Clinical outcomes and patient satisfaction are dependent on proper diagnosis. A definitive diagnosis should create a pathway of care to provide the patient with a realistic prognosis. Unfortunately, that is not always the case in clinical practice.
Lumbar Facet Syndrome is one of the most common diagnoses made by chiropractors. Watch Dr. Steele make the differentiation between diagnosing Facet Syndrome and a less frequent variant called Maigne’ Syndrome. He also shares some clinical pearls addressing evaluation and treatment that will dramatically impact your clinical results.
“Lumbar facet syndrome” describes acute or chronic inflammation of a lumbar zygapophyseal joint. The facet joint is thought to be the source of pain in 15-45% of patients with chronic low back pain. (1-6) The literature is mottled with various explanations for the genesis of facet syndrome, including a capsular sprain, joint hypomobility, synovial cysts, and degeneration. (7-9) The term “facet syndrome” shares many common characteristics with intersegmental joint dysfunction, to the point that some clinicians characterize facet syndrome as the medical equivalent of intersegmental joint dysfunction.
Treatment for Facet Syndrome is often a home run with manipulation.
Routine medical care for facet syndrome includes ADL advice, rehab exercises, myofascial release, and chiropractic manipulation. See ChiroUp’s condition reference to see all the evidence-based evaluations, treatments, and rehabilitation for Facet Syndrome. If management is unsuccessful, a patients’ next option may be pain management. Physiatry management of facet syndrome includes fluoroscopically-guided intra-articular zygapophyseal joint steroid injections and radiofrequency ablation of the medial branch to (temporarily) eliminate all sensory input from the facet joint. Currently, the gold standard for (allopathically) treating facetogenic pain is radiofrequency treatment. The evidence supporting intra-articular corticosteroids is limited: hence, reserved for those individuals who do not respond to radiofrequency therapy.
What do you do when your treatments for Facet Syndrome do not work?
There is a cohort of patients that receive little to no benefit after conservative care and radio frequency ablation. Non-response will often lead to confusion and usually a dissatisfied patient. What if the patient and physician are wrong, and the pain is not originating from the lower lumbar spine?
Failed LBP cases often end up in our offices.
In patients with unilateral LBP not radiating down the leg, worse with extension (Kemp’s Yeomans’s), skin hypersensitivity at the lumbosacral junction, and failed radiofrequency ablation consider Maigne’s Syndrome. Maigne found that some low back pain is from irritation of the lateral branches of the spinal dorsal rami at the thoracolumbar region. These lateral branches originating from T12 and L1 innervate the dermatome just below the lateral iliac crest and posterior to the anterior superior iliac, while the L2 and L3 lateral branches innervate the buttocks. More importantly, there are no cutaneous branches of the L4 and L5; mimicking sensory symptoms occurring in the lower back.
Here are some great tips to make the diagnosis of dorsal ramus mediated LBP originating from the lumbosacral or thoracolumbar spine.
- Thoracolumbar joint dysfunction
- Accompanied by muscle spasm
- Primary pain is in the upper lumbar spine radiating distally
- Lumbosacral joint dysfunction
- Most commonly occurs in the lower lumbar segments such as L5- S1, L4-5, and L3-4 respectively.
- Pain occurs at the level of spinal joint dysfunction
Hindsight is always 20/20—especially in healthcare. Physicians commonly encounter obscure diagnoses resembling a standard presentation on a daily basis. To avoid this common mistake: always ask patients which activities, postures, and past treatments provide relief or exacerbate their condition. These answers with an appropriate exam will lead to a more definitive diagnosis preventing you from reinventing the wheel with procedures and recommendations. Check out ChiroUp’s clinical pearls section within the condition reference section. Our board of directors has outlined the most pertinent information to help solve non-responsive cases in practice.
When people seek chiropractic care, often they are looking for a solution that requires a different thought process. The difference in treatment becomes the mindset and training of the practitioner. Understanding diagnosis, prognosis, the standard of care, patient education, and achieving excellent outcomes is your responsibility as a chiropractor. Access to 700 videos on treatment strategies, learn from condition references from over 90 conditions and network with a group of evidence-based providers looking to advance our profession. ChiroUp will show you how to save time, improve your clinical outcomes, and market your outcomes. Together we can show a greater percentage of the population HOW and WHY we are the best choice for non-surgical musculoskeletal care. Try ChiroUp at no cost for 14 days.
- Ray CD. Percutaneous Radiofrequency Facet Nerve Blocks: Treatment of the Mechanical Low Back Syndrome. Radionics Procedure Technique Series. Burlington, Mass: Radionics Inc; 1982.
- 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, 19:1132-1137.
- Manchikanti L, Singh V, Pampati V, Damron K, Barnhill R, Beyer C, Cash K: Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001, 4:308-316.
- Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333
- van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. 12. Pain originating from the lumbar facet joints. Pain Pract 2010;10:459-69.
- Bogduk N: International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophyseal joint blocks. Clin J Pain 1997, 13:285-302
- Malanga GA et al. Lumbosacral Facet Syndrome MedScape www.emedicine.medscape.com/article/94871-overview. Accessed 2/15/14.
- Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933;101:1773-7.
- Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br. May 1954;36-B(2):304-22
- Kozera K, et al. Posterior Branches of Lumbar Spinal Nerves – Part III: Spinal Dorsal Ramus Mediated Back Pain – Pathomechanism, Symptomatology and Diagnostic Work-up. Ortop Traumatol Rehabil. 2017.
About the Author
Dr. Brandon Steele
Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.