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More than 60% of people in developed countries will experience spinal pain at some time in their lives. Back pain is the most common complaint of patients referred to pain clinics. The pain is nonspecific in about 85% of the cases, and onset of symptoms is most often between the ages of 35 and 55 years. According to some sources, 15% to 45% of all adults experience lower back pain, and 1 in 20 people present with a new episode annually. In 2008, 3.7 million workplace injuries were reported, and of these, 65% were attributed to the low back. In 2012, state workers’ compensation programs provided almost $60 billion in cash and medical care benefits.

Risk factors for spinal pain include trauma, heavy physical labor, frequent twisting, bending, vibrations, pulling and pushing, and repetitive motion, especially that involving static postures. Psychological features such as anxiety, depression, job dissatisfaction, and stress also can play an important role.


The spine consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae in addition to the sacrum and coccyx. They articulate anteriorly through the disks and posteriorly through the left and right synovial facet joints. Anterior to the ligamentum flavum and covering the facet (apophyseal) joint is a variable amount of vascularized adipose tissue, which directly contacts the dural sleeve of the nerve root. The sleeve is located so close to the facet that it is possible, inadvertently, to inject medication directly into the cerebrospinal fluid. The articular surfaces of the facets are covered by cartilage. Joints are lined by synovium and contain variable amounts of fluid. The fibrous joint capsule forms superior and inferior joint recesses and blends anteromedially with the ligamentum flavum. It is located close to the neural foramen and the nerve root. Enlarged and osteophytic joints can contribute to significant narrowing of the neuroforaminal opening and can cause radicular symptoms.

Computed tomography (CT), magnetic resonance imaging (MRI), and intraarticular contrast medium can be used to demonstrate these anatomic features. The volume of injectate that can be accommodated by the facet joints varies as follows: cervical, up to 1.0 ml; thoracic, 1.0 ml to perhaps 1.5 ml; and lumbar, 1.0 ml to perhaps 1.5 ml.

In the upper lumbar spine, approximately 80% of the facet joints are curved and 20% are flat. This situation is reversed in the lower lumbar spine, where approximately 80% of the joints are flat. The upper lumbar facets are oriented more strongly in the sagittal plane, and, by the L5 to Sl level, they rotate obliquely. The lumbar facet joints are oriented 45 degrees from the sagittal plane, but because of the curvature of the joints, the posterior part of the joint is close to the sagittal plane. Lumbar facet syndrome has been considered to be a significant source of lower back pain, with a prevalence from 15% ...

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