61 Pathogenesis, Diagnosis,
and Treatment of
Zygapophyseal (Facet)
Joint Pain
Chad M. Brummett | Steven P. Cohen
Low back pain (LBP) and neck pain represent an epi-
demic throughout the industrialized world. More than
75% of patients reporting spine pain are between 18 and
65 years old, thereby adding cost through lost productivity
and wages.1 Although the prevalence of LBP varies greatly
throughout the literature, some lifetime estimates are as
high as 84% to 90%,2,3 and the 5-year recurrence rate of
LBP may be as high as 69%.4 The lifetime prevalence of
neck pain has been estimated to be about 67%.5 The esti-
mated cost of treatment and lost wages for spine pain in the
United States each year is estimated to be more than $140
billion.1,4 As the population ages, the impact of LBP and
neck pain will continue to grow.
The zygapophyseal (facet) joint (z-joint) is a potential
source of neck, shoulder, midback, low back, and leg pain.
In addition, cervical facet disease can cause headaches.
Interventions on the z-joints are second only to epidural ste-
roid injections as the most common type of procedure per-
formed in pain management centers in the United States.6
Despite a great deal of research on the diagnosis and treat-
ment of facet pain, the issue still remains controversial.
This chapter discusses the relevant anatomy, mechanisms
of injury, prevalence, pain referral patterns, diagnosis, and
treatment of facet arthropathy.
ANATOMY AND FUNCTION
The spine is normally composed of 7 cervical, 12 thoracic,
and 5 lumbar vertebrae (see Fig. 61.1). The z-joints are
paired structures situated posterolateral to the vertebral
body. In conjunction with the intervertebral disk, they make
up what is commonly known as “the three-joint complex.”
Together, these joints function to support and stabilize the
spine and prevent injury by limiting motion in all planes
of movement. The lumbar z-joints are true synovial joints
formed from the superior articular process of one vertebra
and the inferior articular process of the vertebra above.
The volume capacity of these joints is approximately 1 to
1.5 mL in the lumbar region and 0.5 to 1.0 mL in the cervi-
cal region.7 The articular surfaces are covered by hyaline
cartilage and contain a fibrous capsule. The fibrous capsule
is about 1 mm thick and is formed mostly of collagenous tis-
sue arranged in a transverse fashion to provide resistance to
forward flexion.8,9 The superior and inferior joint borders
816
are formed by the fibrous capsule. In the lumbar spine, the
multifidus muscle serves as the posterior joint border, and
the ligamentum flavum replaces the fibrous capsule at the
anterior border.10 The position of the joint relative to the
sagittal and coronal planes helps determine the role that
the joint plays in protecting the spine against excessive
motion. Joints oriented parallel to the sagittal plane provide
little resistance to backward and forward shearing forces
but allow a greater degree of rotation, flexion, and exten-
sion. Joints oriented closer to the coronal plane will allow
less rotation, flexion, and extension but serve as excellent
protection against shearing forces. The cervical z-joints are
inclined at roughly 45 degrees from the horizontal plane
and angled 85 degrees from the sagittal plane. This align-
ment functions to prevent excessive anterior translation and
to assist the disks in weight bearing.11
The medial branch of the posterior rami supplies sen-
sory innervation to the facet joint. Each exiting spinal
nerve splits into an anterior and posterior primary ramus
(Fig. 61.2). The anterior ramus is the largest of the two
branches and the main source of motor and sensory fibers.
The posterior ramus divides into lateral, intermediate, and
medial branches. In the lumbar region, the lateral branch
provides innervation to the paraspinous muscles, thora-
columbar fascia, and sacroiliac joint and variable sensory
fibers to the skin overlying the spinous processes. The small
intermediate branch supplies the longissimus muscle. The
medial branch is the largest branch of the posterior primary
ramus and innervates not only the lumbar z-joint but also
the multifidus muscle, interspinal muscle and ligament,
and periosteum of the neural arch. To block sensory input
from one facet joint, two adjacent medial branches must be
anesthetized. In some people, facet joint innervation may
be derived from other sources.
Facet joints are imbued with a rich innervation contain-
ing encapsulated (Ruffini-type endings, pacinian corpus-
cles), unencapsulated, and free nerve endings.12 In addition
to being a potential pain generator, the z-joint capsule is
thought to serve in a proprioceptive capacity as well, as evi-
denced by the presence of low-threshold, rapidly adapting
mechanosensitive neurons. Kallakuri and colleagues used
immunocytochemistry to characterize the presence of sub-
stance P and calcitonin gene–related peptide–reactive nerve
fibers in the cervical facets of 12 human cadavers.13 In addi-
tion to substance P and calcitonin gene–related peptide, a