Consilium MedicumConsilium Medicum2075-17532542-2170Consilium Medicum94409Research ArticleFacet syndrome: causes, clinical features, diagnosis and treatmentIsaykinA. Ialexisa68@mail.ruKuznetsovI. V-KavelinaA. V-IvanovaM. A-I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian FederationA.Ya.Kozhevnikov Clinic for Nervous Diseases15022016182536128122021Copyright © 2016, Consilium Medicum2016Currently accepted biopsychosocial model of pain in the back, in which the isolated biological component with the identification of anatomic source of pain as well as psychological and social components that contribute to the emergence and maintenance of back pain. The group of patients with non-specific low back pain is not uniform, which requires a differentiated approach to the treatment. The most common sources of back pain are diseased discs, facet joints, sacroiliac joint, muscle spasm, but the definition of the main source of pain is difficult due to the lack of validity of the test used. Facet (facet joints) are the only typical synovial joints of the spine. In the development of the pathology attaches importance to several factors: micro and makrotravmatizatsii, enhancing the load on the joints when disc degeneration, inflammatory lesions in the form of arthritis, similar to other peripheral lesions of synovial joints. Possible mechanisms of pain include stretching of the joint capsule, synovial folds infringement (meniscoids) between the joint surfaces, and compression of the spine osteophytes and joint inflammation in the development of secondary muscle spasm. Facetogenic pain is prevalent in older age groups, more often in women with a higher body mass index. There is no correlation between morphological changes in the facet joints and back pain. The combination of positive and negative test, taking intoaccount the patient's clinical symptoms and complaints can help to identify the main source of pain. "The gold standard" diagnosis is to conduct diagnostic blockade with local anesthetics, performed under the supervision of the neuroimaging with a reduction in pain for at least 70-80%. Treatment of the facet syndrome is carried out according to the general principles of treatment of non-specific back pain using medical methods and non-pharmacological treatment. Drug treatment in the early stages includes a choice of preparations purpose of nonsteroidal antiinflammatory drugs and muscle relaxants.Several studies have shown the effectiveness and safety of baclofen in the treatment of acute and chronic back pain. With the ineffectiveness of 3 months it is recommended to use different versions of blockades and radiofrequencies of facet denervation.non-specific back painfacet syndromebaclofena questionnaire STarT Back toolmultidisciplinary treatmentcognitive-behavioral therapyblockade for pain in the backradio-frequency destructionнеспецифическая боль в спинефасеточный синдромбаклофенопросник STarT Back toolмультидисциплинарное лечениекогнитивно- поведенческая терапияблокады при болях в спинерадиочастотная деструкция[Hestbaek L, Leboeuf-Yde C, Kyvik K.O. The course of low back pain from adolescence to adulthood: eight - year follow - up of 9600 twins. Spine (Phila Pa 1976) 2006; 31 (4): 468-72.][Kosloff T, Elton D, Shulman St. Conservative Spine Care: Opportunities to Improve the Quality and Value of Care Popul Health Manag 2013; 16 (6): 390-6.][Dagenais S, Tricco A.C, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010; 10 (6): 514-29.][Подчуфарова Е.В., Яхно Н.Н. Боль в спине. М.: ГЭОТАР-Медиа, 2010.][Van Tulder M, Becker A, Trudy B et al. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006; 15 (Suppl. 2): S169-S191.][Парфенов В.А., Герасимова О.Н. Лечение неспецифических болей в спине в амбулаторной практике. // Справочник поликлинического врача. 2013; 1: 48-51.][Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low - back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147 (7): 478-91.][Koes B, Van Tulder M, Chung-Wei C.L. An updated overview of clinical guidelines for the management of non - specific low back pain in primary care. Eur Spine J 2010; 19: 2075-94.][Henschke N, Maher C.G, Refshauge K.M et al. Prevalence of and screening for serious spinal pathology in patient presenting to primary care settings with acute low back pain. Arthritis Rheum 2009; 60 (10): 3072-80. Doi: 10.1002/art.24853.][Carey T.S, Freburger J.K, Holmes G.M et al. A long way to go: Practice patterns and evidence in chronic low back pain care. Spine (Phila Pa 1976) 2009; 34: 718-24.][Deyo R.A, Mirza S.K, Turner J.A, Martin B.I. Overtreating chronic back pain: Time to back off? J Am Board Fam Med 2009; 22: 62-8.][Manchikanti L, Standiford Helm, Vijay Singh et al. Algorithmic Approach for Clinical Management of Chronic Spinal Pain. Pain Physician 2009; 12: E225-E264.][Hancock M.J, Maher C.G, Laslett M et al. Discussion paper: what happened to the 'bio' in the bio - psycho - social model of low back pain? Eur Spine J 2011; 20 (12): 2105-10.][Brennan G.P, Fritz J.M, Hunter S.J et al. Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial. Spine (Phila Pa 1976) 2006; 31 (6): 623-31.][Amirdelfan K, Mc Roberts P, Deer T.R. The differential diagnosis of low back pain: a primer on the evolving paradigm. Neuromodulation 2014; 17 (Suppl. 2): 11-7.][Deyo R.A, Weinstein J.N. Low Back Pain. N Engl J Med 2001; 344 (5): 363-70.][De Palma M.J, Ketchum J.M, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med 2011; 12 (2): 224-33.][Laplante B.L, Ketchum J.M, Saullo T.R, De Palma M.J. Multivariable analysis of the relationship between pain referral patterns and the source of chronic low back pain. Pain Physician 2012; 15 (2): 171-8.][Laslett M, Mc Donald B, Aprill C.N et al. Clinical predictors of screening lumbar zygapophyseal joint blocks: Development of clinical prediction rules. Spine J 2006; 6: 370-9.][Hancock M.J, Maher C.G, Latimer J et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007; 16 (10): 1539-50.][Hirsch С, Ingelmark B.E, Miller M. The anatomical basis for low back pain. Acta Orthop Scand 1963; 33: 1.][Lewin Т, Moffets S, Vndik A. The morphology of the lumbar synovial intervertebral joints. Acta Morphologica Netherlands Scand 1962 (4): 299.][Mooney V, Robertson J. The facet syndrome. Clin Orthop 1976; 115: 149.][Jackson R.P. The facet syndrome: Myth or reality? Clin Orthop 1992; 121: 110-21.][Schwarzer A.C, Aprill C.N, Derby R et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine (Phila Pa 1976) 1994; 19 (10): 1132-7.][Yang K.H, King A.I. Mechanism of Facet Load Transmission as a Hypothesis for Low-Back Pain. Spine 1986; 9 (6): 557-65.][Varlotta G.P, Lefkowitz T.R, Schweitzer M et al. The lumbar facet joint: a review of current knowledge: part 1: anatomy, biomechanics, and grading. Skeletal Radiol 2011; 40 (1): 13-23.][Jaumard N.V, Welch W.C, Winkelstein А. Spinal Facet Joint Biomechanics and Mechanotransduction in Normal, Injury and Degenerative Conditions. J Biomech Eng 2011; 133 (7).][Lee K.E, Davis M.B, Mejilla R.M, Winkelstein B.A. In vivo cervical facet capsule distraction: mechanical implications for whiplash and neck pain. Stapp Car Crash J 2004; 48: 373-95.][Videman T, Battie M.C, Gill K et al. Magnetic resonance imaging findings and their relationships in the thoracic and lumbar spine. Insights into the etiopathogenesis of spinal degeneration. Spine 1995; 20 (8): 928-35.][Gellhorn A.C, Katz J.N, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2013; 9: 216-22.][Suri P, Dharamsi A.S, Gaviola G, Isaac Z. Are facet joint bone marrow lesions and other facet joint features associated with low back pain? A pilot study. PM R 2013; 5: 194-200.][Goode А, Carey Т, Jordan J. Low Back Pain and Lumbar Spine Osteoarthritis: How Are They Related? Curr Rheumatol Rep 2013; 15 (2): 305.][Kang Y.M, Choi W.S, Pickar J.G. Electrophysiologic evidence for an intersegmental reflex pathway between lumbar paraspinal tissues. Spine (Phila Pa 1976) 2002; 27 (3): E56-63.][Bykowski J.L, Wong W.H. Role of facet joints in spine pain and image - guided treatment: a review. AJNR Am J Neuroradiol 2012; 33 (8): 1419-26.][Rubinstein S.M, Van Tulder M. A best - evidence review of diagnostic proceduresfor neck and low - back pain. Best Pract Res Clin Rheumatol 2008; 22: 471-82.][Misaggi B, Gallazzi M, Colombo M, Ferraro M. Articular facets syndrome: diagnostic grading and treatment options. Eur Spine J 2009; 18 (Suppl. 1): 49-51.][Morris C.E. Low back pain syndromes. Integrated clinical Management. New York: Mc Graw-Hill, 2006; p. 229-33.][Pathria M, Sartoris D.J, Resnick D. Osteoarthritis of the facet joints: accuracy of oblique radiographic assessment. Radiology 1987; 164: 227-30.][Weishaupt D, Zanetti M, Boos N et al. MR imaging and CT in osteoarthritis of the lumbar facet joints. Skeletal Radiol 1999; 28: 215-9.][Maataoui A, Vogl T.J, Middendorp M et al. Association between facet joint osteoarthritis and the Oswestry Disability Index. World J Radiol 2014; 6 (11): 881-5.][Mainka T, Lemburg S.P, Heyer C.M et al. Association between clinical signs assessed by manual segmental examination and findings of the lumbar facet joints on magnetic resonance scans in subjects with and without current low back pain: a prospective, single - blind study. Pain 2013; 154 (9): 1886-95.][Saal J.S. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine (Phila Pa 1976) 2002; 27 (22): 2538-45.][Cohen S.P, Huang J.H, Brummett C. Facet joint pain - advances in patient selection and treatment. Nat Rev Rheumatol 2013; 9 (2): 101-16.][Lavelle E.D, Lavelle W, Smith H.S. Myofascial trigger points. Med Clin North Am 2007; 91 (2): 229-39.][Alvarez D.J, Rockwell P.G. Trigger points: diagnosis and management. Am Fam Physician 2002; 65 (4): 653-60.][Vining R, Potocki, Seidman A. Paige Morgenthal An evidence - based diagnostic classification system for low back pain. J Can Chiropr Assoc 2013; 57 (3): 189-204.][Mc Carberg B.H, Ruoff G.E, Tenzer-Iglesias P, Weil A.J. Diagnosis and treatment of low - back pain because of paraspinous muscle spasm: a physician roundtable. Pain Med 2011; 12 (Suppl. 4): S119-27.][Bigos S.J, Holland J, Holland C et al. High - quality controlled trials on preventing episodes of back problems: systematic literature review in working - age adults. Spine J 2009; 9 (2): 147-68.][Buchbinder R, Pransky G, Hayden J. Recent advances in the evaluation and management of nonspecific low back pain and related disorders. Best Pract Res Clin Rheumatol 2010; 24 (2): 147-53.][Lee J, Gupta S, Price C, Baranowski A.P. Low back and radicular pain: a pathway for care developed by the British Pain Society. J Anaesth 2013; 111 (1): 112-20.][Roelofs P.D, Deyo R.A, Koes B.W. Non - steroidal anti - inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; 1: CD000396.][White A.P, Arnold P.M, Norvell D.C et al. Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976) 2011; 36 (21 Suppl.): S131-43.][Van Tulder M.W, Touray T, Furlan A.D et al. Muscle relaxants for non - specific low back pain. Cochrane Database Syst Rev 2003; 2.][Chou R. Pharmacological management of low back pain. Drugs 2010; 70 (4): 387-402.][Парфенов В. А., Батышева Т.Т. Боли в спине: болезненный мышечный спазм и его лечение миорелаксантами. Лечащий врач. 2013; 4: 16-8.][Dapas F, Hartman S.F, Martinez L et al. Baclofen for the treatment of acute low - back syndrome. A double - blind comparison with placebo. Spine (Phila Pa 1976) 1985; 10 (4): 345-9.][Корешкина М.И. Баклосан (баклофен) в лечении болей в спине: результаты многоцентрового исследования BRAVO. Журн. неврологии и психиатрии им. С.С.Корсакова. 2009; 8: 68-9.][Raphael J.H, Southall J.L, Gnanadurai T.V et al. Long - term experience with implanted intrathecal drug administration systems for failed back syndrome and chronic mechanical low back pain. BMC Musculoskelet Disord 2002; 3: 17.][European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15 (Suppl. 2): S.192-300.][Chou R. Low back pain (chronic). BMJ Clin Evid 2010; 2010: 1116.][Kаssis А. Antidepressants to Treat Nonspecific Low Back Pain. Am Fam Physician 2008; 78 (1): 51-2.][Hill J.C, Whitehurst D.G, Lewis M et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378 (9802): 1560-71.][Kamper S.J, Apeldoorn A.T, Chiarotto A et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014; 9: CD000963.][Van Middelkoop M, Rubinstein S.M, Kuijpers T et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non - specific low back pain. Eur Spine J 2011; 20 (1): 19-39.][Staal J.B, De Bie R, De Vet H.C et al. Injection therapy for subacute and chronic low back pain: An updated Cochrane review. Spine (Phila Pa 1976) 2009; 34: 49-59.][Manchikanti L, Abdi S, Atluri S et al. An update of comprehensive evidence - based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16 (2 Suppl.): S49-283.][Chambers H. Physiotherapy and lumbar facet joint injections as a combination treatment for chronic low back pain. A narrative review of lumbar facet joint injections, lumbar spinal mobilizations, soft tissue massage and lower back mobility exercises. Musculoskeletal Care 2013; 11 (2): 106-20.][Lakemeier S, Lind M, Schultz W et al. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double - blind trial. Anesth Analg 2013; 117 (1): 228-35.][Falco F.J, Manchikanti L, Datta S et al. An update of the effectiveness of therapeutic lumbar facet joint interventions. Pain Physician 2012; 15 (6): E909-53.][Ribeiro L.H, Furtado R.N, Konai M.S et al. Effect of facet joint injection versus systemic steroids in low back pain: a randomized controlled trial. Spine (Phila Pa 1976) 2013; 38 (23): 1995-2002.][Ha D.H, Shim D.M, Kim T.K et al. Comparison of ultrasonography - and fluoroscopy - guided facet joint block in the lumbar spine. Asian Spine J 2010; 4 (1): 15-22.][Henschke N, Kuijpers T, Rubinstein S.M et al. Injection therapy and denervation procedures for chronic low - back pain: a systematic review. Eur Spine J 2010; 19 (9): 1425-49.][Chou R, Hashimoto R, Friedly J et al. Pain Management Injection Therapies for Low Back Pain [Internet]. Agency for Healthcare Research and Quality (US); 2015 Mar. AHRQ Technology Assessments.][Clinical Management of Chronic Spinal Pain. Pain Physician 2009; 12: E225-E264.][Van Tulder К. Diagnosis and treatment of sciatic. BMJ 2007; 334: 1313.]