AUTHOR AND EDITOR INFORMATION

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
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INTRODUCTION

Section 2 of 11  

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• Workup
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• Follow-up
• Miscellaneous
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Background

Low back pain (LBP) remains a common musculoskeletal complaint, with a reported lifetime incidence of 60-90%. Various structures have been incriminated as possible sources of chronic LBP, including the posterior longitudinal ligament, dorsal root ganglia, dura, annular fibers, muscles of the lumbar spine, and facet joints.

In 1911, Goldwaith first implicated the facet joints as a source of LBP. In 1933, Ghormley described the facet syndrome, and in 1941, Badgley endorsed the idea of the facets as the cause of LBP, based on pathomorphologic studies of the joint.^{1, 2} Rees in 1972 and Shealy in 1974 accepted the notion and developed techniques in which the joint allegedly could be denervated to stop pain stemming from the facet joints.^{3, 4}

In 1963, Hirsch and colleagues injected normal saline into facet joints, demonstrating that facet joints can produce LBP.⁵ Systematic studies began in 1976, when Mooney and Robertson used fluoroscopy to confirm this location of intra-articular lumbar facet joint injections of normal saline in asymptomatic volunteers.⁶ (Three years later, McCall and colleagues did the same.⁷) These injections of normal saline caused back and lower extremity pain. In addition, Mooney and Roberts documented relief of low back and lower extremity pain in these patients after injection of local anesthetic into the provoked facet joints. A 1989 study by Marks demonstrated similar findings in patients with chronic LBP.⁸

In 1991, Kuslich and colleagues probed facet joint capsules in patients undergoing lumbar decompression surgeries and found that pain could be induced.⁹ Many investigators developed techniques to diagnose facet joint pain using intra-articular joint blocks and medial branch nerve blocks, as well as ways to treat such pain with intra-articular steroids, surgical ablation, or radiofrequency (RF) denervation. Controversy continues regarding the true prevalence, most accurate diagnostic methods, and most efficacious treatment of symptomatic lumbar facet joints. (See also the eMedicine articles Lumbosacral Facet Syndrome and Paraspinal Injections: Facet Joint and Nerve Root Blocks.)

Pathophysiology

Bones of the spine articulate anteriorly by intervertebral disks and posteriorly by paired joints. The latter, formally known as zygapophyseal joints (but commonly termed facet joints), are true synovial joints, with a joint space, hyaline cartilage surfaces, a synovial membrane, and a fibrous capsule. Two medial branches of the dorsal rami innervate the facet joints. Medial branches of the lumbar dorsal rami issue from their respective intervertebral foramina, cross the superior border of the transverse process, and then run medially around the base of the facet joint before innervating the joints.

In studies, autonomic nerves and nociceptive, substance P–immunoreactive nerve fibers and autonomic nerves have been identified in the lumbar facet joint capsule and synovial folds. Douglas and colleagues identified substance P–immunoreactive nerve fibers in erosion channels that extended through the subchondral bone and calcified cartilage into the articular cartilage. Giles and Harvey identified them in the inferior recess capsule and synovial folds, whereas Ashton and coauthors found them running freely in the facet capsule stroma.^{10, 11} Grönblad and colleagues demonstrated sparsely distributed substance P–immunoreactive nerve fibers in facet joint plical tissue.¹²

The presence of nociceptive nerve fibers in the various tissue structures of facet joints, as well as the existence of autonomic nerves there, suggests that these structures may cause pain under increased or abnormal loads. Substance P is a well-known inflammatory mediator that may sensitize nociceptors to them and other mediators, resulting in chronic pain.

Like other joints, the facet joints consist of bone, cartilage, synovial tissue, and menisci that are rudimentary invaginations of the joint capsule. In the synovial fluid of patients with rheumatoid arthritis, osteoarthritis, or traumatic joint disease, increased levels of prostaglandins have been measured and are implicated as an important cause of pain. Prostaglandin, a known inflammatory mediator, also is released from facet joints.

Biomechanically, facet joints assume a prominent role in resisting stress, and their importance is well established. A cadaveric study by Adams and Hutton demonstrated that the facet joints resist most of the intervertebral shear force and share in resisting the intervertebral compressive force, albeit only in lordotic postures.¹³ In the rotation of the spine, the facet capsular ligaments are the spinal ligaments that undergo by far the most strain. They protect the intervertebral disks by preventing excessive movement.

Frequency

United States

The prevalence of facet joint pain in the general population or in persons with acute back pain has not been investigated. The reported rate of facet joint pain for patients with chronic LBP ranges from 4-75%. The reported prevalence seems to be a function of the size of the sample studied and the conviction of the authors.

Three studies report the prevalence of lumbar facet joint pain among chronic LBP patients based on 100% relief of pain using less than 2 mL of intra-articular diagnostic injection. In 1988, Jackson and colleagues reported that 7.7% of 454 patients with chronic LBP had 100% relief with diagnostic injection.¹⁴ In 1991, Carette and co-authors reported that 11 (5.8%) of 190 patients experienced complete relief of symptoms with a single lidocaine injection.¹⁵ In 1994, Schwarzer and colleagues reported that 7 (4%) of 176 patients reported 100% relief.^{16, 17} This last study was the most stringent of the 3 because the authors performed a second confirmatory block with bupivacaine, documenting longer relief of pain commensurate with the longer half-life of the local anesthetic.

When less stringent criteria are used, higher prevalences of lumbar facet joint pain are reported. In 1988, Moran and colleagues reported relief in 9 (16.7%) of 45 patients using 1.5 mL of bupivacaine.¹⁸ Pain provocation followed by pain relief with local anesthetic was used as the diagnostic criterion. In 1992, Schwarzer and co-investigators reported relief in 9 (9.8%) of 92 patients, using a 50% reduction of pain as the criterion and employing double-block screening with lidocaine and confirmatory bupivacaine block.¹⁹ In a separate investigation, Schwarzer and colleagues reported a prevalence of 26 (15%) of 176 patients, using the same diagnostic criterion.^{16, 17}

In another study, Schwarzer and co-authors reported that 23 (40.3%) of 57 patients obtained pain relief of 50% or more pain with bupivacaine but experienced no relief with saline control injection.²⁰ A 2004 study by Manchikanti and colleagues reported a 27% prevalence rate of lumbar facet pain, using controlled, comparative local anesthetic blocks of the dorsal medial nerves.²¹

Higher prevalence rates are reported when control blocks are not used. In 1984, Raymond and Dumas—using a strict intracapsular technique but no control block—reported a 16% prevalence rate.²² In 1992, Revel and co-authors reported that 22 (55%) of 40 subjects had pain relief of 75% or more and that 17 (42.5%) of 40 patients had greater than 90% relief of their pain with a single intra-articular lidocaine injection.²³

As seen from these data, reports of prevalence are a function of the investigators' choice of selection criteria. Studies requiring the most stringent criteria (100% relief of symptoms after a diagnostic block) report a 4-7.7% prevalence rate of facet joint pain among chronic LBP patients. Investigations using double blocks and requiring 50% relief report prevalence rates of about 10-15%. Numerous other studies using a single diagnostic block report prevalence rates of 16-75%.

International

See Frequency/United States.

Mortality/Morbidity

No studies specifically address the mortality and morbidity of chronic back pain from facet joint–mediated pain. The mortality and morbidity of chronic LBP, however, have been extensively addressed.

Race

No studies specifically address the correlation between the prevalence of facet-mediated chronic LBP and race.

Sex

No studies specifically address the male-to-female prevalence ratio of chronic, facet-mediated LBP.

Age

A higher prevalence among the older population would be expected if the etiology of facet joint–mediated back pain arose from degenerative changes of the joint, similar to the way it does in other osteoarthritic joint damage. One small study by Revel and colleagues and a larger investigation by Jackson and co-authors noted that older patients responded more commonly to diagnostic injections.^{14, 23} The 1995 study by Schwarzer and colleagues involving 57 patients reported higher positive response rates in older patients (40%), even with the use of saline control injections.²⁰ They noted that the average age of patients was 59 years, which was higher than the average age in studies reporting much lower prevalence rates.

CLINICAL

Section 3 of 11  

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History

Little controversy surrounds the facet joint as a possible source of chronic LBP. Innervation and possible inflammatory mediators of the joint have been elucidated. Pain upon provocation of the joint, relief upon anesthetization of the same joint in healthy volunteers, and chronic LBP in patients have been documented. Although initially described as a syndrome, investigators now prefer to term it facet joint pain. By definition, a syndrome is a group of signs and symptoms that occur together and characterize a particular abnormality; however, no signs or symptoms have been identified as unique to facet-mediated pain.

A major source of frustration for clinicians has been the fact that no reliable means exist to document a clinical diagnosis of lumbar facet joint pain without the use of invasive techniques. If the true prevalence of facet joint pain was 40-75%, as initially reported, a clinical profile might not be crucial, because all chronic LBP patients would warrant investigation for this disorder. However, a prevalence of 10-15% would indicate that a clinical profile would be important in preventing the indiscriminate use of diagnostic and/or therapeutic blocks.

Biomechanical studies of the facet joint during extension and of facet capsular ligaments strained during rotation initially provided the belief that facet joint pain is worse with extension and rotation. Early studies by Helbig and Lee provided initial credence to this belief, but later studies by Revel and co-authors and by Schwarzer and colleagues did not support it.

Revel's investigation found that an increase in pain during hyperextension and extension-rotation was, in fact, less frequent in the group that responded to the facet joint injection than in the group that did not.²³

The characteristics of lumbar facet joint pain include the following:

• Location of pain.
• • Lumbar facet joint pains are lateralized and can radiate below the knee. They rarely, if ever, cause axial or central back pain.
  • In their study of 26 patients selected by way of differential diagnostic blocks, Schwarzer and colleagues observed that no patients with central pain responded to diagnostic blocks of the facet joints.^{16, 17} This study also refuted the commonly held notion that pain below the knee is unlikely to be referred from the facet joint.
• Clinical features of facet joint pain.
• • In their large 1988 study, Jackson and co-authors could not identify clinically specific facet syndromes or predict with any degree of accuracy which patients were more likely to respond to facet diagnostic blocks.¹⁴ They concluded that facet syndrome is not a reliable clinical diagnosis.
  • Studies addressing the pattern of referred pain have been unable to distinguish pain from different levels. However, a generally held belief is that facet joint pain is more prevalent among the older population, is more lateralized, and is a more likely diagnosis when radiographic findings show severe facet arthritis.

Physical

See History.

Causes

The cause of most lumbar facet pain is unknown. On occasion, the lumbar facet joints are affected by systemic inflammatory arthritides, such as rheumatoid arthritis and ankylosing spondylitis. The following is a more specific look at sources of LBP:

• Microtrauma of the facet joints can produce pain. Small fractures, capsular tears, splits in the articular cartilage, and hemorrhage have been documented on postmortem studies of trauma victims who had normal radiographic findings. Whether these abnormalities were painful was not recorded.
• Osteoarthritis is another cause of lumbar facet joint pain. However, not all cases of facet arthritis are painful; the radiographic changes of osteoarthritis are as common in patients with LBP as in those without it. Some studies report that severely degenerated joints are more likely to cause symptoms.
• Dory attributed LBP from facet syndrome to distention and inflammation of the synovial capsule, with resultant stimulation of the nociceptive nerve endings.²⁴ Expanded synovial recesses may also compress nerve roots in the spinal canal and neural foramina, which may explain the presence of radicular pain in patients with facet syndrome. Lippitt attributed pain in facet syndrome to a combination of synovitis, segmental instability, and degenerative arthritis.²⁵
• Other theories regarding the causes of LBP include meniscoid entrapment, synovial impingement, joint subluxation, chondromalacia facette, capsular and synovial inflammation, mechanical injury to the joint capsule, and the restriction of normal articular motion from soft or articular causes.

DIFFERENTIALS

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Other Problems to be Considered

Sacroiliac joint syndrome
Internal disk disruption syndrome
Lumbar spondylosis

WORKUP

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Lab Studies

• No specific laboratory studies are necessary when a diagnosis of lumbar facet arthropathy (LFA) is being considered.

Imaging Studies

• Abnormalities on plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans are not specific for patients with back pain; degenerative changes are often found in asymptomatic persons. Although some clinicians may use plain radiography and CT scanning to investigate or even diagnose facet joint pain, no radiographic findings identify lumbar facet joints as the source of LBP and referred lower extremity pain.
• A limited number of studies have attempted to establish correlation between osteoarthritic changes and response to blocking of the joints. While some earlier studies demonstrated such a relationship, others have failed to do so. Furthermore, findings from MRI scans, CT scans, dynamic bending radiographs, and radionuclide bone scans cannot be used to reliably help predict lumbar facet joint pain.
• Schwarzer and colleagues concluded that CT scanning has no place in the diagnosis of lumbar facet joint pain.²⁶ They used the stringent criteria of 80% pain relief for the duration of bupivacaine anesthesia and negative relief with saline control injection. The investigators did not observe any correlation between CT-scan findings and response to diagnostic injections. (For another view on the use of CT scanning in the diagnosis of facet joint pain see Use of Computed Tomography–Single-Photon Emission Computed Tomography Fusion for Diagnosing Painful Facet Arthropathy, on Medscape.)

Procedures

• The use of diagnostic blocks is fundamental to a diagnosis of lumbar facet joint pain. Regardless of the symptoms, one characteristic that all patients with such pain share is the relief of pain once a local anesthetic has been injected. Fluoroscopically guided blocks of the joints constitute the only available standard to correlate with any clinical or radiographic test for facet joint pain.²⁷
• Single diagnostic blocks are a poor standard. Those employed without the provision of controls led to a false-positive rate of 38% in a lumbar study¹⁶ and a 27% false-positive rate in a cervical study, with a 32% placebo rate in still another investigation. If an investigator relied on a single, uncontrolled block, 1 of every 3 apparently positive blocks would be a false positive. A reliable diagnosis must be accompanied by observation in relation to control subjects.
• Control observation can be achieved either with saline injection around the joint while shielding the patient from view of the injections or through use of a confirmatory block. In a confirmatory block, relief achieved with the first local anesthetic is accompanied by relief provided by a second injection for a duration commensurate with the half-life of the second local anesthetic. A patient with genuine facet joint pain should experience relief with the first injection and feel no relief if injected with saline or, if injected with the confirmatory block, experience the same relief that he/she did with the first injection, but for a longer period of time.
• The use of double blocks to confirm facet pain is not without limitations. When an appropriate duration of relief with a confirmatory block was required, Lord and colleagues found in cervical studies that specificity was high (88%) but that sensitivity was low (54%) in comparison with double-blinded, randomized, placebo-controlled triple blocks.²⁸ When diagnostic criteria for the double blocks were expanded to include all patients with reproducible relief, regardless of duration, sensitivity increased to 100% but specificity was lowered to 65%. The authors concluded that a clinician's choice of controls depends on the implications of the results. If innocuous therapy is prescribed, relief of pain, regardless of duration, with a double block may suffice. When diagnostic certainty is critical, such as in a medicolegal context or when surgical intervention is contemplated, placebo-controlled blocks are recommended.
• The use of saline around the joint for control observation also has limitations. Of the various possible combinations of responses to 2 injections, pain relief in the same patient with local anesthetic and with saline poses a dilemma. The clinician could conclude that the patient does not have facet joint pain, having falsely responded to the local anesthetic and to the saline. However, a response to the saline injection does not necessarily negate the validity of the first injection with local anesthetic; it may instead indicate that the patient responded to a placebo. The individual may have true facet pain in addition to being a placebo responder. Because of this, some clinicians often proceed with RF neurotomy in patients who obtain 80% relief with lidocaine and with saline, depending on the clinical presentation. Studies are being conducted to report outcomes based on such an approach.
• Facet diagnostic blocks can be performed intra-articularly and at the dorsal medial branches that supply the joint. The latter site is used if the joint is not accessible or as a means of avoiding the theoretical risk of needle damage to the joint. Barnsley and Bogduk found that local anesthetic blocks of the cervical medial branches are a specific test for the diagnosis of cervical facet joint pain. In their study, local anesthetic always reached the target nerve and did not affect any other diagnostically important structures.²⁹ Dreyfuss and colleagues determined that, with the use of appropriate technique, lumbar medial branch blocks are target specific.³⁰ The use of 0.5 mL of lidocaine adequately bathed the site of the target nerve and trivialized the spread to the dorsal root or the epidural spread to other potential pain generators.
• With well-controlled studies reporting 7-14% prevalence rates for facet joint pain, clinicians must adopt stringent criteria for diagnosing facet joint pain to avoid unnecessarily subjecting a large portion of chronic LBP patients to various treatments aimed at facet joint pain.

TREATMENT

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Rehabilitation Program

Physical Therapy

No studies have compared the efficacy of one type of physical therapy over another in treating LFA. Once the diagnosis of facet joint pain is confirmed and pain is brought under control with appropriate treatment, experienced clinicians generally recommend physical therapy for reconditioning, as well as lumbar stabilization exercises. (See also Long-Term Effect of a Combined Exercise and Motivational Program on the level of Disability of Patients With Chronic Low Back Pain, on Medscape.)

Surgical Intervention

Currently, no surgical intervention is advocated for lumbar facet joint pain.

Consultations

The diagnosis of LFA can be made by a practitioner who is proficient in diagnostic spinal injections and who has specialty training in musculoskeletal spine medicine. Interventional physiatrists are uniquely qualified to evaluate LFA because they possess the technical skills required to administer spinal injections and have an appreciation of musculoskeletal medicine.

Other Treatment

Facet joint pain is usually not considered until conservative measures for treating LBP have been tried without success. No current studies advocate or assess the efficacy of specific physical therapy or manipulations aimed at treating facet joint pain.

Currently, 2 treatments are available for facet joint pain. These are (1) intra-articular steroid/local anesthetic injection under fluoroscopic guidance (see Images 1-3) and (2) RF ablation to block the joint from all sensory input. Some authorities have also advocated the use of pulsed RF at a lower temperature. A third treatment option is surgical fusion of the joint, but no published reports describe such treatment for LFA. Details about treatment with injection or ablation are as follows:

• Intra-articular facet joint injection - Numerous early studies are not worth mentioning because of their serious flaws with diagnostic criteria, the location of injections, and the injection volumes used. A study by Lynch and Taylor was able to demonstrate that intra-articular injection was superior to extra-articular injection, but, after 6 months of follow-up, the statistical significance had disappeared.³¹
• • In 1989, Lilius and colleagues prospectively studied 109 patients with chronic LBP. They were distributed randomly into 1 of 3 groups that received injections of intra-articular cortisone/anesthetic, intra-articular saline, or pericapsular cortisone/anesthetic. Although pain relief was substantial, with 36% of patients reporting benefits that persisted for up to 3 months, no significant differences were noted between groups. These results led the authors to conclude that facet joint injection is a nonspecific method of treatment and that good results reflect the tendency of LBP to undergo spontaneous remission. Two critical flaws are noted in this study. First, the authors did not preselect subjects with diagnostic facet joint injections. Second, the intra-articular facet joint injection volumes of up to 8 mL were excessive.
  • In 1991, a controlled study by Carette and coauthors randomized patients into 2 groups; one group received an intra-articular methyl prednisolone/local anesthetic mixture and the other received intra-articular saline.¹⁵ Patients were preselected with local anesthetic into the facet joints at L4-5 and L5-S1 and reported pain relief of greater than 50%. When the patients were tracked for 6 months, no difference in pain relief was noted between the 2 groups, with the data suggesting that intra-articular facet joint injections with corticosteroids were not effective in treating chronic LBP. This study was flawed in that only a single lidocaine injection, which is subject to false-positive readings and placebo responses, was used to determine the presence of facet joint pain. Furthermore, the assumption that saline is a true inert placebo may be flawed.

    Other studies have shown that saline provides pain relief to a greater degree than would be expected from placebo. At 6-month follow-up, 46% of the steroid group and 15% of the saline group had good pain relief; however, the authors invalidated this finding because only a portion of both groups that reported pain relief at 1 month had actual pain relief at 6 months.

• RF neurotomy of the dorsal medial nerve branch (see Images 4-7) - Five controlled studies have reported on the effectiveness of this procedure, and 1 study has reported on the effectiveness of repeated RF neurotomy for lumbar facet pain.
• • In the first study, from 1994, Gallagher and colleagues reported successful outcomes at up to 6 months of follow-up in patients who were treated with RF, compared with those who underwent sham treatments.³² Single intra- or extra-articular diagnostic injections were used, with inclusion criteria of good or equivocal response. Shortcomings of the study were the small number of subjects, short duration of follow-up, and poor diagnostic criteria. Differential blocks were not used.
  • In the second study, from 1999, van Kleef and coauthors reported that a 1-year follow-up, significant pain reduction was found in 7 of 15 patients who were treated with RF, compared with 2 of 15 patients who had undergone sham treatment.³³ The diagnostic criterion was a single diagnostic joint injection with subsequent pain relief of 50% or more. Shortcomings of the study were the number of subjects and the fact that differential blocks were not used.
  • In the third study, from 2000, Dreyfuss and co-investigators reported a rate of successful outcome of 87% at 1-year follow-up in 15 patients; the individuals were treated with RF after successful differential diagnostic injections.³⁴ Weaknesses of this study were the number of subjects and the lack of a control group. However, strict diagnostic criteria were used, including 80% pain relief and differential blocks with lidocaine and bupivacaine.
  • In the fourth study, from 2001, Leclaire and colleagues reported on 70 patients who were randomized to RF treatment versus sham treatment after single diagnostic facet injections yielded good pain relief.³⁵ No differences in outcome between the groups were noted at 12 weeks of follow-up. A large patient population was used, but the diagnostic criterion was poor. Single diagnostic injections with good relief are not valid to differentiate a facet joint pain population.
  • In the fifth study, from 2005, van Wijk and coauthors reported on 81 patients randomized to RF treatment versus sham treatment after a single diagnostic facet joint injection yielded 50% pain relief.³⁶ No differences in outcome were noted between the groups. This study was again flawed by the limitation of single diagnostic injections. Careful reading of the study shows that although the authors reported on 462 patients, after accounting for excluded patients and dropouts, 37 had negative responses to the diagnostic injection and 81 had positive responses to the diagnostic injection, yielding an unusually high prevalence of facet joint pain.
  • In 2004, Schofferman and Kine retroactively reported on the effectiveness of repeated RF neurotomy for lumbar facet pain.³⁷ In 20 patients who had undergone a repeat RF treatment, an 85% success rate at a mean duration of 11.6 months was achieved.
• Conclusions for treatment of facet joint pain
• • Studies suggest that intra-articular steroid injections are not a valid treatment option, although they can be used for diagnostic purposes or for short-term pain relief. RF ablation requires further research.
  • Of the first 5 studies reviewed above, 3 showed favorable outcomes, and 2 did not. Although the 2 studies that demonstrated no significant favorable outcomes utilized a larger population of patients, their use of a single diagnostic injection and their employment of a rather loose inclusion criteria of 50% pain relief or good pain relief were inadequate for differentiating a facet joint population. The study that used a strict 80% pain relief with differential block criterion did demonstrate a rather high success rate with RF treatment. However, this study lacked a control group.
  • RF ablation appears to be safe, with most studies reporting no associated complications. The complications that have been previously reported related to electrical faults and included cases of small superficial burns. A 2004 report by Kornick and colleagues on 616 treated lesions showed a 1% complication rate for neuritis.³⁸ The investigators reported no other complications.

MEDICATION

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Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for medical therapy of LFA. Peripherally acting analgesics include NSAIDs and acetaminophen. NSAIDs are the DOC in the initial pharmacologic treatment of acute episodes of LFA or following acute exacerbation of chronic pain.

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Name	Ibuprofen (Ibuprin, Motrin)
Description	DOC for patients with mild to moderate pain. The drug inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	400 mg PO q4-6h; not to exceed 2400 mg/d
Pediatric Dose	<6 months: Not established 6 months to 12 years: 10 mg/kg PO q6-8h; not to exceed 40 mg/kg >12 years: Administer as in adults
Contraindications	Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Naprelan, Naprosyn, Aleve)
Description	For the relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in decreased prostaglandin synthesis.
Adult Dose	250, 375, or 500 mg PO bid; not to exceed 1500 mg/d
Pediatric Dose	<2 years: Not established >2 years: 5 mg/kg PO bid
Contraindications	Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency
Interactions	Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Name	Nabumetone (Relafen)
Description	Nonacidic NSAID that is rapidly metabolized after absorption, becoming a major active metabolite that inhibits the COX enzyme (thereby inhibiting pain and inflammation).
Adult Dose	1000 mg/d PO; not to exceed 1000 mg PO bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; active peptic ulceration, hepatic impairment
Interactions	Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Elderly may require lower doses; caution in hepatic and renal impairment

Drug Name	Ketorolac (Toradol)
Description	Inhibits prostaglandin synthesis by decreasing the activity of COX, which results in the decreased formation of prostaglandin precursors.
Adult Dose	<65 years: 60 mg IM initially, followed by 15-30 mg PO q6h prn; not to exceed 5 d of treatment >65 years: 30 mg IM initially, followed by 15 mg PO q6h prn; not to exceed 5 d of treatment
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Interactions	Co-administration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with pre-existing renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs

Drug Category: Cyclo-oxygenase-2 Inhibitors

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeding is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost and avoidance of GI bleeding will further define populations that will most benefit from COX-2 inhibitors.

Drug Category: Analgesics

Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

FOLLOW-UP

Section 8 of 11  

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• Follow-up
• Miscellaneous
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Further Inpatient Care

• LFA does not require inpatient management; outpatient workups and treatments are adequate.

Further Outpatient Care

• Various treatments are available in an outpatient setting for patients with facet joint arthropathy. Please refer to the Treatment section for a more complete discussion.

Patient Education

• Patients need to be educated in all aspects of their diagnosis and to be informed of all treatment options. As with any condition affecting the back, patients need to have a good understanding of proper body mechanics and back safety techniques; they also require daily activities to prevent worsening of symptoms. Participation in physical therapy may be helpful in improving spinal range of motion and strength. The patient should be instructed in a lumbar spine stabilization program when appropriate.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Muscle Disorders Center. Also, see eMedicine's patient education articles Back Pain, Chronic Pain, and Pain Medications.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to exclude other common and uncommon causes of chronic LBP is a potential pitfall because LFA shares similar features with other conditions. Before lumbar facet joint pain is considered, organic causes of chronic back, pain such as tumor, rheumatologic disorders, and referred pain from the abdomen, pelvis, and thorax, must be considered and excluded.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Anteroposterior view of right L4-5 facet intra-articular injection with contrast.
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Media file 2:  Lateral view of right L4-5 facet intra-articular injection with contrast.
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Media file 3:  Oblique view of right L4-5 facet intra-articular injection with contrast.
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Media type:  X-RAY

Media file 4:  Anteroposterior view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala).
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Media type:  X-RAY

Media file 5:  Lateral view of right L5 dorsal medial branch needle position (tip of the needle is at the neck of the sacral ala, just below the L5-S1 facet joint).
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Media type:  X-RAY

Media file 6:  Anteroposterior view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process).
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Media type:  X-RAY

Media file 7:  Lateral view of right L4 dorsal medial branch needle position (tip of the needle is at the neck of the right L5 transverse process, just below L4-5 facet joint).
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Media type:  X-RAY

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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