290
REVIEW ARTICLE
Low Back Pain and the Zygapophysial (Facet) Joints
Susan J. Dreyer, MD, Paul H. Dreyfuss, M D
ABSTRACT. Dreyer S J, Dreyfuss PH. Low back pain and
the zygapophysial (facet) joints. Arch Phys Med Rehabil
1996; 77:290-300.
A basic science and clinical review of low back pain due to
the lumbar zygapophysial (facet) joints was performed based
on a literature search of scientific journals and textbooks. Recent
studies estimate that 15% to 40% of chronic low back pain
is due to the zygapophysial joints. The histological basis for
zygapophysial joint pain has been scientifically established, but
the precise clinical etiology remains undetermined. There are
no unique identifying features in the history, physical examina-
tion, and radiological imaging of patients with pain of lumbar
zygapophysial joint origin. Spine physicians diagnose zyg-
apophysial joint pain based on analgesic response to anesthetic
injections into the zygapophysial joints or at their nerve supply.
Studies on treatment of isolated zygapophysial joint pain are
limited. This review summarizes current understanding of lum-
bar zygapophysial joint disorders while highlighting the need
for additional research.
© 1996 by the American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and Rehabili-
tation
OW BACK PAIN (LBP) describes an ubiquitous symptom
L complex with a number of etiologies. Lifetime incidence
of LBP ranges between 60% and 90% ~3 and is the leading
cause of disability in people younger than 45 years of age. 4
Historically, LBP has often been attributed to lumbar disc herni-
ations. 5 However, other etiologies include pain due to the zyg-
apophysial joints, sacroiliac joints, exiting spinal nerve roots,
ligaments, muscles, viscera, and other nonspinal causes.
This review focuses on LBP due to the lumbar zygapophysial
(L-z) joints. A total of 145 references were examined based on
a Medline literature search covering the past 28 years, review
of bibliographies in textbooks, and review of bibliographies of
articles obtained throughout the search. Articles were chosen
for their historical, clinical, and scientific value. A trial was
considered to be a randomized controlled trial only if it met all
criteria proposed for reporting of randomized controlled trials. ~
No studies meeting all these criteria were identified. Further-
more, controlled trials specifically on z-joint pain require a gold
standard test of z-joint pain for inclusion. Presently, no such
gold standard exists. More recent research indicates one method
of identifying z-joint LBP is through diagnostic analgesic injec-
tions. Although this concept of diagnostic analgesic injections
From the Departmentof PhysicalMedicineand Rehabilitation,EmoryUniver-
sity, Atlanta,and GeorgiaSpineand Sports Physicians,Smyrna,GA (Dr. Dreyer);
and the Departmentof RehabilitationMedicine,Universityof Texas Health Sci-
ence Center at San Antonio, and The Neuro-Skeletal Center, Tyler, TX (Dr.
Dreyfuss).
Submitted lor publicationSeptember 14, 1995. Accepted in revised torm Au-
gust 3, 1995.
No commercialparty having a direct or indirect interest in the subject matter
of this articlehas or willconfera benefituponthe authorsor uponany organization
with which the authors are associated.
Reprintrequeststo SusanJ. Dreyer, MD, GeorgiaSpineand Sports Physicians,
P.C., 3903 South Cobb Drive, Suite 104, Smyrna,GA 30080.
© 1996by the AmericanCongressof RehabilitationMedicineand the American
Academy of Physical Medicineand Rehabilitation
0003-9993/96/7703-323453.00/0
Arch Phys Med Rehabil Vol 77, March 1996
has gained popularity, it has not been universally accepted as
a gold standard of identifying low back pain of z-joint origin.
Several studies identify themselves as controlled trials on the
treatment of z-joint pain, 7 t, but no study on z-joint pain was
found meeting all criteria proposed by The Standards of Re-
porting Trials G r o u p ) Of the articles included in this review,
29 trials were identified that did not meet all the criteria of
randomized controlled trials, but did compare the study group
with another similar group: 6 evaluated the clinical features of
z-joint pain, tH6 4 reviewed the prevalence, ~3~7-'~and 4 others
studied potential treatments for z-joint pain] "~ The remaining
comparison studies were included because they examined fea-
tures of LBP likely including z-joint pain 2°-28 or because they
provided information on treatment principles used in caring for
those with lumbar z-joint pain. 29 35 Forty-five additional uncon-
trolled research trials consisting mainly of case series were
included in this review. ~-3"3~77 The tendency for uncontrolled
research to yield promising results must be recognized. Further-
more, the difficulty in identifying patients with LBP due to the
z-joints limits the value of many of the studies because a reliable
determination of z-joint etiology was not made prior to inclu-
sion. The contamination of results by patients with LBP stem-
ming from other etiologies predictably dilutes any significant
findings for the z-joint population. These issues are discussed
in more detail in later sections.
In addition to the aforementioned reports, 39 basic science
studies, 5'7s-~5 18 review articles, 4~6 ~2 and 13 opinion state-
ments]33 ~45were included in an attempt to provide a comprehen-
sive, scientific overview of L-z-joint pain. Articles were classi-
fied as basic science studies if they primarily addressed issues
such as anatomy, biomechanics, pathophysiology, or technique.
Eighteen other articles were identified as review papers if their
focus was to summarize the literature rather than present new
data.4,116-132 Fotme~n opinion statements were also included.6"t33-145
Although commonly called "facet joints," the posterolateral,
paired joints of the spine are more accurately known as lumbar
zygapophysial joints. At times, L-z-joint mediated LBP is re-
ferred to as "posterior element pain" because of the posterior
position of the L-z-joints in relation to the intervertebral disc.
However, posterior element pain is a generic term and also
includes spondylolytic pain and pain from injury to the spinal
ligaments and muscles, in addition to pain emanating from the
L-z-joints. True L-z-joint pain is low back and lower extremity
pain caused by pathology in the L-z-joints.
Isolated L-z-joint stimulation may cause both axial and lower
extremity pain (fig 1).~,~.~6,~0~.,~The prevalence of L-z-joint pain
based on single diagnostic blocks has been reported to range
from 7.7% to 75%, 7"15"16"42"44"50"52"55"57"59"65"66"69"87"104"125 with the
larger samples with fewer inclusion criteria reporting the lower
prevalence rates. 52"65"69~25 Recent inquiry using a double-block
diagnostic paradigm found a 15% prevalence of L-z-joint pain
among patients with chronic LBP who were referred to two
tertiary American centers. ~9 Saline controlled diagnostic block
in a population of patients sent to an Australian rheumatologist
found a 40% prevalence of L-z-joint pain. t3 The double block
diagnostic paradigm requires two separate L-z-joint injections
(intra-articular L-z-joint injections or medial branch blocks),
each employing a different local anesthetic. Each injection
should result in a significant and physiologic reduction in pain.
 LOW BACK PAIN AND THE Z-JOINTS, Dreyer 291

provocative injections into the L-z-joints was later confirmed

with fluoroscopically guided injections. ")3J°4

NORMAL ABNORMAL
Fig 1. Pain referral patterns produced by intra-articular injections of hy-
pertonic saline in a~ymptomatic (normal) and symptomatic (abnormal)
patients. (Reprinted with permission? °4)
Duration of pain relief should reflect the pharmacokinetics and
half-life of the local anesthetic employed. For example, pain
relief after an injeCtion of bupivacaine should outlast the analge-
sia obtained after a lidocaine injection. Analgesia after a single
session of L-z-joi it injections has a 32% to 38% false-positive
rate/7'~8 Diagnosi:; of L-z-joint pain based on physiological re-
sponses to two s~parate anesthetic injections best eliminates
these false-positi~ e responses without the use of inert agents or
needle placement:,. 18,29.38J35.136
Lumbar z-joint injections provide diagnostic information, but
their therapeutic iole remains to be determined. A number of
uncontrolled studies report therapeutic benefit from L-z-joint
corticosteroid inj(',ctions. 15"16"42"44'46'55'59'65'87'104'116'126"137However,
significant, lasting benefit has not been uniformly demonstrated,
especially in the more scientific comparison trials. 7'9'") Other
treatments for LB ~ have been applied to L-z-joint pain but have
not been evaluat~ d in populations with pure z-joint pain in a
controlled fashior
ANATOMY
The L-z-joints are paired, true synovial joints that comprise
the posterolateral articulation between vertebral levels. Each
joint is comprised of a larger, posteriorly and medially facing
concave superior articular process from the inferior vertebral
level of the joint and a reciprocally anteriorly and laterally
facing inferior articular process from the superior vertebral
level. The ten L-z-joints form the posterior portion of the inter-
vertebral foramina. Each joint's morphology approximates be-
tween a " C " and " J " shape. H)2Jt9 Lumbar z-joints contain
hyaline cartilage, a synovial membrane, a fibrous capsule, noci-
ceptive fibers carried by the medial branches of the dorsal
rami85.~~6J~s-~2o(fig 2) and a joint space with a potential capacity
o f l t o 2 c c . 9~
Each L-z-joint is innervated by the medial branches of the
primary dorsal rami from that level and the level above. 84'86For
example, the L4/5 L-z-joints are innervated by both the L4 and
L3 medial branches. The L1-L4 medial branches of the dorsal
rami run across the superior portion of the subjacent transverse
process, under the mamillo-accessory ligament at the junction
of the superior articular process and the root of the transverse
process, and then onto the lamina. On the lamina the nerve
divides, giving off branches to the L-z-joint below, the joint at
that level, the interspinous ligament and muscle, and the
multifidus muscle. The L5 dorsal ramus runs in the groove
between the superior articular process of S 1 and the sacral
ala. 85~9"~2° The medial branch of L5 divides from the dorsal
ramus of L5 at the inferior aspect of the L5/SI L-z-joint. A
communicating branch from the S 1 posterior ramus may travel

HISTORY
Goldthwait j3s described LBP due to the L-z-joints m 1911.
In 19 27 , Puttl.14~ p~oposed that local inflammation and
" deformity
"
around the L-z-joints could result in radicular pain from irrita-
tion of the nerve, loot. In 1933, Ghormley 9° coined the phrase
"facet syndrome' to refer to LBP with "sciatica of L-z-joint
origin. Three yeaJ s later, Bagdley T M theorized lower extremity
symptoms seen in the absence of direct nerve irritation may be
due to "referred p fin." Other researchers developed the concept
of referred pain, ~")9 and Kellgren98"99 proposed the concept of
"sclerotomal" pa n based on noxious stimulation of spinal mus- Fig 2. Posterior view of the lumbar spine with location of the z-joints
cles and ligament ~ with 6% saline injections. The mapping of (a) and their innervation by the medial branches (rob) of the dorsal rami.
On the left, needle positions for the L3 and L4 medial branch blocks used
pain responses at ter injections of local irritants was then ex- to anesthetize the L4/5 z-joint are shown. On the right, needle positions
panded to includ( the L-z-joints by Hirsch and colleagues.9<' for L3/4, L4/5, and L5/$1 intra-articular z-joint injections are shown.
The pattern of baJck and lower extremity pain produced after (Reprinted with permission. 11s)

Arch Phys Med Rehabil Vol 77, March 1996

292 LOW BACK PAIN AND THE Z-JOINTS, Dreyer

The L-z-joints' capsular ligaments protect the posterior anu-

his of the disc from excess torsion and flexion stress. 8° The L-
z-joints play a critical role in limiting rotational forces to the
intervertebral disc, which, without the protective z-joints, is
injured with pure axial rotation beyond only 3°. 89'95'115,119
In addition to simple, unidirectional segmental motion, the
L-z-joints allow "coupled motion," the marriage of two move-
ments such that one motion is automatically accompanied by a
second motion. Common coupled motions include flexion with
axial rotation, extension with coronal rotation, ]°5-~°7 and side-
bending with ipsilateral or contralateral rotation. TM However,
coupled motions can vary, and no consensus exists regarding
what represents abnormal coupling. Various nonvalidated phi-
losophies have emerged based on interpretation of presumed
abnormal coupled motions. 14°']45

P A T H O P H Y S I O L O G Y AND PROPOSED
ETIOLOGIES
The ability of the L-z-joints to cause pain has been well
established c l i n i c a l l y 13'14'17'19'96'1°3'j°4with fluoroscopically con-
trolled injections. In addition, anatomic 86'119 and histologi-
cal 81'83'91'92 studies have documented the rich innervation of the
L-z-joints. Despite these studies, which reproduce (or alleviate)
back and leg pain with L-z-joint stimulation (or analgesia), and
the supportive anatomic and histological findings, the precise
cause of most L-z-joint pain remains unknown.
Hyperextension increases the load borne by the L-z-joints and
stretches the capsule. This mechanical deformation may stimulate
the nociceptors in the joint's capsulefl 'It5 Microtrauma, such as
Fig 3. AP radiograph shows the sagittal orientation of the upper L-z- small articular fractures, have been proposed to cause post-trau-
joints.
matic L-z-joint pain. Microfractures not readily apparent on routine
X-rays occasionally can be detected with stereoradiography.1°8
from the superior edge of the posterior S 1 foramen up to the Lumbar z-joint fractures, capsular tears, splits in the articular carti-
inferior margin of the L5/S 1 L-z-joint.~2° lage, and hemorrhage have all been documented on postmortem
Usually, the more superior L-z-joints are oriented in the sagit-
tal plane (fig 3), whereas the lower L-z-joints are oriented at
45 ° with respect to the sagittal plane such that the posterior
aspect of the joint is located laterally (fig 4). The most inferior
joints may approach a frontal plane orientation.
The fibrous L-z-joint capsule is lmrn thick and attaches 2mm
from the articular margins. 88'113The capsule serves to limit bend-
ing forces and resists a backward sliding motion during exten-
sion. 88 The capsule is richly innervated with nociceptive and
autonomic nerve fibers.8LgL92Mechanoreceptors have been dem-
onstrated in rabbit L-z-joint capsules 82'114 and substance P has
been isolated in degenerative L-z-joint subchondral bone. 83 The
synovium may contain nociceptors,91'92 although these synovial
nerves may serve only to regulate blood f l o w . 94'101
Capsular redundancy at the superior and inferior portions of
the L-z-joint creates two subcapsular recesses. ]]9 Fibroadipose
meniscoids are reported to project into the joint and may protect
exposed cartilaginous articular surfaces during movement.tt 8.1~9

BIOMECHANICS
L-z-joints limit motion between vertebrae and, at times, assist
in axial weight bearing.47'8°'95'jlo.ll].120The more sagittally orien-
tated L-z-joints limit axial rotation, whereas the more coronal
ones limit shearing forces. Full forward flexion occurs through
sliding of the inferior articular process in relation to the superior
articular process by 5 to 7mm. ~°2 In lordotic postures, the L-z-
joints bear an average of 16% of the axial load, and in the
presence of lumbar spondylosis, up to 70% of the compressive
load. 47'79"115 Maximal pressure in the L-z-joints occurs during
extension. 47 Hyperextension can cause an inferior articular pro-
cess to slide past a superior articular process to contact the
subjacent laminae. ~~5 Fig 4. Oblique radiograph shows the orientation of the lower L-z-joints,

Arch Phys Med Rehabil Vol 77, March 1996

 LOW BACK PAIN AND THE Z-JOINTS, Dreyer
studies of trauma victims who had normal X-rays, ~~2but the pres-
ence or absence of LBP in these patients was not investigated.
Osteoarthritis is another proposed cause of L-z-joint pain, but
radiographic changes of osteoarthritis are equally common in
symptomatic and asymptomatic patients. 56'6~ Some studies report
that severely degenerated joints are more likely to be symptom-
atic, 42's7whereas other studies document that even advanced degen-
erative joint changes seen on computed tomography (CT) or mag-
netic resonance imaging (MRI) are not always painful. 15'39'50'76In
addition, L-z-joints that are radiographically normal both on plain
X-ray and single photon emission computed tomography (SPECT)
scans can be painful. 15'a2'48'55'59'66'72'120Diagnostic, fluoroscopically
confirmed, intra-articular anesthetic injections may relieve low
back and lower extremity pain, whether or not arthritic changes
of the L-z-joints late radiographically evident, and even in the
presence of structmal abnormalities of the intervertebral disc on
CT or MRI) s'66 One recent study, however, suggests that disco-
genic and L-z-joinl mediated pain tend to occur as separate entities
in the lumbar spi0e. 19 In this study, only 3% of 92 patients had
both concordant pain on discography and pain relief after L-z-
joint injections, in0icating combined pain sources.
Other theories On L-z-joint pain include meniscoid entrapment
and extrapment, j]!'~9 synovial impingement, ~4~ chondromalacia
facetae, 48 and capsular and synovial inflammation." 8,,,9 Occasion-
ally, the L-z-joints are affected by systemic arthritides such as
rheumatoid arthritis and ankylosing spondylitis. 37'53However, no
studies have explo~ed the prevalence of L-z-joint pain in this popu-
lation using L-z-j0int analgesic injections. Other rarities such as
villo-nodular syno~,itis, synovial cysts, and infection are potential
sources of L-z-joint pain. 41's1'7°
C L I N I C A L PICTURE
Initially, the cllnician must base the presumptive diagnosis
of L-z-joint pain I,on a constellation of historical and physical
findings after fracture, infection, neoplasm, viscerogenic re-
ferred pain, isolated muscular/ligamentous pain, sacroiliac joint
pain, and discogenic pain sources have been reasonably ex-
cluded. No noninvasive pathognomonic finding or constellation
of findings definitively distinguish L-z-joint mediated pain from
other sources of LBP. 12'14'15'52A2°'125The diagnosis of L-z-joint
pain remains one of exclusion and confirmation by analgesic
injections.
Signs and Symptoms
The clinical p~esentation of L-z-joint mediated back pain
appears to overlap considerably with the presentation of LBP
due to other etiolpgies. Although patients with L-z-joint pain
are neurologicaUyintact, they can demonstrate pain-inhibited
weakness, subjective nondermatomal extremity sensory loss,
and other sensory complaints as far distal as the foot. 14'~6A°4
The largest study of provocative, historical, and other tests
for L-z-joint painl involved 390 LBP patients. 52 Patients were
selected from a pc )ulation of more than 2,500 for their localized
lower back pain, aormal neurological examination, and ability
to participate in ~-z-joint injections. The authors report their
study population mdoubtedly included patients with back pain
due to other etiolc ;ies, including discogenic disease. Postopera-
tive patients, patk its with spondylolysis, spondylolisthesis, and
scoliosis, were all included as long as they presented with local
lumbar pain and a normal neurological exam. The response of
this mixed popul~ tion to either unilateral or bilateral L4-5 or
L5-S1 L-z-joint illjections was evaluated with regard to 127
potentially predict ive variables. Older age, history of LBP, ab-
sence of leg pain, !absence of exacerbation by Valsalva, normal
293
gait, absence of "muscle spasm," and maximal pain on exten-
sion after forward flexion all correlated significantly with post-
injection relief. However, none of these variables were unique
to the group of patients responding to L-z-joint injections, s2 The
most significant flaws in this study were failure to definitively
diagnosis L-z-joint pain and inclusion of patients with pain of
other etiologies. The 30 patients who achieved complete pain
relief postinjection were perhaps the patients with true L-z-joint
pain. The authors report that there were no unique identifiable
features even in this group, but do not report details of this
subanalysis.
In a retrospective review of 22 patients, prolonged relief from
single L-z-joint injections of a mixture of anesthetic and cortico-
steroid was seen in 67% of those with localized paravertebral
tenderness, 67% of those with provocation of symptoms with
extension/rotation, 77% of those with nondermatomal loss of
leg sensation, and 80% of those with upper thigh/groin pain. 5°
This study was flawed by its lack of controls and retrospective
design, both factors that bias toward positive outcomes. In addi-
tion, these clinical features have not been found to be statisti-
cally significant predictors of analgesic response to z-joint injec-
tions in more recent studies. ]2"~4'~s
Because of the potential for false-positive responses to injec-
tions, a recent, prospective, cross-sectional, analytical study re-
quired physiological analgesic responses to two separate and dis-
tinct anesthetic injections to be included in the group diagnosed
with true L-z-joint pain) 4 The clinical features of this group were
compared with those who did not achieve pain relief after both
anesthetic blocks. Despite the rigorous selection criteria, no clinical
symptom or sign reliably predicted those with true L-z-joint pain
versus those who did not respond to each of the anesthetic blocks
in a physiologic fashion) 4 Pain production/relief with sitting, stand-
ing, or walking did not predict those who would respond to L-z-
joint injections versus those who did not, ~4nor was there a statisti-
cally significant difference between responders and nonresponders
with pain provocation on flexion, extension, rotation, rotation plus
extension, or straight leg raising) 4 The major flaw in this study
was it included only 26 patients with definite L-z-joint pain and
this group was further subdivided by presenting signs and symp-
toms. The net result is a study biased toward not detecting signifi-
cant differences.
Another author retrospectively developed a scorecard (point)
system to try to predict which patients would obtain substantial
relief from L-z-joint injections, s° However, the findings in this
uncontrolled study were later discredited by a controlled study
that found the diagnostic scorecard (point) criteria to be unrelia-
ble in distinguishing pain of L-z-joint origin. ~2 The controlled
study involved comparing 22 patients selected for their repro-
ducible response to two blocks with 154 patients who did not
respond to both blocks. The limitation of the controlled study
was its small true positive sample size. Two studies have evalu-
ated the use of pain provocation during injection as a diagnostic
criteria and found it was not predictive, j ' ' 6 3
One uncontrolled study of 25 previously undiagnosed and
untreated LBP patients found that acute back pain, pain aggra-
vated by sitting and bending, and straight leg raising that caused
back pain but not leg pain were associated with a favorable
response to L-z-joint injections, t6 These findings have not been
confirmed by controlled studies. Another study of 22 patients
selected for their analgesic response to a single intra-articular
L-z-joint injection compared 90 items, including provocative
maneuvers, and reported symptoms to 18 nonresponders.~S No
unique predictors were noted. Pain during lumbar extension,
hip hyperextension, standing, and walking were all diminished
after the block, but some nonresponders also experienced pain
Arch Phys Med Rehabil Vol 77, March 1996
294 LOW BACK PAIN AND THE Z-JOINTS, Dreyer
on these provocative maneuvers. Radiographic evidence of L-
z-joint degeneration did not correlate with response. However,
the responders were more likely to be older, free of pain exacer-
bated by coughing, able to obtain relief when recumbent, free
of pain exacerbated by forward flexion, and without increased
discomfort on hyperextension or extension-rotation. The main
limitation of this study was that it potentially included more
than true L-z-joint pain in the "responder" group, as confirma-
tory blocks were not used to exclude false-positive responders.
Reproducible analgesia after L-z-joint injection remains the
only well-accepted method of confirming a clinical suspicion
of L-z-joint pain.
DIFFERENTIAL DIAGNOSIS
Disc disease, nerve root compression, sacroiliac joint syn-
drome, primary or secondary myofascial syndromes, and non-
spinal etiologies may all mimic L-z-joint pain. In fact, painful
changes to the L-z-joints are often accompanied by changes
in the segmental disc and ligaments. ~°° Nonspinal disorders,
including gastrointestinal disorders and genitourinary or gyne-
cologic sources, can usually be distinguished on clinical grounds
and with supportive laboratory investigations. A number of al-
gorithms have been reported and are useful in diagnosing non-
spinal etiologies of LBP. 45'77
DIAGNOSTIC STUDIES
Diagnostic studies can evaluate structural changes, functional
or metabolic abnormalities, or nociceptive capabilities. Various
diagnostic tests commonly employed in the evaluation of LBP
will be briefly addressed.
Imaging Studies
There are no pathognomonic diagnostic imaging studies in
symptomatic L-z-joints and, as in other causes of LBP, the
imaging studies must be closely correlated with the clinical
presentation. Pain is a subjective experience, The presence of
an anatomic abnormality is not diagnostic of pain from that
abnormality. A cost-effective screening test with high specific-
ity and sensitivity for L-z-joint pain is lacking. Cost constraints
and the overall benign nature of L-z-joint pain may limit the
search for such a test. However, because diagnostic tests are
typically undertaken to exclude more ominous causes of LBP,
the spinal practitioner must be aware of the potential findings.
Radiographs, CT, CT/myelography, bone scans, SPECT, and
MRI provide additional diagnostic information when used in
a judicious and logical manner. Imaging studies only provide
anatomic information and cannot independently determine
whether a particular structure is painful. ~3"54'76'~24
Advanced spinal imaging often shows signs of L-z-joint de-
generation even in asymptomatic individuals. More than half
of persons age 40 or older have evidence of L-z-joint arthropa-
thy on CT s c a n s . 76 Whether such degenerative findings account
for a given patient's pain complex requires clinical correlation
with selective analgesic injections of the suspected structures.
Analogous to the high incidence of L-z-joint abnormalities on
advanced spinal imaging, the prevalence of disc abnormalities
on CT or MRI scans increases with age. 54 Therefore, radio-
graphic evidence of disc pathology is not a contraindication to
L-z-joint injection procedures if the clinical evaluation provides
sufficient cause to investigate the L-z-joints and not the
discs. 15'66 Furthermore, the absence of degenerative or patho-
logic L-z-joint changes on plain radiographs, CT, MRI, bone
scan, or SPECT scan does not exclude the potential for L-z-
joint mediated pain. ~3']5"42"59'66"68"72"73'12°
Arch Phys Med Rehabil Vol 77, March 1996
Diagnostic Injections
Because no reliable, noninvasive diagnostic tools exist for the
accurate diagnosis of L-z-joint mediated pain, and because the
clinical features of L-z-joint pain, discogenic pain, ligamentous/
muscular pain, and sacroiliac joint pain overlap, fluoroscopically
guided L-z-joint injections of local anesthetics are commonly em-
ployed for isolating or excluding the L-z-joints as the source of
back and leg pain, 64't16 although neither of the methods used has
been broadly accepted as a true "gold standard" for z-joint pain.
Either intm-articnlar or medial branch blocks can be used in the
diagnostic work-up.~'78"t16,~2]Physiologic analgesia is the underl)
ing principle of these blocks; pain relief following blockade of the
nociceptive fibers implicates the blocked structure as the source
of pain. 29"38"t35'136Therefore, analgesia following local anesthetic
blocks of the L-z-joint or its nerve supply (two medial branch
nerves) indicates that the pain emanates from the blocked joint(s).
However, because analgesic blocks rely on the patient's subjective
response, they are prone to false-positive responses. Patients' de-
sire to obtain relief and physicians' enthusiasm for a procedure
inadvertently encourage such false-positive responses. False-posi-
tive responses may be eliminated when a control injection is em-
ployed. To avoid subjecting patients to inert injections as a control,
comparative anesthetic blocks have been advocated. 29'~8'135'136The
principle of comparative local anesthetic blocks is based on con-
trolled, double-blind, randomized studies demonstrating bupiva-
caine's significantly longer duration of action than lidocaine. 33-35
Only patients who accurately report different durations of analgesia
with the different anesthetics are then considered to be Irue re-
sponders. Physiological response to two different anesthetics, ie,
pain relief of different durations corresponding to the known half-
lives of the injected anesthetics, is thought to exclude a false-
positive response to the injection, j8 ff the intent of the L-z-joint
procedure is purely diagnostic, then anesthetic alone should be
used. Proposed "therapeutic" L-z-joint injections are reviewed
separately below. The specifics of L-z-joint block techniques can
be found elsewhere, t J7.~20.~2,
TREATMENT
Controlled, prospective studies comparing treatment and nat-
ural history of L-z-joint pain are lacking and are desperately
needed to guide the practitioner in selecting the most appropriate
and cost-effective program. Conservative care of acute LBP
includes L-z-joint mediated low back and leg pain, and confir-
mation of the exact pain generator is usually not required be-
cause most episodes of LBP are self-limitedY "36 Initial care is
prescribed on the basis of a presumptive diagnosis established
by considering the mechanism of injury, pain patterns, physical
findings, and imaging results. Conservative care of acute LBP,
including L-z-joint pain, may include oral non-narcotic analge-
sics and anti-inflammatory medications, modalities, traction, in-
struction in body mechanics, education, selective strengthening,
flexibility training, specialized manual physical therapy, aerobic
conditioning, and time.
The authors advocate confirming a clinical suspicion of L-z-
joint pain with diagnostic L-z-joint injection procedures only
after a minimum of 4 weeks of appropriate, directed conserva-
tive care has failed to bring relief. ~3 If pain is substantially
inhibiting progress in physical therapy, earlier use of L-z-joint
injection procedures may help focus therapies on a specific
level and provide adequate analgesia to facilitate participation.
Treatment of subacute and chronic LBP is potentially more
efficacious when an anatomic diagnosis is established and a
multidisciplinary team approach is undertaken. Isolating the
pain generator is critical to the development of scientific treat-
ment protocols for LBP of various etiologies. Ultimately, this
will allow specific rather than empiric therapeutic interventions.
 LOW BACK PAIN AND THE Z-JOINTS, Dreyer
The following discussion pertaining to various noninvasive
treatments for L-z-joint pain reflects the authors' opinion and
general construct for treatment. Specific individual care based
on a detailed clinical evaluation should be provided rather than
a generic prescription based on a standard algorithm. Unfortu-
nately, there is not one single prospective controlled study on
the efficacy of any treatment for proven (via analgesic response
to double blocks~ L-z-joint pain. Furthermore, no studies have
assessed the effidacy of medication, physical therapy (modal-
ities, flexibility/ekercise), manual therapy (manipulation and
other direct/indirect joint/soft tissue mobilization techniques),
psychological iniervention, or miscellaneous treatments em-
ployed alone or ifl combination with potentially therapeutic L-
z-joint blocks in !those patients with L-z-joint pain diagnosed
by even single diagnostic blocks. The studies evaluating treat-
ment of LBP of L-z-joint origin documented by analgesia after
single diagnostic blocks involved assessment of the efficacy
of isolated cortic0steroid L-z-joint injections, posterior lumbar
fusion, and radiofrequency denervation. These studies will be
reviewed in subsequent sections.
General principles of rehabilitation apply when treating L-z-
joint mediated LBP. Flexibility and strength deficits should be
identified and coffected. Education and training with respect to
proper body mechanics, posture, and proprioception are essen-
tial. Early mobilization and physiological stresses promote soft
tissue healing through optimal alignment of collagen fibers ~2v
while preventing the deleterious effects of immobilization, in-
cluding atrophy, iweakening of ligaments, and impaired joint
nutrition. TM Rehabilitation goals for L-z-joint injuries include
complete return of function, full pain-free range of motion,
"normal" flexibility and strength, and education for prevention
of future injury.
Medications
In the authors' opinion, non-narcotic analgesic medications
should be used s! .aringly, and in general, there is no role for
prolonged narcotiq ', analgesics in the treatment of L-z-joint pain.
The so-called "rr uscle relaxants" act via general central ner-
vous system depr •,ssion rather than selectively on the skeletal
muscle. The use o Fantidepressants in low doses may be helpful
for some individl tals to augment sleep and to assist in pain
control. Potential mechanisms of pain control from the antide-
pressants include :ontrolling low central nervous system seroto-
nin levels or enh, ncing the naturally occurring analgesics, en-
dorphins, and enkephalins.~22
:PHYSICAL THERAPY
Modalities
In the authors' i opinion, ice or cold therapy appears to be
helpful acutely in irelieving muscle spasms and local swelling.
Heating modalitids, including superficial heat, diathermy, and
ultrasound, may I~e beneficial in subacute and chronic injuries;
however, these m~dalities should not be employed in treatment
isolation. The use~f transcutaneous electrical nerve stimulation
(TENS) and other forms of electrical stimulation should be
used sparingly, if i at all, and only as part of a comprehensive
rehabilitative program. ~29
Intermittent m~chanical traction in a 900-90 ° lying position
or oscillatory inversion traction between 30 ° and 60 may unload
the L-z-joints without overstretching the joint capsule as does
static traction. 88 However, the indiscriminate use of inversion
traction has been ~ssociated with significant complications, in-
cluding hyperextqnsion, gastroesophageal reflux, headaches,
and ruptured berry aneurysm. Active axial traction applied while
295
the patient ambulates or performs other functional activities is
referred to as "unloading" and is gaining popularity. Exercising
in water with a floatation device is a form of "unloading"
successfully employed in sports rehabilitation. Applying these
same principles to unload an injured spine appears to have merit
but awaits rigorous scientific scrutiny.
Exercise
To our knowledge, no research evaluating the effect of exer-
cise therapy in proven L-z-joint pain has been published. In-
stead, generalizations are extrapolated from the treatment of
nonspecific, nonradicular LBP. Generally, flexibility, strength-
ening, aerobic conditioning, and education are included in an
exercise prescription.
Balanced lumbo-pelvic-lower extremity flexibility has been
said to require stretching of the hip flexors and lumbar exten-
sors) z3 Achieving independent hip and lumbar spine motion
has been proposed to help eliminate excess anterior pelvic tilt. ]2s
Increased anterior pelvic tilt causes increased lumbar lordosis
and increased stress to the L-z-joints via segmental extension
loading.47.79:15 Thus, adequate flexibility is believed to prevent
excessive stress to the lower lumbar spine ~39 and allow for
improved mechanical functioning via symmetrical distribution
of forces. Again, these opinions have not been scientifically
proven in a population of patients with proven L-z-joint pain.
Strengthening protocols/goals for L-z-joint mediated pain are
not established. The philosophy of establishing a "neutral
spine" without requiring a precise anatomic diagnosis can be
applied./44 The neutral spine is achieved through the application
of graded, specific exercise in the "neutral" position or position
of greatest patient comfort. It appears a slight flexion bias in
the lumbosacral spine is the position of comfort for most pa-
tients with L-z-joint mediated pain. "Dynamic muscular stabili-
zation" therapy involves strengthening the muscles and liga-
ments supporting the back. It is one author's opinion that this
"stabilization" theoretically reduces microtrauma from daily
repetitive activities. ]44 It also has been shown that those suffer-
ing from chronic LBP, presumably including those with chronic
LBP from their L-z-joints, will undergo a significant loss of
extensor strength over flexor strength and an attempt should be
made to reestablish a "normal" flexion/extension strength ratio
through extensor strengtheningY
Manual Therapy
The role of manual therapy in documented L-z-joint pain
remains empiric. Existing literature reviews manual techniques
in the treatment of presumed L-z-joint pain. Controlled clinical
trials comparing manipulations to placebo or more conservative
treatments in LBP have produced variable (32% to 92% experi-
encing relief) and generally short-lived r e s u l t s . 2°-24'26'28 Most
studies have demonstrated improved outcome with manipula-
tion when compared with other treatment modalities for LBP.
However, the most efficacious treatment appears to be a proto-
col combining manual therapy and other therapies. 43'~28
Lumbar Z-Joint Injections
L-z-joint injection procedures may be part of a comprehen-
sive program hut should not he used as an isolated form of
therapy. L-z-joint injections of local anesthetic provide diagnos-
tic information, ~~6hut the isolated therapeutic effect from intra-
articular corticosteroids has been quite variable in open, noncon-
trolled clinical trials, 42~'~'55"57"59"~'87"I°4"~37 and of minimal to no
benefit in semicontrolled trials, 7'9 ie, trials designed as random-
ized, controlled studies hut that did not meet all the criteria
Arch Phys Med Rehabil Vol 77, March 1996
296 LOW BACK PAIN AND THE Z-JOINTS, Dreyer
established for the reporting of such trials.6 However, the poten-
tial for significant, lasting relief from administration of intra-
articular corticosteroids in conjunction with other cointerven-
tions exists as observed in a well-designed study. 7 Further
research is needed to confirm or refute such combined therapies.
The therapeutic effect of intra-articular L-z-joint corticoste-
roids remains presumptive. The need for a potent anti-inflam-
matory agent in L-z-joint pain is controversial. In fact, immuno-
histochemical evaluation of L-z-joint tissues removed from
patients with lumbar spondylosis have failed to demonstrate
inflammatory cells. ]°~ Despite this uncertainty, several authors
endorse the use of corticosteroids.42'44'55'57'59"1°4"]°'j37In addition
to their anti-inflammatory effects, corticosteroids may exert reg-
ulatory effects on the local nerve endings, 75 cellular responses
within the microenvironment of bone itself,7~ or an inert effect
such as lavage of the joint or an intra-articular lysis of adhesions.
Only three studies of intra-articular corticosteroid injections
into L-z-joints have been performed that compare the results
with a similar group not receiving intra-articular steroids.7'9'~°
The first study9 included patients with greater than 3 months'
duration of unilateral, nonradicular LBP who failed to respond
to medication and physical therapy. Twenty-seven patients with
pain despite previous discectomy were also included. Patients
were prospectively randomized into three treatment groups: in-
tra-articular L-z-joint injection with cortisone and local anesthe-
tic, intra-articular injection with saline alone, or pericapsular
injection of cortisone and local anesthetic. At 1 hour postinjec-
tion, 70 of the 109 patients (64%) achieved pain relief. Thirty-
six percent achieved pain relief lasting 3 months. No statistically
significant difference in response rate between the groups was
found. Thus, no benefit could be attributed to the corticosteroid.9
Although reported as randomized and controlled, the afore-
mentioned study's research design contained several flaws and
met only four of the 32 criteria proposed for reporting of ran-
domized controlled trials.6 The four criteria met were: stating
the unit of assignment, adequately presenting summary data,
reporting the actual probability values, and appropriately inter-
preting the probability values. Problems with this study were
not limited to the method of reporting, but also included several
design flaws. First, the selection criteria were overly broad.
Lumbar z-joint mediated pain was the presumptive diagnosis
but no attempt to confirm the diagnosis with anesthetic L-z-
joint injections was made. Thus, the study population was not
pure L-z-joint pain. Second, the volumes (3 to 8cc) injected
"into" the L-z-joints were excessive in many cases. Maximum
lumbar intra-articular volumes have been estimated at 2CC.46'69'93
Larger volumes of anesthetics may cause extravasation onto
other pain-sensitive structures in the epidural space, interverte-
bral foramen, and paraspinal tissues, resulting in a loss of both
diagnostic and therapeutic specificity.69 Injecting 8cc of saline
into a space that physiologically holds only 2cc may cause
significant mechanical effects that can potentially modulate pain
responses, m Third, failure to exclude false-positive responders
from any of the groups dilutes any potential difference between
groups. Finally, large standards of deviation for the variables
measured and suboptimal outcome measures further limited the
statistical power of this study.
A second study reported as a randomized, prospective, con-
trolled study on treatment of L-z-joint pain concluded that intra-
articular methylprednisolone L-z-joint injections "have very
little efficacy in patients with LBP."7 This study met the major-
ity (22 of 32) of the criteria for reporting of randomized, con-
trolled trials.6 The criteria not met focused on a failure to report
how successful the blinding method was and whether blinding
was maintained during data entry. Patients for this study were
selected based on an analgesic response of greater than 50%
Arch Phys Med Rehabil Vol 77, March 1996
with a single intra-articular lidocaine block (58% of 101 pa-
tients). These patients were then randomized to receive either
intra-articular saline or intra-articular methylprednisolone. Ini-
tial follow-up was at 1 month postinjection when 20 (42%) of
the methylprednisolone group had substantial pain reduction
compared with 16 (33%) of the saline group. 7 The difference
was not statistically significant. At 6 months, 46% of the methyl-
prednisolone group and 15% of the saline group continued to
experience marked pain relief.7 The difference was statistically
significant but was attributed to increased cointervention in the
methylprednisolone group. 7
Although well designed, this study by Carette and colleagues7
is not without limitations. Failure to exclude false-positive re-
spenders may account for the relatively high incidence of pa-
tients with presumed L-z-joint pain compared with other false-
positive controlled prevalence studies, t3'19 A mixed subject
population that includes both patients with the disease in ques-
tion and patients without the clinical entity contaminates the
group being studied; the number of false-positive responders
included proportionately dilutes the findings of the true subjects
and will make detecting a difference between the study group
and controls more difficult. In addition, selection criteria of only
50% reduction in pain after single blocks may allow for those
with combined painful entities rather than pure L-z-joint medi-
ated pain to enter the study. Another design flaw in this study
was the assumption that intra-articular saline was a true placebo;
others propose intra-articular saline injection may have a thera-
peutic effect because it may theoretically break painful adhe-
sions or modulate the type 1 mechanoreceptors in the joint
capsule which inhibit the trans-synaptic centripetal flow of type
4 nociceptors. 132 Furthermore, saline is known to provide pain
relief in excess of that expected from placebo in other pain
syndromes, including myofascial pain and reflex sympathetic
dystrophy. 3°32'58 Finally, the effects of intra-articular L-z-joint
corticosteroids were evaluated in isolation and not as part of a
comprehensive conservative treatment plan provided equally to
both groups. In fact, when cointervention occurred, there was
some indication of significant benefit from the combination.
Marked or very marked pain relief in 46% of the methylprednis-
olone group after 6 months is substantial, considering that these
were patients who had pain for longer than 6 months. Poten-
tially, the analgesic effects of L-z-joint injections serve as a
"window of opportunity" for the patient to progress through a
previously intolerable active conservative treatment, although
this was not specifically assessed.
The third study reported as a controlled treatment trial on L-
z-joint pain was prospective but not randomized or blinded 1°
and, therefore, cannot be considered a controlled, randomized
trial. In this third study, 50 patients with chronic (longer than
6 months' duration) low back pain with focal paraspinal tender-
ness and increased pain on hyperextension but no "true motor
weakness or anesthesia," systemic arthropathy, spondylosis, or
spondylolisthesis were included in the study. "True motor
weakness or anesthesia" was not defined. Intra-articular injec-
tions were attempted at the level the authors' believed to be
clinically symptomatic and the level above. Intra-articular
placement of the corticosteroid was attempted in all 50 patients;
however, in 15 patients the needle was noted to be extra-articu-
lar on injection of both joints, and in 8 others, only one of the
two injections was confirmed to be intra-articular on injection
of radio-opaque contrast agent. The patients who received extra-
articular injections were then used as a control group with which
the intra-articular group was compared. Total pain relief oc-
curred in 9 of 27 patients who received fluoroscopically con-
firmed intra-articular corticosteroids in both joints compared
 LOW BACK PAIN AND THE Z-JOINTS, Dreyer
with 0 of 15 patients who received only extra-articular cortico-
steroids. Only 2 patients in the intra-articular group did not
obtain at least partial benefit, whereas 7 of the 15 control pa-
tients had no pain relief. The authors' concluded that intra-
articular injections were far more effective than extra-articular
corticosteroids.'°
The limitations of this third study ~° include: lack of random-
ization, failure tO select patients with isolated z-joint pain as
determined by analgesic response to injection of local anesthe-
tics, failure to blind the examining physician, and the use of a
physiologically active agent (periarticular corticosteroids) for
the control group. These designs flaws weaken the results of
this study.
Open, uncontrolled clinical studies evaluating the long-
term relief of back and leg pain from intra-articular L-z-
joint corticoste~'oids report relief in 18% to 63% of
subjects. 9'42'44'55~57'59~66"87"104'137However, because of the open
study design, the results are inherently biased toward favor-
able outcomes. The variability of results may represent het-
erogeneity of paiient populations and lack of uniform post-
injection rehabifitation programs. The rates reported were
for populations of patients with chronic LBP who received
injections and not just those individuals who responded fa-
vorably to an initial diagnostic injection of local anesthetic.
Several uncontrolled studies suggest that sustained relief after
intra-articular L-z-joint injections is more common in patients
with demonstrable degenerative changes in the L-z-joints.42"5°'$7
However, other open trials including patients with no or mini-
mal L-z-joint degeneration shown on CT have also resulted in
long-term Success. 15'55'57'59~66
The response tO L-z-joint corticosteroid injections in patho-
logically distinct i subgroups such as patients with spondy-
loarthropathies ori spondylolysis affecting the L-z-joints has not
been studied in a controlled fashion or even in large open trials.
One uncontrolled study reported relatively long-term benefit
from L-z-joint corticosteroids in 5 of 11 patients (45%) with
presumed symptomatic spondylolysis.62
Fusion
Several uncontrolled studies have evaluated posterior fusion
for lumbar z-joint pain relieved by single diagnostic z-joint
blocks. These authors concluded that lumbar fusion is not help-
ful for z-joint paitl. 49']25'j3°
Lumbar Z-Joint ]Denervation
Analgesia following diagnostic z-joint blocks has been em-
ployed as selectibn criteria for medial branch neurotomy in
several o p e n studies 6°'67'74 with 32% to 75% of patients achiev-
ing long-term relief from the neurotomy. Consistently, patients
who have had pre~¢ious lumbar surgery experience a less favor-
able response to percutaneous z-joint denervation procedures
(sustained relief in 26% to 50%) 60,74 than patients who have not
had lumbar surgery (sustained relief in up to 75%). 60.74 One
study claims to be a prospective, controlled, randomized trial
comparing the results of neurotomy, myotomy, and stimulation
procedures, but failed to meet 23 of the 32 criteria for reporting
randomized, controlled trials.6 Many of the criteria this study
failed to meet centered on the blinding and randomization proce-
dures. The statistical planning and reporting was another key
weak area of this trial and resulted in 8 of the missed criteria.
Despite its shortcomings, this was the closest to a randomized,
controlled trial on z-joint denervation identified in our search.
This study reported significant and sustained improvement
(greater than 50%]pain relief at 6 months) in 27% and 53% of
patients who were!treated with either fluoroscopically controlled
297
radiofrequency neurotomies or myotomies, respectively) None
of the control stimulation group had sustained pain relief at 6
months. Notably, inclusion criteria included only a history of
chronic low back pain and palpable areas of discrete tenderness
on examination of the lumbar spine) The results of lumbar z-
joint denervation procedures must be viewed cautiously until
more scientific evaluations can be completed.
Clearly, additional controlled trials comparing the various
treatment interventions are needed to more scientifically guide
practice recommendations.
Acknowledgments: The authors thank Drs. Kevin Pauza and Mark
Michaelsen for their critiques of this manuscript.
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