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Anesthesiology 2007; 106:591614 Copyright 2007, the American ociety o! Anesthesiologists, "nc# $ippincott %illiams & %il'ins,

"nc#

Pathogenesis, Diagnosis, and Treatment ofLumbarZygapophysial (Facet) Joint Pain

Steven P. Cohen, M.D.,*Srinivasa N. Raja, M.D.

This article has been selected for the AnesthesiologyCME Program. After reading the article, go to http://www.asah.org/!o"rnal#cme to ta$e the test and appl% forCategor% & credit. Complete instr"ctions ma% be fo"nd inthe CME section at the bac$ of this iss"e.

Lumbar zygapophysial joint arthropathy is a

challenging condition afecting up to 15% o patients

with chronic low back pain. The onset o lumbar acet

joint pain is usually insidious with predisposingactors including spondylolisthesis degener!ati"e disc

pathology and old age. #espite pre"ious reports o a

$acet syndrome the e&isting literature does not

support the use o historic or physical e&amination

'ndings to diagnose lumbar zygapophysial joint pain.

The most accepted method or diagnosing pain arising

rom the lumbar acet joints is with low!"olume

intraarticular or medial branch blocks both o which

are associated with high alse!positi"e rates. (tandard

treatment modalities or lumbar zygapophysial joint

pain in!clude intraarticular steroid injections and

radiore)uency de!ner"ation o the medial branches

inner"ating the joints but the e"idence supporting

both o these is con*icting. +n this article the authorspro"ide a comprehensi"e re"iew o the anatomy

biomechanics and unction o the lumbar

zygapophysial joints along with a systematic analysis

o the diagnosis and treatment o acet joint pain.

"(C) its original *escription almost 100 yrago, tho+san*s o! scienti-c articles ha.e /eenp+/lishe* on l+m/ar ygapophysial l 3ointpain, an* !acet inter.entions represent thesecon* most common type o! proce*+re

per!orme* in pain management centers

thro+gho+t the nite* tates#1+t *espite the

plethora o! research an* clinical emphasis onthis *isor*er, almost e.ery aspect o! l 3ointpain, !rom *iagnosis to treatment, remainsmire* in contro.ersy# ).en among painspecialists, l+m/ar !acet 3oint pain remains amis+n*erstoo*, mis*iagnose*, an* improperlytreate* me*ical con*ition# "n this article,

* Associate ro!essor, epartment o! Anesthesiology an* CriticalCare 8e*icine, ohns op'ins chool o! 8e*icine, altimore,

8arylan*, an* %alter ee* Army 8e*ical Center, %ashington, #C# ro!essor, epartment o! Anesthesiology an* Critical Care 8e*icinean* epartment o! (e+rology, ohns op'ins chool o! 8e*icine#

ecei.e* !rom the ain 8anagement i.ision epartment o!

8e*icine, altimore, 8arylan*#+/mitte* !or p+/lication 8ay16, 2006# Accepte* !orp+/lication s o! the a+thors an* are notto /e constr+e* as o?icial or asre@ecting the .ie>s o! theepartment o! the Army or theepartment o! e!ense# r#Cohen recei.es partial salarys+pport !rom the ohn # 8+rtha(e+roscience an* ain"nstit+te, ohnsto>n,ennsyl.ania, an* the Army#r# a3a has +nrestricte* grants!rom Allergan "r.ine,

Cali!ornia an* ersey, an*ser.es as scienti-c a*.isor !orraleB =herape+tics =oronto,>>#anesthesiology#org#

l 3oint pain is *e-ne*in a !+nctionalcapacity as painoriginating !rom anystr+ct+re integral to/oth the !+nction an*con-g+ration o! thel+m/ar !acet 3oints,incl+*ing the -/ro+scaps+le, syno.ialmem/rane, hyaline

cartilage s+r!aces,an* /onyartic+lations#

A critical iss+e thatm+st /e a**resse*/e!ore em/ar'ing onany re.ie> o! l 3ointpain is >hether paincan /e *e-niti.elyattri/+te* to these

3oints# "n the 1960san* 1970s, this

E+estion pose* alegitimate contro.ersythat >as .igoro+sly*e/ate* in the

me*ical literat+re#2,

o>e.er, in the past20 yr, the scales o!this contro.ersy ha.eresol+tely tippe*to>ar* the con.ictionthat l 3oints can /ean* o!ten are a

primary so+rce o! lo>/ac' pain

$#4

Compelling e.i*ence+n*erlies thispara*igmatic shi!t inthin'ing# =he !acet

3oint caps+le an*s+rro+n*ingstr+ct+res are richlyim/+e* >ithnociceptors that -re

>hen the caps+le isstretche* or s+/3ecte*to local compressi.e

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patients an* .ol+nteers, chemical ormechanical stim+lation o! the !acet 3oints an*their ner.e s+pply has /een sho>n to elicit /ac'

an*For leg pain#710

+ring spine s+rgery per!orme* +n*er local anesthetic $A, l+m/ar !acetcaps+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.atingthem ha.e /een sho>n to relie.e pain in as+/stantial percentage o! patients >ith chronic

$#12

=here!ore, li'e other syno.ial 3oints in the

h+man /o*y, the l 3oints represent a potentialpain generator in patients >ith chronic $#

"n light o! the pre.alence o! l+m/ar !acet 3oint

pain an* the !reE+ency >ith >hich !acet /loc'sare per!orme*, se.eral re.ie>s ha.e /een+n*erta'en on this phenomenon in the past 15

yr# Altho+gh some o! these articles pro.i*e*

'een insight on.ario+s aspects o! thecon*ition, most >erelimite* /y theircon-ne* scope an*specialie* target

a+*iences# =hep+rpose o! this re.ie>

is there!ore to pro.i*ea comprehensi.e,e.i*ence/ase*!rame>or' on theanatomy,pathophysiology,pre.alence,*iagnosis, an*treatment o! l+m/ar!acet pain# Articlesre.ie>e* >ereo/taine* via

8)$"() an* aite1

-rstnote* that thepec+liarities o!

Anesthesiology, I 106, (o , 8ar 2007

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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 *issections o! 75 ca*a.ers,

+tti14

s+ggeste* that local in@ammation an*

*egenerati.e changes in l+m/ar !acet 3ointsco+l* res+lt in sciatica !rom irritation o! ner.e

roots# "n 19, Hhormley15 coine* the termJ!acet syn*rome,K >hich he *e-ne* asl+m/osacral pain, >ith or >itho+t sciatica, that>as li'ely to occ+r a!ter a s+**en rotatorystrain# hortly therea!ter, interest in the l

3oints as potential so+rces o! /ac' pain >ane*

a!ter the lan*mar' article /y 8iBter an* arr16

implicating l+m/ar *isc r+pt+re as the ma3orca+se o! lo> /ac' an* leg pain# =he 1940s sa> ares+rgence in the interest o! l 3oints as pain

generators >hen a*gley17

s+ggeste* that +p to

L0G o! cases o! $ an* sciatica are *+e tore!erre* pain !rom l 3oint pathology, ratherthan *irect ner.e root compression# "n 196,

irsch et al.7 p+/lishe* the -rst acco+nt

>here/y the in3ection o! l 3oints repro*+ce*

patientsM /ac' pain# ees,1L

>ho reporte* as+ccess rate o! 99#LG, is generally cre*ite* >ithpromoting perc+taneo+s J!acet rhiolysisK >ithhis gro+n*/rea'ing report in the early 1970s#$ater, it >as sho>n that the techniE+ea*.ocate* /y ees may not ha.e /een s+?icient

to achie.e rhiotomy in most patients#+oye*

/y a high inci*ence o! hemorrhagiccomplications, healy

19,20pioneere* the +se o!

@+oroscopically g+i*e* ra*io!reE+ency !acet*ener.ation to treat l 3oint pain in the mi*1970s#

specti.ely# =he me*ial/ranches o! $1$4*orsal rami co+rseacross the top o! theirrespecti.e trans.erseprocesses one le.el/elo> the name*

spinal ner.e e.g., $4crosses the trans.erseprocess o! $5,tra.ersing the *orsallea! o! theintertrans.erseligament at the /aseo! the trans.erseprocess# )ach ner.ethen r+ns *o>n>ar*along the 3+nction o!the trans.erse an*

s+perior artic+larprocesses, passing/eneath themamilloaccessory ligament an* *i.i*inginto m+ltiple /ranchesas it crosses the

.erte/ral lamina -g#1# "n some cases, themamilloaccessoryligament /ecomescalci-e*, >hich may

lea* to ner.eentrapment#

27 =his is

most common at $5approBimately 20G/+t also occ+rs at $410G an* $ 4G# "na**ition to t>o l

3oints, the me*ial

/ranches alsoinner.ate them+lti-*+s m+scle, theinterspino+s

m+scle an* ligament,an* the perioste+m o!

the ne+ral arch#7,2L 0

=he $5 ner.e *i?ersin that it is the *orsalram+s itsel! that r+nsalong the 3+nction o!the sacral ala an*s+perior artic+larprocess o! the

sacr+m#29,1

"ts

me*ial /ranch arisesopposite thein!erolateral corner o!the /ase o! the lo>est!acet 3oint# At thisle.el, it is the *orsalram+s rather than itsme*ial /ranch that isamena/le to/loc'a*e#

ome people mayha.e a/errant ora**itional inner.ationo! the !acet 3oints# "n ast+*y con*+cte* inasymptomatic

.ol+nteers, Naplan etal.2

!o+n* that 1 in 9s+/3ects >ho+n*er>ent $4 $5 n5 an* $51 n 4!acet 3oint me*ial/ranch /loc's 8!elt pain *+r

natomy and +nner"ation

=he l+m/ar !acet 3oints !ormthe posterolateral artic+lationsconnecting the .erte/ral arch o!one .erte/ra to the arch o! thea*3acent .erte/ra# As tr+esyno.ial 3oints, each !acet 3ointcontains a *istinct 3oint spacecapa/le o! accommo*ating/et>een 1 an* 1#5 ml o! @+i*, asyno.ial mem/rane, hyalinecartilage s+r!aces, an* a -/ro+s

caps+le#21

=he -/ro+s caps+leo! the l+m/ar !acet 3oint isapproBimately 1 mm thic' an*

tiss+earrange* in amore or lesstrans.erse

!ashion topro.i*emaBim+mresistance to

@eBion#22,2

=he 3ointcaps+le isthic'posteriorly,s+pporte* /y-/ers arising!rom the

m+lti-*+sm+scle#+periorly

* i ! i l

the caps+leattaches!+rther a>ay!rom the

osteochon*ralmargins,!ormings+/caps+larrecesses thatin the normal

3oint are -lle*>ith-/roa*iposemenisci#

Anteriorly, the-/ro+scaps+le isreplace* /ytheligament+m

@a.+m#24

)ach !acet3oint

recei.es*+alinner.ation!rom me*ial

/ranchesarising !romposteriorprimary ramiat the samele.el an* onele.el a/o.ethe

3oint#25,26

oreBample,the in!eriorpole o! the $4$5 !acet 3oint

recei.esinner.ation!rom the $4me*ial /ranch

an* itss+perior poleis inner.ate*/y the $me*ial/ranch, >hichare typically/loc'e* onthe trans.erseprocesses o!$5 an* $4, re

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/ig. 1. -ightlateral obli)ue

"iew o thelumbar

"ertebral bodiesand the dorsalrami medialbranches.

#rawing by /rank 0. ort0.(. 2-esearch

ssociate#epartment o-adiology

3ohns ,opkins,ospital4altimore0aryland.

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M0A 1ACET -(2T PA2 59

ing repeate* caps+lar *istension concor*ant>ith pain eBperience* *+ring pre.io+s l 3ointpro.ocation >itho+t 8# Ass+ming the /loc's>ere technically s+ccess!+l, one eBplanation !orthis -n*ing is that in a small s+/set o!

in*i.i*+als, a/errant inner.ation may acco+nt!or !alsenegati.e *iagnostic 8# ome a+thorsha.e s+ggeste* that l 3oints may also recei.einner.ation

!rom the me*ial /ranch /elo> the 3oint i.e., 1!or the $51 3oint,

,4 the *orsal root

ganglion,5

an* the

para.erte/ral sympathetic ganglia,6,7

/+tthese assertions remain +npro.en -g# 2#

istologic st+*ies ha.e *emonstrate* that thel+m/ar !acet 3oints are richly inner.ate* >ithencaps+late* +?initype en*ings, pacinian

corp+scles, +nencaps+late*, an* !ree ner.een*ings#

5 =he presence o! lo>threshol*,

rapi*ly a*apting mechanosensiti.e ne+ronss+ggests that in a**ition to transmittingnocicepti.e in!ormation, the l !acet caps+lealso ser.es a propriocepti.e !+nction# esi*ess+/stance an* calcitonin generelate*pepti*e, a s+/stantial percentage o! ner.een*ings in !acet caps+les ha.e also /een !o+n*containing ne+ropepti*e O, in*icating the

presence o! sympathetic e?erent -/ers#L,9

(er.e -/ers ha.e also /een !o+n* in

s+/chon*ral /one an* intraartic+lar incl+sionso! l 3oints, signi!ying that !acetme*iate* painmay 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*ins4

an* the in@ammatory cyto'ines

interle+'in 1 , interle+'in 6, an* t+mor necrosis

!actor44

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 three3oint compleB, consistso! the paire*

ygapophysial 3ointsan* the inter.erte/ral*isc# =ogether, these

3oints !+nction tos+pport an* sta/iliethe spine, an* pre.ent

in3+ry /y limitingmotion in all planes o!mo.ement#8acroscopically, each!acet 3oint is compose* o! aposterome*ially!acing conca.es+perior artic+larprocess !rom thein!erior .erte/ral/o*y, an* a smaller

anterolaterally !acingin!erior artic+larprocess !rom thes+perior spinal le.el#=he shape an*orientation o! the l

3oints *etermine therole each plays inprotecting the spineagainst eBcessi.emotion# acet 3ointsoriente* parallel to

the sagittal planepro.i*e s+/stantialresistance to aBialrotation /+t minimalresistance to shearing!orces /ac'>ar* an*!or>ar* sli*ing,>hereas 3ointsoriente* more in acoronal plane ten* toprotect against @eBionan* shearing !orces

/+t pro.i*e minimalprotection against

rotation -g# #24

"n

an anatomical st+*yp+/lishe* in 1940 /y

or>it an* mith,45

the a+thors !o+n* thatthe $4 $5 3ointsten*e* to /e morecoronally positione*almost 70P >ithrespect to the sagittalplane, >hereas the

$2$ an* $$43oints >ere li'ely to /eoriente* more parallel 40P to the sagittalplane# "n more recentst+*ies /y 8ashara>i

et al.46

an* +n3a/i et

al.,47

the in.estigators

!o+n* that the +pperl+m/ar !acet 3oints=12$2 >ereoriente* closer to themi*sagittal plane o!the .erte/ral /o*ymean range, 26P4P, >hereas thelo>er !acet 3ointsten*e* to /e oriente*a>ay !rom that plane40P56P# "n the+pper l+m/ar spine,approBimately L0G o!the !acet 3oints arec+r.e*, an* 20G are

@at# "n the lo>erl+m/ar spine, thesen+m/ers are

re.erse*#45

t+*ies /y

Hro/ler et al.4L

an*

o*en et al.49

!o+n* a

positi.e association/et>een *egenerati.espon*ylolisthesis an*more sagittally oriente* lo>er l+m/ar

!acet 3oints#

"n yo+ng people, thel 3oints are E+itestrong, capa/le

/ig. 6. (chematicdrawing o the spinal

cord and segmentalspinal inner"ation.#rawing by (pecialist/rank and ngela#ill 7( rmy and/rank 0. ort 0.(.2-esearch ssociate

#epartment o-adi!ology

3ohns ,opkins,ospital4alti!more0aryland.

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