ecei.e* !rom the 6ain 8anagement 7i.ision, 7epartment o!
Anesthesiology an* Critical Care 8e*icine, 9ohns :op'ins chool o!
8e*icine, 5altimore, 8ary,lan*#
+/mitte* !or p+/lication 8ay
16, 2006# Accepte* !or
p+/lication <cto/er 24, 2006#
=he opinions or assertions
containe* herein are the pri.ate
.ie>s o! the a+thors an* are not
to /e constr+e* as o?icial or as
re@ecting the .ie>s o! the
7epartment o! the Army or the
7epartment o! 7e!ense# 7r#
Cohen recei.es partial salary
s+pport !rom the 9ohn 6# 8+rtha
(e+roscience an* 6ain
"nstit+te, 9ohnsto>n,
6ennsyl.ania, an* the 4 Army#
7r# ;a3a has +nrestricte* grants
!rom Allergan 1"r.ine,
Cali!ornia2 an* <rtho,8c(eil
1;aritan, (e> 9ersey2, an*
ser.es as scienti-c a*.isor !or
AraleB =herape+tics 1=oronto,
<ntario, Cana*a2# :e recei.es
salary s+pport !rom grant (o#
(,26C6C !rom the (ational
"nstit+tes o! :ealth, 5ethes*a,
8arylan*#
A**ress correspon*ence to
7r# Cohen: 7i.ision o! 6ain
8e*icine, 9ohns :op'ins chool
o! 8e*icine, 550 (orth
5roa*>ay, +ite C01, 5altimore,
8ary,lan* 21205#
scohen40D3hmi#e*+# "n*i.i*+al
article reprints may /e
accesse* at no charge thro+gh
the 9o+rnal %e/ site,
>>>#anesthesiology#org#
l,0 3oint pain is *e-ne*
in a !+nctional
capacity as pain
originating !rom any
str+ct+re integral to
/oth the !+nc,tion an*
con-g+ration o! the
l+m/ar !acet 3oints,
incl+*,ing the -/ro+s
caps+le, syno.ial
mem/rane, hyaline
car,tilage s+r!aces,
an* /ony
artic+lations#
A critical iss+e that
m+st /e a**resse*
/e!ore em/ar',ing on
any re.ie> o! l,0 3oint
pain is >hether pain
can /e *e-niti.ely
attri/+te* to these
3oints# "n the 1960s
an* 1970s, this
E+estion pose* a
legitimate contro.ersy
that >as .igoro+sly
*e/ate* in the
me*ical literat+re#
2,C
:o>,e.er, in the past
20 yr, the scales o!
this contro.ersy ha.e
resol+tely tippe*
to>ar* the con.iction
that l,0 3oints can /e
an* o!ten are a
primary so+rce o! lo>
/ac' pain
1$562#
4
Compelling e.i*ence
+n*erlies this
para*igmatic shi!t in
thin'ing# =he !acet
3oint caps+le an*
s+rro+n*ing
str+ct+res are richly
im/+e* >ith
nociceptors that -re
>hen the caps+le is
stretche* or s+/3ecte*
to local compressi.e
!orces#
5,6
"n /oth pain
patients an* .ol+n,teers, chemical or
mechanical stim+lation o! the !acet 3oints an*
their ner.e s+pply has /een sho>n to elicit /ac'
an*For leg pain#
710
7+ring spine s+rgery per,
!orme* +n*er local anesthetic 1$A2, l+m/ar !acet
caps+le stim+lation elicits signi-cant pain in
approBimately 20G o! patients#
11
$ast an* most
signi-cantly, $A /loc's o! either the !acet 3oints
themsel.es or the me*ial /ranches inner.ating
them ha.e /een sho>n to relie.e pain in a
s+/stantial percentage o! patients >ith chronic
$56#
12
=here!ore, li'e other syno.ial 3oints in the
h+man /o*y, the l,0 3oints represent a potential
pain generator in patients >ith chronic $56#
"n light o! the pre.alence o! l+m/ar !acet 3oint
pain an* the !reE+ency >ith >hich !acet /loc's
are per!orme*, se.eral re.ie>s ha.e /een
+n*erta'en on this phenom,enon in the past 15
yr# Altho+gh some o! these articles pro.i*e*
'een insight on
.ario+s aspects o! the
con*i,tion, most >ere
limite* /y their
con-ne* scope an*
speciali0e* target
a+*iences# =he
p+rpose o! this re.ie>
is there!ore to pro.i*e
a comprehensi.e,
e.i*ence,/ase*
!rame>or' on the
anatomy,
pathophysiology,
pre.a,lence,
*iagnosis, an*
treatment o! l+m/ar
!acet pain# Articles
re.ie>e* >ere
o/taine* via
8)7$"() an* <.i*
search engines, /oo's
an* /oo' chapters,
an* /i/lio,graphic
re!erences *ating to
the early 1900s#
,istoric -e"iew
=he l,0 3oints, o!ten
re!erre* to as !acet
3oints, ha.e long /een
recogni0e* as a
potential so+rce o!
$56# "n 1911,
Hol*th>aite
1C
-rst
note* that the
pec+liarities o!
Anesthesiology, I 106, (o C, 8ar 2007
591
592 '. P. C()E* A*+ '. *. ,A-A
the !acet 3oints co+l* /e a signi-cant so+rce o!
/ac' pain an* insta/ility# iBteen years later,
a!ter anatomical *is,sections o! 75 ca*a.ers,
6+tti
14
s+ggeste* that local in,@ammation an*
*egenerati.e changes in l+m/ar !acet 3oints
co+l* res+lt in sciatica !rom irritation o! ner.e
roots# "n 19CC, Hhormley
15
coine* the term
J!acet syn,*rome,K >hich he *e-ne* as
l+m/osacral pain, >ith or >itho+t sciatica, that
>as li'ely to occ+r a!ter a s+**en rotatory
strain# hortly therea!ter, interest in the l,0
3oints as potential so+rces o! /ac' pain >ane*
a!ter the lan*,mar' article /y 8iBter an* 5arr
16
implicating l+m/ar *isc r+pt+re as the ma3or
ca+se o! lo> /ac' an* leg pain# =he 1940s sa> a
res+rgence in the interest o! l,0 3oints as pain
generators >hen 5a*gley
17
s+ggeste* that +p to
L0G o! cases o! $56 an* sciatica are *+e to
re!erre* pain !rom l,0 3oint pathology, rather
than *irect ner.e root compres,sion# "n 196C,
:irsch et al.
7
p+/lishe* the -rst acco+nt
>here/y the in3ection o! l,0 3oints repro*+ce*
patientsM /ac' pain# ;ees,
1L
>ho reporte* a
s+ccess rate o! 99#LG, is generally cre*ite* >ith
promoting perc+taneo+s J!acet rhi0olysisK >ith
his gro+n*,/rea'ing report in the early 1970s#
$ater, it >as sho>n that the techniE+e
a*.ocate* /y ;ees may not ha.e /een s+?icient
to achie.e rhi0otomy in most patients#
C
5+oye*
/y a high inci*ence o! hemorrhagic
complications, healy
19,20
pi,oneere* the +se o!
@+oroscopically g+i*e* ra*io!re,E+ency !acet
*ener.ation to treat l,0 3oint pain in the mi*,
1970s#
specti.ely# =he me*ial
/ranches o! $1$4
*orsal rami co+rse
across the top o! their
respecti.e trans.erse
pro,cesses one le.el
/elo> the name*
spinal ner.e 1e.g., $4
crosses the trans.erse
process o! $52,
tra.ersing the *orsal
lea! o! the
intertrans.erse
ligament at the /ase
o! the trans.erse
process# )ach ner.e
then r+ns *o>n>ar*
along the 3+nction o!
the trans.erse an*
s+perior artic+,lar
processes, passing
/eneath the
mamilloaccessory lig,
ament an* *i.i*ing
into m+ltiple /ranches
as it crosses the
.erte/ral lamina 1-g#
12# "n some cases, the
mamil,loaccessory
ligament /ecomes
calci-e*, >hich may
lea* to ner.e
entrapment#
27
=his is
most common at $5
1ap,proBimately 20G2
/+t also occ+rs at $4
110G2 an* $C 14G2# "n
a**ition to t>o l,0
3oints, the me*ial
/ranches also
inner.ate the
m+lti-*+s m+scle, the
interspino+s
m+scle an* ligament,
an* the perioste+m o!
the ne+ral arch#
7,2L C0
=he $5 ner.e *i?ers
in that it is the *orsal
ram+s itsel! that r+ns
along the 3+nction o!
the sacral ala an*
s+perior artic+lar
process o! the
sacr+m#
29,C1
"ts
me*ial /ranch arises
opposite the
in!erolateral corner o!
the /ase o! the lo>est
!acet 3oint# At this
le.el, it is the *orsal
ram+s rather than its
me*ial /ranch that is
ame,na/le to
/loc'a*e#
ome people may
ha.e a/errant or
a**itional inner.a,tion
o! the !acet 3oints# "n a
st+*y con*+cte* in
asymp,tomatic
.ol+nteers, Naplan et
al.
C2
!o+n* that 1 in 9
s+/3ects >ho
+n*er>ent $4 $5 1n
52 an* $51 1n 42
!acet 3oint me*ial
/ranch /loc's 18552
!elt pain *+r,
.natomy and +nner"ation
=he l+m/ar !acet 3oints !orm
the posterolateral artic+,lations
connecting the .erte/ral arch o!
one .erte/ra to the arch o! the
a*3acent .erte/ra# As tr+e
syno.ial 3oints, each !acet 3oint
contains a *istinct 3oint space
capa/le o! accommo*ating
/et>een 1 an* 1#5 ml o! @+i*, a
syno.ial mem/rane, hyaline
cartilage s+r!aces, an* a -/ro+s
cap,s+le#
21
=he -/ro+s caps+le
o! the l+m/ar !acet 3oint is
approBimately 1 mm thic' an*
compose* mostly o! collageno+s
tiss+e
arrange* in a
more or less
trans.erse
!ashion to
pro.i*e
maBim+m
resistance to
@eBion#
22,2C
=he 3oint
caps+le is
thic'
posteriorly,
s+pporte* /y
-,/ers arising
!rom the
m+lti-*+s
m+scle#
+periorly
an* in!eriorly,
the caps+le
attaches
!+rther a>ay
!rom the
osteochon*ral
margins,
!orming
s+/caps+lar
recesses that
in the normal
3oint are -lle*
>ith
-/roa*ipose
me,nisci#
Anteriorly, the
-/ro+s
caps+le is
replace* /y
the
ligament+m
@a.+m#
24
)ach !acet
3oint
recei.es
*+al
inner.ation
!rom me*ial
/ranches
arising !rom
posterior
primary rami
at the same
le.el an* one
le.el a/o.e
the 0,
3oint#
25,26
Aor
eBample,
the in!erior
pole o! the $4
$5 !acet 3oint
recei.es
inner,.ation
!rom the $4
me*ial /ranch
an* its
s+perior pole
is inner.ate*
/y the $C
me*ial
/ranch, >hich
are typically
/loc'e* on
the trans.erse
processes o!
$5 an* $4, re,
/ig. 1. -ight
lateral obli)ue
"iew of the
lumbar
"ertebral bodies
and the dorsal
rami medial
branches.
#rawing by
/rank 0. 1ort
0.(. 2-esearch
.ssociate
#epartment of
-adiology
3ohns ,opkins
,ospital
4altimore
0aryland5.
Anesthesiology, I 106, (o C, 8ar
2007
./M0A, 1ACET -(2*T PA2* 59C
ing repeate* caps+lar *istension concor*ant
>ith pain eBperience* *+ring pre.io+s l,0 3oint
pro.ocation >ith,o+t 855# Ass+ming the /loc's
>ere technically s+ccess,!+l, one eBplanation !or
this -n*ing is that in a small s+/set o!
in*i.i*+als, a/errant inner.ation may acco+nt
!or !alse,negati.e *iagnostic 855# ome a+thors
ha.e s+ggeste* that l,0 3oints may also recei.e
inner.ation
!rom the me*ial /ranch /elo> the 3oint 1i.e., 1
!or the $51 3oint2,
CC,C4
the *orsal root
ganglion,
C5
an* the
para.erte/ral sympathetic ganglia,
C6,C7
/+t
these asser,tions remain +npro.en 1-g# 22#
:istologic st+*ies ha.e *emonstrate* that the
l+m/ar !acet 3oints are richly inner.ate* >ith
encaps+late* 1;+?ini,type en*ings, pacinian
corp+scles2, +nencaps+,late*, an* !ree ner.e
en*ings#
5
=he presence o! lo>,thresh,ol*,
rapi*ly a*apting mechanosensiti.e ne+rons
s+ggests that in a**ition to transmitting
nocicepti.e in!ormation, the l,0 !acet caps+le
also ser.es a propriocepti.e !+nction# 5esi*es
s+/stance 6 an* calcitonin generelate*
pepti*e, a s+/stantial percentage o! ner.e
en*ings in !acet caps+les ha.e also /een !o+n*
containing ne+ropepti*e O, in*icat,ing the
presence o! sympathetic e?erent -/ers#
CL,C9
(er.e -/ers ha.e also /een !o+n* in
s+/chon*ral /one an* intra,artic+lar incl+sions
o! l,0 3oints, signi!ying that !acet,me*i,ate* pain
may originate in str+ct+res /esi*es the 3oint
caps+le#
40 42
"n *egenerati.e l+m/ar spinal
*isor*ers, in,@ammatory me*iators s+ch as
prostaglan*ins
4C
an* the in@ammatory cyto'ines
interle+'in 1 , interle+'in 6, an* t+mor necrosis
!actor
44
ha.e /een !o+n* in !acet 3oint cartilage
an* syno.ial tiss+e#
/unction and 4iomechanics
=he /asic anatomical +nit o! the spine, o!ten
re!erre* to as the three,3oint compleB, consists
o! the paire*
0ygapophysial 3oints
an* the inter.erte/ral
*isc# =o,gether, these
3oints !+nction to
s+pport an* sta/ili0e
the spine, an* pre.ent
in3+ry /y limiting
motion in all planes o!
mo.ement#
8acroscopically, each
!acet 3oint is com,
pose* o! a
posterome*ially
!acing conca.e
s+perior ar,tic+lar
process !rom the
in!erior .erte/ral
/o*y, an* a smaller
anterolaterally !acing
in!erior artic+lar
process !rom the
s+perior spinal le.el#
=he shape an*
orientation o! the l,0
3oints *etermine the
role each plays in
protect,ing the spine
against eBcessi.e
motion# Aacet 3oints
ori,ente* parallel to
the sagittal plane
pro.i*e s+/stantial
resistance to aBial
rotation /+t minimal
resistance to shearing
!orces 1/ac'>ar* an*
!or>ar* sli*ing2,
>hereas 3oints
oriente* more in a
coronal plane ten* to
protect against @eBion
an* shearing !orces
/+t pro.i*e minimal
protection against
rotation 1-g# C2#
24
"n
an anatomical st+*y
p+/lishe* in 1940 /y
:or>it0 an* mith,
45
the a+thors !o+n* that
the $4 $5 0,3oints
ten*e* to /e more
coronally positione*
1almost 70P >ith
respect to the sagittal
plane2, >hereas the
$2$C an* $C$4
3oints >ere li'ely to /e
oriente* more parallel
1 40P2 to the sagittal
plane# "n more recent
st+*ies /y 8ashara>i
et al.
46
an* 6+n3a/i et
al.,
47
the in.estigators
!o+n* that the +pper
l+m/ar !acet 3oints
1=12$22 >ere
oriente* closer to the
mi*sagittal plane o!
the .erte/ral /o*y
1mean range, 26P
C4P2, >hereas the
lo>er !acet 3oints
ten*e* to /e oriente*
a>ay !rom that plane
140P56P2# "n the
+pper l+m/ar spine,
approBimately L0G o!
the !acet 3oints are
c+r.e*, an* 20G are
@at# "n the lo>er
l+m/ar spine, these
n+m/ers are
re.erse*#
45
t+*ies /y
Hro/ler et al.
4L
an*
5o*en et al.
49
!o+n* a
positi.e association
/et>een *egenerati.e
spon*ylolisthesis an*
more sagittally ori,
ente* lo>er l+m/ar
!acet 3oints#
"n yo+ng people, the
l,0 3oints are E+ite
strong, capa/le
/ig. 6. (chematic
drawing of the spinal
cord and segmental
spinal inner"ation.
#rawing by (pecialist
/rank and .ngela
#ill 7( .rmy and
/rank 0. 1ort 0.(.
2-esearch .ssociate
#epartment of
-adi!ology
3ohns ,opkins
,ospital
4alti!more
0aryland5.
Anesthesiology, I
106, (o C, 8ar 2007
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