IV
Chapter
90
Lumbar Facet Syndrome
Nikolai Bogduk
CHAPTER OUTLINE
Anatomy 716
Normal Volunteers 716
Diagnostic Blocks 717
Clinical Features 719
Prevalence 719
Lumbar facet syndrome does not exist. A syndrome is a ­clinical
entity defined, and recognized, by a specific ­constellation of
clinical features. Reiter's syndrome is defined by the com-
bination of urethritis, uveitis, and spondyloarthropathy.
­Tolosa-Hunt syndrome is headache combined with palsy of
one or more of the third, fourth, or sixth cranial nerves.
No combination of clinical features defines lumbar facet
syndrome. Although some proponents contended that aggra-
vation 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.3–6 Even the features proposed by
Revel et al7 do not define a facet syndrome; they may serve to
identify patients who do not have facet pain,8 but they fail to
identify those who do.9,10
No syndrome exists. Instead, what patients have is lumbar
zygapophysial joint pain. This is an entity defined not by clini-
cal features, but by a specific source of pain. In many circles, it
is a diagnosis that is rejected or disdained, but ironically it is
one of the best studied, and most strongly validated, entities
in pain medicine. Those who deny this condition either sim-
ply do not want to know or are unaware of the literature and
its strength.
Few, if any, other conditions in pain medicine satisfy the fol-
lowing theoretical and practical criteria.
n The pain has an anatomic basis.
The pain has been produced experimentally in normal
n
volunteers.
n The pain can be diagnosed by a test that has been
validated.
n The test used to diagnose the condition protects normal
volunteers from experimentally induced versions of the
condition.
n When tested, patients with the condition obtain complete
relief of their pain.
n When diagnosed with the condition, patients can be
treated.
n When treated, patients obtain complete relief of pain.
n When pain recurs, it can again be completely relieved.
716
Pathology 720
Treatment 720
Intra-articular Steroids 720
Radiofrequency Neurotomy 720
Conclusion 721
Anatomy
The lumbar zygapophysial joints are formed by the superior
and inferior articular processes of consecutive lumbar vertebrae
(Fig. 90.1). Each joint is named according the segmental num-
bers of the vertebrae that form it. The joint between L5 and the
sacrum is known as the lumbosacral, or L5-S1 zygapophysial,
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, as well as from the
medial branch above11,12 (see Fig. 90.1). The joints are there-
fore endowed with the necessary neurologic apparatus to be a
potential source of pain.
Confusion arises around the names of the nerves that inner-
vate 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 clar-
ity in communication, practitioners should take care when refer-
ring to a segment, whether they are referring to the joint or to
the nerves that innervate the joint. 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 conjunction and therefore a joint;
a comma indicates a sequence and therefore a pair of nerves.
Normal Volunteers
When lumbar zygapophysial 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,13,14
injections of contrast medium to distend the capsules of the
joints,15 and electrical stimulation of the nerves that innervate
the joints.15,16
In all studies that have been conducted, noxious stimula-
tion of the zygapophysial joints has produced low back pain
and some degree of referred pain. Studies have differed with
© 2011 Elsevier Inc. All rights reserved.

respect to the distribution of referred pain (Fig. 90.2). As a
rule, the referred pain tends to radiate inferolaterally from the
site of stimulation. Pain from upper lumbar zygapophysial
joints extends into the loin or toward the posterior iliac crest
from above. Pain from lower lumbar joints extends across the
iliac crest into the buttock.
The pattern of referred pain is segmental insofar 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 distribution of
pain from particular segments overlaps with the ­distribution
Superior
articular process
Medial branch of
dorsal ramus
Zygapophysial j.
Inferior articular process
Fig. 90.1 Sketch of a posterior view of a lumbar segment that
illustrates the structure and innervation of the zygapophysial
joints. The zygapophysial joint is formed by the adjacent superior
articular process and inferior articular process. Each is innervated by
articular branches from the medial branch of the same segment and the
one above.
L1-2
L4-5
A B
Chapter 90—Lumbar Facet Syndrome 717
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 quantified,
­investigators have 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.13
Also not rigorously studied, but noted in one study, experi-
mentally induced referred pain from the lumbar zygapophy-
sial joints can be associated with increased electromyographic
activity in the hamstring muscles.13 This finding is in accord
with the more general observation that pain from structures
innervated by the lumbar dorsal rami can be accompanied by
involuntary activity in muscles of the lower limb.17
Diagnostic Blocks
Pain from a lumbar zygapophysial joint can be relieved temp-
orarily by anesthetizing the joint. This procedure can be done
by injecting local anesthetic into the cavity of the joint or by
anesthetizing the medial branches that innervate the joint.
Intra-articular blocks constitute a direct test of zygapophy-
sial joint pain and were originally promoted in orthopedic and
radiologic circles.18–34 Intra-articular blocks have face validity,
in that it can be shown, by injecting contrast medium into the
joint, that the local anesthetic accurately and exclusively tar-
gets the joint. However, although still used by some ­operators,
intra-articular blocks have not been validated ­further. In par-
ticular, these blocks have not been subjected to controls and
have not been shown to have predictive validity or therapeu-
tic utility. Provocation of pain during injection of a joint is
not diagnostic of joint pain. Provocation is not ­associated with
subsequent relief when the joint is anesthetized.35
L2
Fig. 90.2 Maps of referred pain
L3 patterns elicited from the lumbar
zygapophysial joints in normal
L4 volunteers. A, Following injection
L5 of hypertonic saline into the lower
lumbar joints, with segments not
specified. B, Following injection
of hypertonic saline into the L1-2
and L4-5 joints. C, Following
electrical stimulation of the medial
branches at the segments indicated.
(A, Adapted from Mooney V, Robertson
J: The facet syndrome, Clin Orthop Relat
Res 115:149–156, 1976; B, adapted from
McCall IW, Park WM, O'Brien JP: Induced
pain referral from posterior elements
in normal subjects, Spine 4:441, 1979;
and C, adapted from Windsor RE, King
FJ, Roman SJ, et al: Electrical stimulation
induced lumbar medial branch referral
C patterns, Pain Physician 5:347, 2002.)
718 Section IV—Regional Pain Syndromes
In contrast, medial branch blocks have been extensively
tested. They involve injecting a tiny amount of local anesthetic
(0.3 mL), under fluoroscopic control, onto each of the medial
branches that innervate the target joint. The blocks require a
preliminary test dose of contrast medium, because in approxi-
mately 8% of cases the injection can be into the vena comitans
of the medial branch.36 Venous uptake is not a complication,
given the small volume of local anesthetic injected, but it risks
producing a false-negative response.
The face validity of lumbar medial branch blocks has been
established. Provided that correct target points are used, the
local anesthetic covers the target nerve and does not spread to
affect other structures that may be alternative sources of pain.
The correct target point lies midway between two points36: the
notch between the superior articular process and the trans-
verse process, where the medial branch enters the posterior
compartment of the spine, and the mammilloaccessory notch,
where it hooks medially beneath the mammilloaccessory lig-
ament37 (Fig. 90.3). When deposited in the correct location,
local anesthetic surrounds the nerve reliably. It may spread
dorsally into the cleavage plane between the multifidus and
longissimus lumborum, or between fascicles of the multifi-
dus at lower lumbar levels, but it does not indiscriminately
anesthetize the back muscles. Target points more rostral on
the transverse process risk spread of some of the local anes-
thetic to the intervertebral foramen, where, theoretically, the
drug may affect the spinal nerve and compromise the speci-
ficity of the block. Pointing the bevel of the needle caudally
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. Placement of the needle further rostrally risks
flow of injectate to the L5-S1 intervertebral foramen. More
caudal placement risks flow to the S1 posterior foramen.
A B
Fig. 90.3 Lumbar medial branch blocks. A, At typical segmental levels (L1-5), 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
homologous 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 for an L4 medial branch block. C, Anteroposterior view of a needle in position for an L5 dorsal ramus block.
The face validity of medial branch blocks was established
by stimulating the lumbar zygapophysial 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
­zygapophysial joint pain.38
Single, uncontrolled blocks of lumbar medial branches
are not valid. They have a false-positive rate of between 25%
and 41%.39–41 This means that investigators who encoun-
ter a ­positive response to a block cannot be certain whether
the response is truly positive or falsely positive. The diagnos-
tic confidence depends both on the false-positive rate and on
the prevalence of zygapophysial joint pain. For most preva-
lence estimates, the diagnostic confidence is low, and the posi-
tive response is more likely to be false than true (Table 90.1).
To achieve clinically useful diagnostic confidence, some form
of control needs to be applied in all cases. Unless this is done,
the diagnosis will be wrong more often than correct.
In the past, comparative local anesthetic blocks were used.
These procedures involved the same block on each of two, sep-
arate occasions, with a different local anesthetic agent used on
each occasion. The agents typically used were lignocaine and
bupivacaine. Under these conditions, a true-positive response
was defined as one in which the patient reported longer-­lasting
relief when the longer-acting agent was used and shorter-
­lasting relief when the shorter acting agent was used.
The validity of comparative blocks was established for cervi-
cal medial branch blocks.42,43 That validity was subsequently
extrapolated and applied to lumbar medial branch blocks.
However, investigators have since shown that this extrapolation
creates an illusion of diagnostic confidence.44 Comparative blocks
remain valid for cervical medial branch blocks because the prev-
alence of cervical zygapophysial joint pain is high. Comparative
blocks are not valid for lumbar medial branches because the
prevalence of lumbar zygapophysial joint pain is low.
Comparative blocks are not perfect. They have a sensitiv-
ity of 100% but a specificity of only 65%.44 When applied to
C
 Chapter 90—Lumbar Facet Syndrome 719

low prevalence rates, these values yield low diagnostic confi- anesthetic. The third block uses the agent not used for the
dence (Table 90.2). For typical prevalence rates of 15% or 5%, second block. Under these ­conditions, the response is con-
the diagnostic confidence is so low that the diagnosis will be sidered positive when the patient obtains complete relief of
wrong twice or seven times as often as correct. pain whenever a local anesthetic is used but no relief when
The only means by which to be confident of a correct the placebo is used.
diagnosis of lumbar zygapophysial joint pain is to perform Some practitioners, and some insurers, object to controlled
placebo controls. This procedure requires three blocks. blocks. Mistaken, or misguided, they believe that they can
The first block is with a local anesthetic agent, to establish diagnose zygapophysial joint pain with a single block, and that
prima facie that the joint is putatively symptomatic. The controlled blocks simply increase costs. This attitude overlooks
second block uses either an inactive agent or another local the cost of false-positive responses. If only single blocks are
used, diagnosis will be false in more than 60% of cases, and all
subsequent decisions about these patients will be founded on
a false premise. Cost saving pays for diagnostic noise and ther-
apeutic failure. Meanwhile an economic study showed that,
Table 90.1 Selected Examples of How even at modest rates of reimbursement, ­controlled blocks are
Different Prevalence Rates and Different cost effective.45
False-Positive Rates Affect the Diagnostic
Confidence that a Positive Response to a
Single Diagnostic Block Is Truly Positive
Joint
Clinical Features
False- Diagnostic
Pain* Lumbar zygapophysial joint pain has no clinical diagnostic
Prevalence Positive Single Confidence
(%) Rate (%) Block Yes No (%) features. The patient has lumbar spinal pain and may have
somatic referred pain into the lower limb. Most often, the pain
30 25 Positive 30 18 63
is referred only to the region of the buttock or proximal thigh,
Negative 0 52 but it can extend beyond the knee and even into the foot. It
41 Positive 30 29 51 is not true that pain below the knee always represents sciat-
Negative 0 41 ica. Pain distal to the knee has successfully been relieved, in
some patients, by anesthetizing lower lumbar zygapophysial
15 25 Positive 15 21 42
joints.13,25
Negative 0 64 No associated features, however, are unique to lumbar
41 Positive 15 35 30 zygapophysial joint pain. Aggravation of pain by any move-
Negative 0 50
ments or by any applied, clinical maneuver does not distin-
guish lumbar zygapophysial joint pain from pain stemming
5 25 Positive 5 24 17 from other sources.3–6 This finding should not be surpris-
Negative 0 71 ing. All the elements of the lumbar spine share a similar
41 Positive 5 39 9 segmental innervation. Therefore, the symptoms that they
produce should be similar. No movement selectively stresses
Negative 0 56
just the zygapophysial joints. The disk is also stressed by
*Percent of patients who experience joint pain. movement, along with ligaments and muscles. Therefore, all
sources of pain should be aggravated in a similar manner by
movement.
Nevertheless, this lack of distinctive clinical features is not
an indictment of the condition. Demands for a distinctive,
clinical syndrome are based on the cynical and artificial expec-
Table 90.2 Selected Examples of How tation that all disorders in medicine must have distinctive
Different Prevalence Rates Affect the ­features, and that if they do not, they cannot exist. Elsewhere
Diagnostic Confidence that a Positive in medicine, conditions abound that do not constitute distinc-
Response to a Comparative Diagnostic Block tive clinical syndromes. Most causes of chest pain cannot be
Is Truly Positive determined unless and until investigations such as radiography
are performed. Most causes of abdominal pain are not distinc-
Joint Pain* Diagnostic tive until imaging, laboratory tests, ultrasound scans, or endo-
Prevalence Comparative Confidence
(%) Block Yes No (%) scopic examinations are performed. For ­lumbar ­zygapophysial
joint pain, the definitive test consists of ­placebo-controlled,
30 Positive 30 24 55 diagnostic blocks.
Negative 0 46
15 Positive 15 30 33
Negative 0 55 Prevalence
5 Positive 5 33 13 Multiple studies have provided estimates of the prevalence of
Negative 0 62 lumbar zygapophysial joint pain. The prevalence estimates dif-
fer according to the population studied and the criteria used to
*Percent of patients who experience joint pain.
define a positive response.
720 Section IV—Regional Pain Syndromes
Among injured workers, with a median age of 38 years,
the prevalence was found to be 15% (95% confidence inter-
val, 10% to 20%).4 In an older population, without a history
of trauma, it was found to be 40% (27% to 53%).5 A similar
prevalence (45%; 39% to 54%) was found in a heterogeneous
population attending a pain clinic.40
These figures, however, may constitute an overestimate,
because the studies often used a generous criterion for a posi-
tive response to blocks. These studies considered that results
were positive for anyone who had greater than 50% relief of
pain. This response falls short of 100% relief, which would be
more compelling evidence that the zygapophysial joint tested
was the sole source of pain.
When complete relief of pain has been the required crite-
rion for a positive response to blocks, the prevalence in general
populations has been 7% or 5%.9,10,46,47 This finding suggests
that the prevalence of lumbar zygapophysial joint pain is sub-
stantially lower than commonly believed.
A modifying factor is the nature of the population tested.
Whereas lumbar zygapophysial joint pain seems uncommon
in younger, injured workers, it may be more common in older
persons. Using placebo controls and a criterion of 90% relief, a
study of older patients reported a prevalence of 32%.5
Pathology
The pathologic basis of lumbar zygapophysial joint pain is
not known. Lumbar zygapophysial joint pain is an entity with
an established source but elusive pathogenesis.
Although evident as a disease of the lumbar zygapophysial
joints,48,49 osteoarthrosis cannot be blamed. The radiologic
features of osteoarthrosis, as seen radiographically,50,51 or on
computed tomography (CT),52 do not correlate with the pres-
ence or absence of pain in the affected joint. Osteoarthrosis is
a normal age change and does not constitute a basis for zyga-
pophysial joint pain.
At postmortem examination, investigators showed that the
lumbar zygapophysial joints can sustain small fractures, which
are not evident in radiographs.53,54 In principle, such lesions
could be construed as likely causes of pain. Such lesions have
been detected stereoradiographically in living patients.55
However, these lesions have not been investigated with CT,
or other imaging tests, and have not been correlated with
­zygapophysial joint pain.
Disorders that can rarely affect the lumbar zygapophysial
joints are rheumatoid arthritis,56 infection,57–60 and pigmented
villonodular synovitis.61,62 These conditions, however, do not
explain the large numbers of patients whose pain is relieved
when their zygapophysial joints are anesthetized.
Treatment
Although readily diagnosed, lumbar zygapophysial joint pain
is not easily treated. Few treatments, explicitly for diagnosed
lumbar zygapophysial joint pain, have been tested, let alone
validated. No evidence indicates that conservative therapy of
any kind relieves zygapophysial joint pain, nor does evidence
suggest that fusing a segment relieves zygapophysial joint
pain. The tested treatments are limited to minimally invasive
procedures.
Intra-articular Steroids
Perhaps the most prolific treatment for lumbar zygapo-
physial joint has been intra-articular injection of corticos-
teroids.18–22,27–34 This treatment has a checkered past and a
vexatious future.
A review of the literature showed an abundance of descrip-
tive and observational studies on the use of intra-articular ste-
roids for lumbar zygapophysial joint pain.63 In none of these
studies, however, was injection of steroids tested in patients
with proven zygapophysial joint pain. Steroids were injected
presumptively, and without controls. The reported success
rates are therefore meaningless.
No rationale exists for the use of intra-articular steroids.
No evidence indicates that lumbar zygapophysial joint pain is
caused by inflammation. Steroids were adopted for zygapo-
physial joint pain simply on the strength that they appeared to
be effective for osteoarthritis in joints of the limbs.
Two controlled studies denied any efficacy of intra-articular
steroids. One studied patients with a presumed diagnosis of
zygapophysial joint pain and found no differences in outcome
among patients treated with intra-articular steroids, extra-
articular steroids, or intra-articular saline solution.64–66 The
other study attempted a diagnosis and recruited patients who
responded to a single diagnostic block.47 The outcomes after
intra-articular injection of steroids were no different from
those after injection of normal saline solution.47,63
Despite the objections that have been raised about these
studies, no other study has produced data that refute these neg-
ative results. Intra-articular steroids are no more effective than
sham treatment.
Radiofrequency Neurotomy
Radiofrequency neurotomy is a procedure in which pain from
a zygapophysial joint can be relieved by percutaneous coagula-
tion of the nerves that innervate the joint. It, too, is a treatment
with a checkered past.
This treatment was originally described as facet dener-
vation,67–71 and astounding results were claimed for it.67–87
Anatomic studies showed, however, that no nerves were
located where the electrode was placed.88,89 Nonetheless, this
finding did not dissuade some operators, who continued to
use the discredited technique,90,91 even in controlled trials.92
Anatomic studies showed that the articular branches to
the zygapophysial joints could not be selectively coagulated,
but their parent nerves—the medial branches of the dorsal
­rami—could be.88,89 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.88,89
Using the modified surgical anatomy, some studies claimed
successful results,93,94 but even that technique was flawed. A
­laboratory study showed that electrodes do no ­coagulate ­distally
from their tip.95 Therefore, an electrode placed ­perpendicular to
the course of the nerve would not reliably coagulate it. Because
electrodes coagulate circumferentially (i.e., sideways), to coag-
ulate the nerve, the electrode must be placed parallel to it.
This explanation has not been heeded. Operators still insist
on placing electrodes perpendicular or semiperpendicular to
 Chapter 90—Lumbar Facet Syndrome 721

A B C
Fig. 90.4 Lumbar radiofrequency neurotomy. A, Lateral view of the target zone. The course of the medial branch is depicted by the dotted lines.
B, Lateral view of the electrode in place, parallel to and on the nerve. C, Anteroposterior view of the electrode, inserted obliquely from below to lie
parallel to the nerve.

the target nerve, in the manner in which block needles are Similar success rates were encountered in three controlled
introduced onto the nerve.96–101 Doing so limits the chances of trials, two using sham treatment as the control100, 117 and one
coagulating the nerve thoroughly. If the nerve is incompletely using pulsed radiofrequency as the control.118 All three ­studies
coagulated, pain may not be relieved. If only a short length showed that relief of pain was associated with reduced need
of nerve is coagulated, pain relief may be only brief. Accurate for analgesics, and two studies showed improvements in
technique is paramount. An anatomically accurate technique disability.100,118
requires placing the electrode parallel to the target nerve and
creating either a lesion of sufficient magnitude or a sufficient
number of lesions to encompass all possible locations of the Conclusion
nerve102,103 (Fig. 90.4).
An irony applies. Lumbar zygapophysial joint pain is one of
Medial branch neurotomy is not a permanent cure. The
the best-studied and best-validated entities in pain medicine.
coagulated nerve will regenerate. Pain will recur. In that event,
At the same time, it is one of the most abused. Few other con-
however, the procedure can be repeated, and relief can be
ditions have an established anatomic basis, have a validated
reinstated. One study104 showed that, in patients whose pain
diagnostic test, and have a treatment that can abolish the pain.
recurred after an initially successful neurotomy, repeating the
Nonetheless, few practitioners practice according to the evi-
treatment reinstated relief. Two, three, and even four repeti-
dence. They do not use diagnostic blocks. They do not use pla-
tions continued to provide relief. The median duration of relief
cebo-controlled blocks so that their diagnosis is valid. They
following each repetition was just short of a calendar year.
use treatments that do not work, yet ignore treatments that do.
Multiple systematic reviews cast doubts on the efficacy of
They claim to use a procedure that has been proven to work,
lumbar medial branch neurotomy,105–108 as did several prac-
but use the wrong technique. It is difficult to find another
tice guidelines.109–112 In all instances, however, the procedure
realm of medicine with so much dissonance between science
was misrepresented. The reviews did not recognize the impor-
and practice.
tance of technical accuracy. As a result, they included studies
It is no wonder therefore that insurers and others are so
that used refuted or flawed techniques. Not surprisingly, these
opposed to lumbar facet syndrome and its management.
studies yielded negative results. This amounts to ­selection bias:
They are justified in being opposed to what is practiced, but
choosing studies for their negative results rather than stud-
they are not justified in opposing the science. Unfortunately,
ies that used correct technique. When only studies that used
those who follow the science responsibly are compromised by
correct or reasonable techniques were reviewed, the evidence
those who abuse it. Lack of recognition of lumbar facet syn-
supported lumbar medial branch neurotomy.113 The results
drome is not a scientific issue; it is a social one, in which the
of controlled trials did not refute the results of observational
lack of responsibility and discipline by medical practitioners
studies.
is to blame.
Three observational studies reported success rates of
80%,114 56%,115 and 43%,116 for relief of pain at up to 1 year.
All three studies showed that relief of pain was associated with
improvement of disability, and two studies showed reduced References
requirements for analgesia.115,116 Full references for this chapter can be found on www.expertconsult.com.