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Lumbar Facet Syndrome

By Emily Ball
Fall 2014

Brief Review
Syndrome: a group of symptoms that consistently occur
together or a condition characterized by a set of
associated symptoms.
Not just one cause, a mixture of multiple things

Facet syndrome: form of osteoarthritis. Usually in older


people affecting their cervical and lumbar spine.

Facet joint
Also referred to as zygapophysial joint or z-joint.
Gives stability as well as allows for bending and twisting
of the spine.

EBP Question
What is lumbar facet syndrome
and how is it treated?

Background
Male baseball player, 19 years old
Former football player in HS
Some previous injury but ignored symptoms and kept playing. The
symptoms eventually faded with rest.

Right handed pitcher.


Began having LBP on his left side after pitching in scrimmages
during practice.
Described pain as nagging and sharp.
Weight room caused great discomfort

Continued activity with conservative treatment for 1 week


Heat, e-stim, stretching
Still complained of severe LBP in the same spot for over 1 week.
TTP over L4/L5.

Background
Re-evaluation completed
Special tests performed
single leg stance w/rotation (+)
Straight leg raise (-)
Fabers (-)

Removed from activity until further evaluation by physician.

Evaluation done by Dr. Stull (10/19)


Raised concerns of possible spondylysis on the left side, L4/L5.
Insisted on further imaging

X-ray results
No spondylysis, spondylolisthesis or disc degeneration
Pars interarticularis defect.

MRI for further results

Results
MRI
Inferior articular facet fracture at L5 on the left side
Fluid at fracture sight and in facet joint
No right side fracture or pars defect
Diagnosed as lumbar facet syndrome

Treatment
Walking on the treadmill
Starting at a slow pace and shorter time and then
increasing weekly
Good posture while walking

Wall sits
Varying time, number of sets, as well as form.

Watkins lumbar stabilization exercises


Core strengthening exercises
Alternating plank and push up series by day.

Research
Clinical Features of Patients with Pain Stemming from the Lumbar
Zygapophysial Joints: Is the lumbar facet syndrome a clinical entity? by
A. Schwarzer et al.
176 patients with low back pain
106 men, 70 women

17-80 years old; mean age of 38.4


Patients that had back surgery and/or neurological symptoms were excluded

Injuries
52% work related
20% motor vehicle accident
62% Unilateral pain
9% Central pain
29% Bilateral pain

Research
Questionnaire for all participants
History, physical examination, and results of all procedures.
Date of onset of LBP
Mechanism of injury
Site of LBP
Pattern of referred pain
Worse with sitting/standing/walking?

ROM exam
Testing for pain
Flexion, extension, rotation of trunk L/R, rotation to R w/L extension
(and vice versa).

Supine straight leg raise


Pain in leg or back?

Research
Treated with z-joint (facet joint)
blocks
0.5 mL of 2% Lignocaine (local
anesthetic) and 0.5% bupivacaine
(local anesthetic)
Used Lignocaine at initial
treatment and bupivacaine for
comfirmatory block.

Applied at site of pain


Re-evaluated after 10 minutes
Worse, no change, partial,
definite, and complete
If definite or complete asked to
return for confirmatory block
71 patients

Research
Results
83 patients reported definite or complete responses to
lignocaine blocks
26 patients reported 50% or greater improvement of pain
with bupivacaine block.
Still not sure if patients strictly responded to diagnostic
blocks of zygapophysial joints
May be source of pain but unsure if facet syndrome is
an actual cause of pain.

Research
The Impact of Sagittal Balance on low back pain in
Patients Treated with Zygoapophysial Facet Joint
Injection by L. Proietti et al.
40 patients
Evaluated degree of degradation of facet joints with MRI
Results reported with the visual analogue scale pre and
post treatment.
Injected with 1 mL Triamcinolone acetonide
(coricosteroid) 40 mg and 0.5 mL Bupivacaine (anesthetic)
0.5%
Outcomes measured pre-operative, days 1-15, 1 month,
and 3 months out.

Results
28/40 patients had improvements of symptoms
12/40 had showed no improvements
93 articular joints treated
22 patients had level 1 injection
18 patients had double level injection

L3-L4 treated in 25% of cases


L5-S1 treated in 17% of cases
Lumbar facet joint syndrome common 15-52% in patients
presenting with LBP

How it applies
Currently starting athlete on throwing exercises
Will monitor daily to check for any problems

If pain persists after returning to play, CT scan will be


done and the possibility of facet injections will be
discussed if necessary.

Capsular stretching
Capsule tears can also be a concern.
Happen due to trauma at facet joint
Can lead to subluxation of facet joint which leads to
damage of the capsule

This is relevant for the athlete due to the stresses he


applies on the capsule with his rotation during pitching.

Surgical vs. non-surgical


Non-surgical
Rest
Rehab
Core and back strengthening exercises
Light passive stretching

Hot/cold modalities
Injections
Facet blocks

Medications
NSAIDS, opiods, facet joint blockers

Massage, yoga, acupuncture.

Surgical vs. non-surgical


Surgical:
Lumbar spine fusion surgery
Only severe cases that also have disc involvement
Degenerative disc

Majority of people handle it conservatively


Found primarily with elderly population

Progression
Currently walking, running, and lifting normally
Weight room restrictions
Only body weight or weight vest
No activities loading the spine

Starting playing catch last week (12/1)


Reports that he does have slight pain while throwing.
Decreased distance that he was throwing 90-120ft
Re-evaluate on Monday.

Compare and contrast


As of now our patient has received only conservative
treatment
Not many studies on this to compare.

Lumbar facet joint injections may be an option


Both studies proved that this was beneficial for patients

Surgery is currently not necessary for the patient

Answer question
Lumbar facet syndrome:
Not just one cause
Irritation of spinal nerves due to pressure caused by
inflammation of the facet joint
Capsular stretching causing irritation
Also tiny tears possibly causing inflammation

Possible fracture and/or defect of the pars interartiularis


Degenerative vertebral discs
Seen primarily in elderly

Activity
Everyone find a wall!

Questions?

References
Proietti, L., Schiro, R., Sessa, S., Scaramuzzo, L., The impact of sagittal
balance on low back pain in patients treated with zygapophysial facet
joint injection. European Spine Journal, 23: S628-S633, 2014.
Schwarzer, A., Aprill, C., 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, 19:10 1132-1137, 1994.
Tessitore, E., Molliqaj, G., Schatlo, B., Schaller, K., Clinical evaluation
and surgical decision making for patients with lumbar discogenic pain
and facet syndrome. European Journal of Radiology. 1-5, 2014.
Willems, P., Decision making in surgical treatment of chronic low back
pain: The performance of prognostic tests to select patients for lumbar
spinal fusion. ACTA Orthopaedica Supplementum 84: 3-35, 2013.

References
http://www.physio-pedia.com/Lumbar_Facet_Syndrome
http://www.spine-health.com/conditions/arthritis/treat
ment-options-facet-joint-pain
http://emedicine.medscape.com/article/310069-clinica
l
http://www.spine-health.com/treatment/injections/cervi
cal-thoracic-and-lumbar-facet-joint-injections
http://www.thehealthybackblog.com/tag/holistic-chiro
practor-abbotsford/page/3/
http://www.sullivanil.us/SYB.html
https://www.bnasurg.com/patient-resources-back-pain

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