Low back pain and other degenerative spinal conditions can present with varying degrees of pain, disability, radiculopathy, and neurologic deficits that the clinical picture can be ambiguous for even skilled clinical practitioners. 

In the majority of presentations, facetogenic lumbosacral pain often presents secondary to chronic pain alone.  An exception to this theme can be seen in the setting of rather large synovial cysts causing direct mechanical compression and creating ensuing inflammation to further irritate the surrounding nerve roots. 

Historically, lumbosacral facet loading during a physical exam has been used to diagnose facetogenic pain. This maneuver is performed by having the patient extend and rotate the spine. This serves to increase pressure on the facet joints thus eliciting a pain response. However, studies have shown that facet loading is unreliable in diagnosing facetogenic pain. Additionally, paraspinal muscle tenderness has been shown to be weakly associated with facetogenic pain, although this finding is considered to be non-specific. [7]

Physical examination can be useful in ruling out other causes of chronic low back pain; however, studies have shown that physical exam is relatively nonspecific. Degenerative changes in the facet joints can be visualized in radiologic studies. In patients with chronic low back pain, degenerative changes on CT scan are cited to range from 40% to 85%. Studies have shown MRI to be more than 90% sensitive and specific in visualizing facet degeneration. Due to the poor correlation between history, physical exam, and lumbosacral facet syndrome, diagnostic blocks are considered to be the mainstay in establishing a diagnosis. Of note, false positive results have been documented to be as high as 25% to 40% in the lumbar spine. Because of this, it is recommended that two diagnostic medial branch blocks are performed to confirm a diagnosis. A positive response is considered to be greater than 80% pain relief post-procedure. [8][9][10][11]

Treatment for lumbosacral facet syndrome usually includes a multidisciplinary approach.  If the diagnosis is uncertain, consideration is given to performing diagnostic medial branch blocks.

Nonoperative Treatment

Nonoperative management includes oral medications such as NSAIDs, acetaminophen, and oral steroids during acute flares. Additionally, weight loss and physical therapy have demonstrated successful outcomes. [12]

More invasive nonoperative modalities that can be considered include a CT-guided aspiration.  The literature is controversial with respect to the overall effectiveness of this modality.  Patients should also be counseled regarding the risk of facet cyst recurrence and return of symptoms even after the aspiration is performed.

Surgical Treatment

• Indications for surgical intervention include: 
  • Symptoms refractory to nonoperative modalities (e.g. 3 to 6 month trial) 
  • Large associated synovial facet cyst correlating with clinical exam and presentation
    • Laminectomy with decompression is the classic first line treatment for symptomatic, intraspinal synovial cysts
    • The literature also supports the utilization of facetectomy, decompression, and instrumented fusion (as opposed to a simple "lami decompression")

Minimally invasive techniques

Other management modalities include facet injections, radiofrequency denervation of the medial branch nerves. [13][14]

• Lumbosacral discogenic pain syndrome

• Lumbosacral facet syndrome

• Lumbosacral radiculopathy

• Lumbosacral spine acute bony injuries

• Lumbosacral spine sprain/strain injuries

• Lumbosacral spondylolisthesis

• Lumbosacral spondylosis

• Piriformis syndrome

• Sacroiliac joint injury

Complications of facet interventions are rare. However, cases of spinal anesthesia, dural puncture with associated headache, and transient numbness and dysesthesias have all been described in the literature. Overall, lumbosacral facet syndrome is recognized as a relatively common cause of low back pain. The prevalence increases with age, and treatment is typically conservative. For refractory cases, intra-articular steroid injections and diagnostic medial branch block followed by radiofrequency ablation are commonly used. For refractory cases, surgical intervention may be considered. [15][16][17]

While complications are uncommon, the healthcare team including physicians, nurses, and other professionals assisting should be aware the patient may experience headache, and transient numbness and dysesthesias. The nurses monitoring the patient post-procedure should report any new findings to the physician.