6.

CAD2 - Lower back conditions

• Katey Paczek
• August 2019
Learning Outcomes:
At the end of this presentation the student will be able to:
• Describe sensory innervation to the lumbar Z joints
• Explain how the Z joint can be a possible source of pain
• Describe conditions which can affect lumbar Z joints
• Describe features of facet pain: referral pain patterns, aggravating
factors
• Describe etiology, presentation & diagnosis of a patient with piriformis
syndrome
• Differentiate piriformis syndrome from piriformis trigger points &
piriformis hypertonicity
Lumbar Z joints/Facet Joints (FJ)
• Synovial joints - hyaline cartilage overlying subchondral bone synovial
membrane and a joint capsule.
• Joint space presents capacity of 1–2mL
Lumbar Z joint (Facet Joint – FJ) as a source
of pain, continued from previous lecture
• Dual nerve supply: medial branch of dorsal rami from same level &
level above => multilevel innervation could be one reason why pain
from Z joints has broad referral pattern (nociceptive innervation has
also been found in lig. Flavum adjacent to z joints)
• Substance P has been found in subchondral bone of articular facets in
patients with degen. facets = subchondral bone can be source of pain
in individuals with O.A.
• Facet joint block – confirm that Z joints can be a source of lumbar
pain
Conditions which affect Z joints
• Zygapophyseal joints develop osteoarthritis similar to that of all
diarthrodial joints
• Facet joint degenerative osteoarthritis is the most frequent form of FJ
pain - tied to degeneration of the intervertebral discs. Degen. discs =>
increased facet weight bearing
• Inflammation generated by degeneration of FJs and surrounding
tissues is believed to be a cause of local pain
• Radicular symptoms may be evident in the presence of facet
hypertrophy, synovial cysts and osteophytes.
Conditions which affect Z joints
Other Conditions which may also affect zygapophyseal joints and cause
pain:
• inflammatory arthritides
• synovial impingement
• meniscoid entrapment
• pseudogout (Calcium Pyrophosphate Dihydrate - Crystal Deposition
Disease or CPPD)
• Intrafacet cysts
Source: 2008 K.Saravanakumar and A.Harvey
Z joint Synovial folds
Z joint synovial folds (menisci) – synovium lined
extensions of joint capsule that protrude into
joint and cover part of hyaline cartilage.
Thought to: - provide lubrication to Z joint
through secretion of synovial fluid & protect
articular cartilage margins
Synovial fold is attached to capsule by loose
connective tissue. Synovial tissue and blood
vessels are distal to the attachment followed by
dense connective/fibrous tissue
Sensory nerve endings have been found in Z joint
synovial folds => entrapped synovial folds can be
a source of pain

Picture B: Coronal section through articular facet

shown in box
Picture C: Entrapped Synovial Fold
Z joint Synovial folds
Intra-articular synovial fold (Menisci) -
between articular surfaces of Z joint
Named as synovial folds rather than menisci
due to histologic composition
Chiropractic treatment
• Chiropractic adjustment may produce therapeutic benefit by relieving
synovial fold entrapment (synovial fold entrapment between capsule
& articular process)
• Theorised that spinal adjusting separates/gaps opposed articular
surfaces of the Z joint -> relieves direct pressure on synovial fold and
provide traction to the joint capsule => pulls the synovium
peripherally away from the entrapment
Z joint pain referral
• pain may be referred distally into the lower limb, thereby mimicking
sciatica: “Pseudo-radicular” lumbar pain
• typically radiates uni - or bilaterally to the buttock and the
trochanteric region (from the L4 and L5 levels), the groin and the
thighs (from L2 to L5), ending above the knee, without neurological
deficits.
• However, radiating pain may reach the foot, mimicking sciatic pain,
especially in cases of facet osteophytes or synovial cysts
(Source: R. Perolat 2018)
Facet joint radiating
pain (Source: R. Perolat 2018)
Blue: Posterior aspect of lower limb
from most frequent (dark blue), to less
frequent (light blue)
Dark blue: pain limited to lower back
Intermediate blue: radiating pain to the
posterior aspect of the buttocks
Light blue: radiating pain to posterior aspect
of lower limbs, may extend lower than knee
level

Green: Anterior aspect of lower limb possible

radiation areas
Facet joint radiating pain patterns (Source S. Cohen et.
al. 2007) – see article for full description
Facet pain aggravating factors:
• usually worse in the morning, during periods of inactivity
• following stress exercise, lumbar spine extension or rotary trunk
motions
• standing or sitting positions
• may be elicited on FJ palpation

(Source: R. Perolat 2018)

Piriformis Syndrome:
Piriformis Syndrome:
Patient presentation:
• Buttock pain & posterior thigh pain. Occasional calf pain
• Non traumatic onset
Piriformis Syndrome
• Peripheral entrapment of sciatic nerve at the pelvis
• Sciatic neuritis: due to piriformis spasm => mechanical &/or chemical
irritation of nociceptors of epineurium => pain/paraesthesia in
distribution of sciatic nerve. (May not be actual compression of nerve)
• Possible cause of extra spinal sciatica
• Local muscle spasm is usually palpable (Travel & Simonds Trigger Point
Manual - need to palpate muscle to confirm source of pain)
• Pain aggravated by: getting up from sitting position, hid adduction &
internal rotation, prolonged sitting position
Piriformis surface anatomy:

Piriformis palpation:
• https://www.youtube.com/watch?v=K8HdxiWnoVo
Sciatic Nerve
• L4-S2 Nerve roots
• Composed of two divisions: Peroneal (Common fibular) & Tibial
Anatomic relationship of
Sciatic nerve & piriformis
muscle – Different authors
variation in percentages
Anatomical proximity of sciatic nerve to
piriformis muscle puts it at risk of entrapment:
In about 15% of people all or part of sciatic
nerve passes through piriformis muscle=> these
people are more likely to be affected by
piriformis syndrome
84.2% people – undivided nerve exits sciatic
notch anterior to piriformis
11.7% - division of sciatic nerve pass between &
below bifid piriformis muscle belly (Peroneal
portion through piriformis, tibial portion is
anterior)
3.3% - division of nerve pass above & below
undivided muscle (Peroneal portion posterior,
tibial portion anterior to piriformis)
0.8% - undivided nerve passes between bifid
muscle bellies
(Beaton & Anson 2005)
Piriformis Syndrome
Etiology/predisposing factors:
• anomaly of sciatic nerve
• incorrect posture
• overuse of muscle
• sitting on a wallet
• activities that externally rotate thigh => strain of piriformis => local swelling
& irritation of sciatic nerve sheath => sciatic neuritis.
• direct trauma/blow to muscle (not common) -> fibrosis & adhesions
• hypertonic/spasm of piriformis
• sacroiliac joint dysfunction
Ortho testing
- Piriformis test (Magee)
- Bonnet’s test
- Hibb’s test
Piriformis syndrome cause?:
• Cause? - due to SI Joint dysfunction?
Note: Piriformis syndrome v’s piriformis
trigger points v’s piriformis hypertonicity
Piriformis Syndrome v’s Piriformis trigger
points
Piriformis Syndrome:
• Note some patients >1 condition.
• If patient presents with LBP => can confuse diagnosis!
Source
• Illustrated Orthopedic Physical assessment. 3rd ed. Ronald C Evans
Mosby
• Clinical Anatomy of the Spine, Spinal Cord and ANS. 3rd Ed. G. Cramer
& S. Darby
• Conditions Manual – Vizniak 3rd Ed