Curr Rev Musculoskelet Med (2009) 2:15–24 DOI 10.1007/s12178-008-9039-y The provocative lumbar facet joint David S. Binder Æ Devi E. Nampiaparampil Published online: 31 March 2009 The Author(s) 2009. This article is published with open access at Springerlink.com Abstract Low back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increas- ingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints them- selves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diag- nostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint- mediated pain, but at this time, there is insufﬁcient evidence that it is a wholly efﬁcacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the per- formance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain. Keywords Facet joint Zygapophyseal joint Low back pain Pain Radiculopathy Sciatica D. S. Binder (&) Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA e-mail: dbind2003@yahoo.com D. E. Nampiaparampil Division of Pain Medicine, VA Hudson Valley Healthcare System, Castle Point, NY, USA D. E. Nampiaparampil Muscle and Nerve Pain Specialists, Chicago, IL, USA Catheter ablation Steroids Lumbar vertebrae Humans Male Female Nerve block Diagnostic errors Introduction Low back pain is the most common pain symptom expe- rienced by American adults and is the second most common reason for primary care physician visits [1]. One study reported that over one-quarter of the U.S. population had experienced an episode of low back pain in the three months prior to the survey [2]. Although the majority of episodes last less then 3 months, many patients experience recurrent attacks [3]. Those patients who go on to develop chronic low back pain (lasting greater than 3 months) account for an estimated $100–$200 billion dollars of healthcare spending per year [4]. Despite our enhanced understanding of pain neural pathways and improvements in imaging technology, diagnosing the exact etiology of low back pain and treating it continues to be a challenge. There are many structures in the lumbar spine that can serve as pain generators and often, the etiology of low back pain is multifactorial. Since being described as a potential pain generator by Joel Goldthwait in 1911 [5], the facet joint has been increasingly recognized as an important cause of low back pain. The use of the term facet syndrome was ﬁrst coined by Ghormely in 1933 [6]. A facet joint (also referred to as a zygapophysial joint) is located at the junction of the inferior articular process of a more cephalad vertebra and the superior articular process of a more caudal vertebra. It has been estimated that facet joint pathology is a contributory factor in 15–52% of patients with chronic low back pain [7–13]. However, it has also been reported that the prevalence of isolated facet joint pain may be as low as 4% [14].