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Lumbar Zygapophysial Joint Pain

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Anatomy

The lumbar zygapophysial joints are true synovial joints. They have hyaline cartilage that overlies the subchondral bone, a synovial membrane, a fibrous joint capsule, and a joint space (1-2mL).

Histological studies have shown encapsulated and free nerve endings, and the presence of substance P and calcitonin gene-related peptide.

Pathology

The causative pathology of lumbar zygapophysial joint pain is unknown.[1] It is thought to occur through trauma and cumulative stress over a lifetime. Possible sources are the synovial villi, capsule, and meniscal or synovial entrapments. What is clear however is that degenerative changes as detected radiographically are not associated with low back pain.[2]

Excessive compression or torsion can lead to microfracture and capsular avulsion of the zygapophysial joints. These post-traumatic structural changes have been shown in laboratory studies and postmortem pathoanatomic studies, but not in any antemortem studies. There are no validated techniques of identifying pathology during life[3]

It can be illustrative to compare with the cervical zygapophysial joints. In the cervical spine the joints face upwards and backwards, and therefore equally share the compressive load with the discs. Injuries are most likely to occur from weight bearing, and degenerative changes occur at all levels, most commonly at C3/4. In the lumbar spine, the zygapophysial joints face posteriorly and laterally, and share little of the axial load. The joints resist axial rotation and anterior translation. Degenerative changes arise earlier, most commonly at L4/5.

Epidemiology

Figure 2. Sources of pain in chronic low back pain as a function of age.[4] Copyright © 2020 American Academy of Pain Medicine
Figure 3. Probability of CLBP sources by age and BMI for males and females.[5] FJP = facet joint pain, SIJP = sacroiliac joint pain, IDD = internal disc disruption.

On the whole, studies have reported prevalence rates of around 30%.[6] This compares to about 40% for disc pain, and 20% for sacroiliac joint pain.

In many studies, complete relief of pain was not a diagnostic criterion, but was usually 50% or 80%. As a diagnostic test, there is a balance between sensitivity and specificity depending on the cut off, with a higher relief of pain criterion resulting in a higher specificity but lower sensitivity.

The argument of using a cut-off lower than 100% is usually around the possibility of having more than one source of pain. King and Bogduk[3] reference two studies[7][8] to argue that patients with chronic low back pain only rarely have concurrent sources of pain, and so placebo responses can't be excluded. They note that if 100% relief of pain is used then the prevalence drops to about 5% or less.[9][10][11][12]

They continue however that the prevalence appears to be highly dependent on age. In a study of the elderly using a 90% criteron, 34% were positive.[13] A later study with two publications found that the prevalence was 2% in those 20-35, 5-10% in those 35-50, 20% in those 50-65, and 30-40% in those over 65. There was also an association with age and BMI.[14][15] (figures 2 and 3) It appears that in certain groups the prevalence is as high as internal disc disruption.

Importantly, there is no association with zygapophysial joint osteoarthritis.[3]

Clinical Features

No reliable clinical features or imaging findings that are diagnostic

ZJ pain can cause back pain with referral into the lower limb Some cases of chronic low back pain can be relieved by anaesthetisation of the lumbar ZJ

  • Like IDD, no clinical features that distinguish lumbar ZJ pain from other causes
  • Often unilateral, but can be bilateral
  • In a study by Mooney and Robertson[16], which demonstrated pain referral patterns of 5 normal and 15 abnormal volunteers (chronic LBP +/- sciatica) by injecting hypertonic saline:
    • 2 patients – pain crossed the midline
    • 3 patients – pain encompassed entire leg and foot
    • Increased stimulus (i.e volume) = increased pain and increased radiation distally
    • Localization of pain in the low back, buttock, and leg is a non-specific finding
    • In all subjects, pain abolished by lignocaine

Diagnosis

Lumbar zygapophysial joint pain cannot be diagnosed through standard clinical means, nor through plain films, CT, or MRI. It can only be diagnosed by controlled diagnostic blocks.

The diagnostic criteria utilising controlled comparative diagnostic local anaesthetic blocks of the medial branches is the gold standard for diagnosis. This method has been shown to be durable over time with repeated testing at 1 year and 2 years.[17] A single block is not recommended due to the high false positive rate.[18] See Causes and Sources of Chronic Low Back Pain for a full discussion.

Treatment

Precision Treatment

Main article: Lumbar Facet Joint Precision Treatment

Lumbar radiofrequency ablation has level 2 evidence but but patients must be selected by two positive medial branch blocks with >80% pain relief. Repeated therapeutic medial branch blocks also has level 2 evidence.

See Also

References

  1. ↑ Bogduk. Low back pain In: Clinical and Radiological Anatomy of the Lumbar Spine. 5th Edition. Elsevier 2012
  2. ↑ Kalichman L, Li L, Kim DH, Guermazi A, Berkin V, O'Donnell CJ, Hoffmann U, Cole R, Hunter DJ. Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976). 2008 Nov 1;33(23):2560-5. doi: 10.1097/BRS.0b013e318184ef95. PMID: 18923337; PMCID: PMC3021980.
  3. ↑ 3.0 3.1 3.2 Wade King and Nikolai Bogduk. Chronic Low Back Pain In: Bonica's Management of Pain. 2018
  4. ↑ DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011 Feb;12(2):224-33. doi: 10.1111/j.1526-4637.2010.01045.x. Epub 2011 Jan 25. PMID: 21266006.
  5. ↑ DePalma et al.. Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain medicine (Malden, Mass.) 2012. 13:498-506. PMID: 22390231. DOI.
  6. ↑ DePalma MJ. Diagnostic Nihilism Toward Low Back Pain: What Once Was Accepted, Should No Longer Be. Pain Med. 2015 Aug;16(8):1453-4. doi: 10.1111/pme.12850. Epub 2015 Jul 27. PMID: 26218010.
  7. ↑ 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 (Phila Pa 1976). 1994 Apr 1;19(7):801-6. doi: 10.1097/00007632-199404000-00013. PMID: 8202798.
  8. ↑ Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine (Phila Pa 1976). 1995 Jan 1;20(1):31-7. doi: 10.1097/00007632-199501000-00007. PMID: 7709277.
  9. ↑ Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, Latulippe M. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med. 1991 Oct 3;325(14):1002-7. doi: 10.1056/NEJM199110033251405. PMID: 1832209.
  10. ↑ Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine (Phila Pa 1976). 1988 Sep;13(9):966-71. doi: 10.1097/00007632-198809000-00002. PMID: 2974632.
  11. ↑ 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 Nov 16;5:43. doi: 10.1186/1471-2474-5-43. PMID: 15546487; PMCID: PMC534802.
  12. ↑ 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-Aug;6(4):370-9. doi: 10.1016/j.spinee.2006.01.004. PMID: 16825041.
  13. ↑ 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. doi: 10.1136/ard.54.2.100. PMID: 7702395; PMCID: PMC1005530.
  14. ↑ DePalma et al.. Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain medicine (Malden, Mass.) 2012. 13:498-506. PMID: 22390231. DOI.
  15. ↑ DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011 Feb;12(2):224-33. doi: 10.1111/j.1526-4637.2010.01045.x. Epub 2011 Jan 25. PMID: 21266006.
  16. ↑ Mooney V, Robertson J. The facet syndrome. Clin Orthop Relat Res. 1976;115:149–156.
  17. ↑ Pampati S, Cash KA, Manchikanti L. Accuracy of diagnostic lumbar facet joint nerve blocks: a 2-year follow-up of 152 patients diagnosed with controlled diagnostic blocks. Pain Physician. 2009 Sep-Oct;12(5):855-66. PMID: 19787011.
  18. ↑ Manchikanti L, Kosanovic R, Pampati V, Cash KA, Soin A, Kaye AD, Hirsch JA. Low Back Pain and Diagnostic Lumbar Facet Joint Nerve Blocks: Assessment of Prevalence, False-Positive Rates, and a Philosophical Paradigm Shift from an Acute to a Chronic Pain Model. Pain Physician. 2020 Sep;23(5):519-530. PMID: 32967394.
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