Lumbar Facet Syndrome

Definition
  1. Lower back pain originating from the facet (zygapophyseal joint) and/or joint capsule is referred to as Lumbar Facet Syndrome.
  2. Medical branch of posterior primary rami innervate joint capsule (each joint is innervated from two spinal levels)
  3. Estimated that 15% – 40% of lower back pain cases originate from the facet joints.

Aetiology

Facet Syndrome Pain may be due to:

  1. Sprain of surrounding ligaments / joint capsule
  2. Synovial fold / meniscoid entrapment
  3. Degenerative joint disease of the zygapophyseal joint

Facet Joints & joint capsules are innervated by the medial branch of the dorsal nerve root from the segment above. For example, L4-L5 segment is innervated by L3 nerve root. Medial branch also innervates spinalis muscles (transversospinalis), skin of the back (sensory) & ligaments around articular structures. Lumbar Facet Syndrome


History, Signs & Symptoms

  1. Antalgic Posture, patient is laterally bent away from the side of the lesion.
    • Typically patients posture is away from the facet in acute phase, resulting in a slight flexion & lateral flexion position
    • May notice abnormal pelvic tilt / hip rotation secondary to tight hamstrings
    • In chronic cases, a decreased lumbar lordosis is often observed (body’s response to decreased facet loading)
  2. Dull, Achy Pain – May be sharp during acute episodes
  3. Local pain – Patient can pinpoint pain
    • Scleroderma! referral of pain
    • Pain may radiate to buttock & proximal thigh but does not extend bellow knee
  4. More Pain on Extension than flexion
    • Pain increases with movement & extension – due to the proximation of the facet joints
  5. Possible muscle splinting & guarded motions
  6. Orthopaedics
    • (+) Kemp’s Test – For back pain, NOT radiculopathy
    • (+) Tests that cause lumbar spine extension or lateral
    • (-) Nerve root tension signs
  7. Look for postural and/or activity-induced predispositions to extension motions
  8. No neurological deficits, negative nerve root tension signs
  9. Consider Meniscoid Entrapment, Discogenic Pain & Lumbar Strain or Sprain as potential differentials or coexisting factors.

Management

  1. Lumbar facet syndrome response extremely well to osseous manipulation
    • May free entrapped meniscoid
    • Muscle relaxation reflex may help with symptoms of pain and limited movement
  2. Standard manual therapy protocol
    • Ice and rest
    • Lumbar spine traction
    • Corsets/brace – neutral to slightly flexed lumbar brace may help unload the facet joints
    • Massage therapy, hydrotherapy
    • Electrotherapy: TENS, IFC, Ultrasound
  3. Conditioning and proprioceptive retraining
  4. Patient education – Avoid postions & activities that cause increased facet loading
  5. Surgical treatment: chronic cases that fail to respond to conservative care may respond well to facet denervation as a last resort.