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Facet Joint Syndrome

General Information

 

Description:

  • Persistent or fluctuating musculoskeletal pain of lower back and lumbar spine
    • Chronic low back pain lasts for > 3 months
    • Subacute low back pain lasts for 6 weeks to 3 months
  • This topic covers both chronic and subacute low back pain

Incidence/Prevalence:

  • Incidence and prevalence of chronic low back pain difficult to interpret due to differences in definitions (Lancet 1999 Aug 14;354(9178):581)
  • Prevalence of chronic low back pain increasing
    • Based on cross-sectional telephone surveys to 9,794 households in 1992 and 2006
    • Chronic low back defined as pain at waist level or below and activity limitations nearly every day for 3 months or > 24 pain episodes for ≥ 1 day in past year
    • Prevalence 3.9% in 1992, 10.2% in 2006
    • Reference - Arch Intern Med 2009 Feb 9;169(3):251, commentary can be found in Arch Intern Med 2009 Jul 27;169(14):1338
  • Low back pain common in rural Tibet; survey of 499 adults from 19 rural villages, 34% point prevalence of low back pain, 42% 1-year prevalence, 20% had substantial functional disability associated with low back pain (Lancet 2003 Jan 18;361(9353):225 ), commentary can be found in Lancet 2003 May 10;361(9369):1653
  • Back pain is thirteenth most common diagnosis made during family physician visits; analysis of patient visits to family physicians in United States 1995-1998 in National Ambulatory Medical Care Survey; back pain diagnosis coded in 2.7% of visits (Ann Fam Med 2004 Sep-Oct;2(5):411  )

Causes and Risk Factors

Causes:

  • Chronic low back pain in pediatric population often does not have definitive diagnosis
    • Based on prospective cohort study
    • 73 children < 18 years old with low back pain for > 3 months had diagnostic tests including radiographs, magnetic resonance imaging, computed tomography, bone scan, and laboratory studies and followed for 2 years
    • 60 (82%) had no definitive diagnosis (including 3 patients with abnormal laboratory tests)
    • Definitive diagnosis in 13 (18%)
      • Spondylolysis in 9 (12%)
      • Scheuermann's disease in 2 (3%)
      • Osteoid osteoma in 1
      • Herniated disc in 1
    • Reference - J Pediatric Orthop 2008 Mar;28(2):230, commentary can be found in J Bone Joint Surg Am 2008 Nov;90(11):2554

Possible risk factors:

  • Psychosocial factors and not mechanical factors may be associated with low back pain in children
    • Based on cross-sectional study
    • 1,446 school-aged children aged 11-14 years using self-completed questionnaire and 5-day bag weight diary
    • Strong associations with low back pain seen with emotional problems, conduct problems, troublesome headaches, abdominal pain, sore throat, and daytime tiredness
    • Mechanical factors (physical activity, school bag weight) were not associated with low back pain
    • Reference - Arch Dis Child 2003 Jan;88(1):12 in Pediatric Notes 2003 Feb 27;27(9):36, editorial commentary can be found in Lancet 2003 Apr 26;361(9367):1403 
    • Similar authors reported similar results in 1-year follow-up of 1,046 schoolchildren aged 11-14 years free of low back pain at baseline (Pediatrics 2003 Apr;111(4 Pt 1):822  
    • similar results in systematic review of 18 cohort studies of patients with low back pain Fam Pract 2011 Feb;28(1):12)

  • Overweight/obesity associated with increased risk of low back pain
    • Based on systematic review with inadequate assessment of trial quality
    • Systematic review of 33 studies evaluating association between overweight/obesity in adolescents and adults and low back pain
    • Overweight/obesity associated with increased risk of (p < 0.05 for all)
      • Low back pain in past 12 months (odds ratio [OR] 1.33) in analysis of 5 studies
      • Seeking care for low back pain (OR 1.56) in analysis of 3 studies
      • Chronic low back pain (OR 1.43) in analysis of 5 studies
    • Reference - Am J Epidemiol 2010 Jan 15;171(2):135

  • Cigarette smoking associated with low back pain
    • Based on systematic review of 40 observational studies
    • Compared to never smoking, current smoking associated with
      • Low back pain in preceding month and in preceding 12 months
      • Seeking care for low back pain
      • Chronic low back pain
      • Disabling low back pain
    • Former smoking associated with increased low back pain incidence compared to never smoking
    • Reference - Am J Med 2010 Jan;123(1):87e7

Factors not associated with increased risk:

  • Epidural anesthesia does not appear to increase risk of back pain
    • Epidural anesthesia does not appear to increase risk of back pain except possibly in first day after delivery, study of 329 patients (BMJ 1995 Nov 18;311(7016):1336 in J Watch 1996 Jan 1;16(2):18)
    • Epidural anesthesia did not increase back pain at 1 year compared to intramuscular pethidine in randomized trial of 369 primigravid women, but epidural anesthesia was associated with increased risk for instrumental delivery (BJOG 2001 Jan;108(1):27 in BMJ 2001 Feb 24;322(7284):500), commentary can be found in ACP J Club 2001 Sep-Oct;135(2):65
    • No long-term difference in incidence of back pain after epidural analgesia in randomized trial of 369 women, 306 were assessed at mean 26 months (BMJ 2002 Aug 17;325(7360):357), correction can be found in BMJ 2002 Sep 14;325(7364):580, commentary can be found in BMJ 2002 Nov 2;325(7371):1037, and Am Fam Physician 2003 Jan 1;67(1):169
  • Occupational factors
    • Occupational manual handling or patient-assisting do not appear significantly associated with low back pain
      • Based on systematic review of 32 observational studies evaluating association of manual handling or patient-assisting with low back pain
      • No significant effect on low back pain of
        • Manual handling in 3 studies identified as higher quality by review authors
        • Patient-assisting in 4 studies identified as higher quality by review authors
      • Reference - Spine J 2010 Jul;10(7):639
    • Awkward occupational postures do not appear significantly associated with low back pain
      • Based on systematic review lacking high quality trials and without meta-analysis
      • Systematic review of case-control, cross sectional and prospective cohort studies evaluating association of awkward occupational postures and low back pain (any, subacute, chronic or severe) in 6,119 persons
      • 6 of 8 studies report primarily nonsignificant associations between awkward occupational postures and low back pain
      • Reference - Spine J 2010 Jan;10(1):89
    • Conflicting evidence for association of occupational lifting with low back pain
      • Based on systematic review of 35 observational studies evaluating association of occupational lifting with low back pain
      • Conflicting evidence reported among 9 observational studies identified as high-quality by review authors
      • Authors report that lifting unlikely to be independently causative of low back pain
      • Reference - Spine J 2010 Jun;10(6):554
    • Conflicting evidence for association of occupational pushing or pulling with low back pain
      • Based on systematic review of 13 observational studies evaluating association of occupational pushing or pulling with low back pain
      • Conflicting evidence reported among 6 observational studies identified as higher quality by review authors
      • Authors report that pushing or pulling unlikely to be independently causative of low back pain
      • Reference - Spine J 2010 Jun;10(6):544
    • Insufficient evidence to support occupational bending or twisting as cause of low back pain
      • Based on systematic review of case-control and prospective cohort studies
      • Reference - Spine J 2010 Jan;10(1):76, editorial can be found in Spine J 2010 Jan;10(1):73
    • Insufficient evidence to support occupational standing or walking as cause of low back pain
      • Based on systematic review of 18 studies
      • Reference - Spine J 2010 Mar;10(3):262

 

Complications and Associated Conditions

Associated conditions:

  • Recurrent pain associated with impaired health-related quality of life in children
    • Based on cohort study in Sweden
    • 1,455 children aged 8-14 years assessed by questionnaire for pain in head, stomach or back and health-related quality of life
    • 69% reported recurrent pain at least monthly
    • Recurrent pain significantly associated with ≥ 1 health-related quality of life impairment
    • Reference - Pediatrics 2009 Oct;124(4):e759
  • Trochanteric bursitis common in patients with chronic low back pain and generally more treatable (J Rheumatol 1996 Dec;23(12):2104 in QuickScan Reviews in Fam Pract 1997 Jun;22(3):17)
  • Chronic low back pain associated with sleep disturbances
    • Based on systematic review of 17 studies in patients with chronic low back pain
    • Chronic low back pain significantly associated with
      • Greater sleep disturbance in 15 studies
      • Reduced sleep quality in 4 studies
      • Poor daytime function in 5 studies
      • Greater sleep dissatisfaction and distress in 4 studies
    • Reference - Clin J Pain 2011 Feb;27(2):169

 

History and Physical

History:

Chief concern (CC):

  • Low back pain

History of present illness (HPI):

  • Duration > 3 months for chronic low back pain
  • Duration > 6 weeks to 3 months for subacute low back pain
  • Red flag findings may indicate serious SPECIFIC causes of chronic low back pain and include
    • Age > 50 years
    • Fever
    • Chills
    • Recent urinary tract or skin infection
    • Significant trauma
    • Unrelenting night pain
    • Pain at rest
    • Progressive motor or sensory deficit
    • Saddle anesthesia
    • Bilateral sciatica or leg weakness
    • Difficulty urinating
    • Fecal incontinence
    • Unexplained weight loss
    • History or strong suspicion of cancer
    • History of osteoporosis
    • Immunosuppression
    • Chronic oral steroid use
    • IV drug use
    • Substance abuse
    • Failure to improve after 6 weeks conservative therapy
  • See also Acute low back pain

Past medical history (PMH):

  • Ask about previous problems with back pain
  • Ask about
    • Osteoporosis
    • Osteoarthritis
    • Cancer

Social history (SH):

  • Patients who develop chronic back pain are more likely to have poor job satisfaction
    • Based on prospective study of 82 men aged 18-50 years with daily acute low back pain for 6-10 weeks who were reassessed at 6 months
    • Reference - Arch Phys Med Rehabil 1998 Apr;79(4):366 in Am Fam Physician 1998 Jul;58(1):220
  • Patients with compensation issues have a worsened prognosis for improvement
    • Based on 12-month follow-up of 96 patients with and 96 patients without compensation involvement referred to spine rehabilitation center
    • Reference - Spine 1997 Sep 1;22(17):2016

Review of systems (ROS):

  • Ask about
    • Unexplained fevers
    • Weight loss
    • Morning stiffness
    • Gynecologic symptoms
    • Urinary problems
    • Gastrointestinal problems
  • Distress, depressive mood and somatization may be associated with chronic low back pain

Physical:

General physical:

  • See also Acute low back pain
  • Straight leg raise exam
    • Positive test is pain with leg fully extended at knee and flexed at hip between 30 and 70 degrees
    • May detect lumbar disc herniation (contralateral pain more specific for detecting herniation and ipsilateral pain more sensitive for ruling out herniation)
  • Focused neuromuscular exam may help identify involved nerve roots by assessing deep tendon
    • Reflexes
    • Strength
    • Sensation