ChiroACCESS Clinical Review



Lumbar Facet Pain: Diagnosis

This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Lead Author(s): 

Dwain M. Daniel, D.C.

  

How this evidence was rated:

Strength of Recommendation Taxonomy (SORT)



Published on

July 31, 2008

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Several different authors estimate that 15 to 45% of all chronic low back pain is lumbar facet mediated pain (LFMP) (1-4). The “gold standard” for diagnosis, which is recognized by most experts, is a series of two facet blocks using anesthetics which are active for different periods of time. An initial block is given and if the patient receives a significant reduction of pain a second block is performed. If the second provides a longer period of relief then it is assumed the pain arises from the facet (5-8). It must be mentioned when Schulte et al reported on the outcomes of 21 studies of LFMP using injection therapy, radiofrequency therapy or cryorhizotomy only 50% of patients achieved successful outcomes (9). If the pain generator in these cases were the facet joints, why were the results not more impressive? It is possible that the gold standard may be better described as the “best standard available” but not quite golden.

LFMP is a clinically difficult diagnosis to make. The reader should be aware that many experts conclude only 15% of all non disc lesions can be accurately identified on clinical examination (10-14). Even when LFMP is suspected, it may be more accurate to provide a functional diagnosis in many cases.

In an attempt to identify patients for diagnostic blocks, several authors have attempted to determine if there are clinical signs which can accurately predict the presence of LFMP (15-18). The results of these investigations are the basis for the following reviews.

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References

1. 

Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine 1994 Apr 1;19(7):801-6.



2. 

Dreyer SJ, Dreyfuss PH. Low back pain and the zygapophysial (facet) joints. Arch Phys Med Rehabil 1996 Mar;77(3):290-300.



3. 

Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord 2004 May 28;5:15.



4. 

Manchukonda R, Manchikanti KN, Cash KA, Pampati V, Manchikanti L. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech 2007 Oct;20(7):539-45.



5. 

Manchikanti L, Pampati V, Rivera J, Fellows B, Beyer C, Damron K. Role of facet joints in chronic low back pain in the elderly: a controlled comparative prevalence study. Pain Pract 2001 Dec;1(4):332-7.



6. 

Bani A, Spetzger U, Gilsbach JM. Indications for and benefits of lumbar facet joint block: analysis of 230 consecutive patients. Neurosurg Focus 2002 Aug 15;13(2):E11.



7. 

Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, et al. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician 2007 May;10(3):425-40.



8. 

Sehgal N, Dunbar EE, Shah RV, Colson J. Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician 2007 Jan;10(1):213-28.



9. 

Schulte TL, Pietila TA, Heidenreich J, Brock M, Stendel R. Injection therapy of lumbar facet syndrome: a prospective study. Acta Neurochir (Wien ) 2006 Nov;148(11):1165-72.



10. 

Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363-70.



11. 

Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low bac pain? JAMA 1992;268:760-5.



12. 

Bogduk N. Diagnosing lumbar zygapophysial joint pain. Pain Med 2005 Mar;6(2):139-42.



13. 

Bogduk N, McGuirk B. Medical Management of Acute and Chronic Low Back Pain. An Evidenced Based Approach. Bogduk N, McGuirk B, editors. 115-126. 2002. Amsterdam, Elsevier Science BV. Ref Type: Serial (Book,Monograph)



14. 

Kirwan EO. Text Book of Pain. Wall PD, Melzack R, editors. 1989. Edinburgh, Churchill Livingstone. Ref Type: Serial (Book,Monograph)



15. 

Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique. Phys Ther 2007 Oct;87(10):1348-61.



16. 

Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994 May 15;19(10):1132-7.



17. 

Laslett M, McDonald B, Aprill CN, Tropp H, Oberg B. Clinical predictors of screening lumbar zygapophyseal joint blocks: development of clinical prediction rules. Spine J 2006 Jul;6(4):370-9.



18. 

Revel M, Poiraudeau S, Auleley GR, Payan C, Denke A, Nguyen M, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 1998 Sep 15;23(18):1972-6.



19. 

Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007 Oct;16(10):1539-50.



20. 

Schwarzer AC, Wang SC, Bogduk N, McNaught PJ, Laurent R. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995 Feb;54(2):100-6.



21. 

Laslett M, Oberg B, Aprill CN, McDonald B. Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test. BMC Musculoskelet Disord 2004;5:43.



22. 

Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 2003 Nov;3(6):460-5.



23. 

Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique. Phys Ther 2007 Oct;87(10):1348-61.



24. 

Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y. Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain 1997 Dec;13(4):303-7.



25. 

Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology 2007 Mar;106(3):591-614.



26. 

Borenstein D. Does osteoarthritis of the lumbar spine cause chronic low back pain? Curr Rheumatol Rep 2004 Feb;6(1):14-9.



27. 

Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine 2002 Nov 15;27(22):2538-45.



28. 

McDonald M, Cooper R, Wang MY. Use of computed tomography-single-photon emission computed tomography fusion for diagnosing painful facet arthropathy. Technical note. Neurosurg Focus 2007;22(1):E2.



29. 

Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology 2006 Feb;238(2):693-8.



30. 

Holder LE, Machin JL, Asdourian PL, Links JM, Sexton CC. Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome. J Nucl Med 1995 Jan;36(1):37-44.