Lumbar facet joint pain
Pain arising from the joints at the back of the spine: understanding symptoms, clarifying the diagnosis and choosing treatment.
The facet joints connect the vertebrae at the back of the spine and contribute to stability and movement. When they become a source of pain, this is known as facet joint pain or lumbar facet syndrome. However, osteoarthritis on an X-ray or MRI does not automatically mean that these joints are causing the pain.
What symptoms can occur?
Pain is mainly in the lower back and may extend into the buttock or thigh. Prolonged standing, arching the back or twisting may aggravate it. Stiffness and restricted movement may also occur.
These symptoms help guide assessment but are not specific. Tingling, altered sensation or weakness also warrant assessment of the nerve roots.
What contributes to facet pain?
Joint degeneration, altered loading, disc degeneration and changes in spinal alignment can contribute. Several pain mechanisms may coexist in the same person.
For an overview of the different causes, see our guide to chronic low back pain.
Diagnosis: beyond the scan
Assessment includes the history of the pain, a clinical examination and, when indicated, review of X-rays, MRI or CT. Imaging helps describe the anatomy and investigate other causes; it cannot confirm facet joint pain on its own.
When denervation is being considered, a diagnostic medial branch block with local anaesthetic can help identify suitable patients. The extent and duration of relief, together with the ability to repeat normally painful activities, are assessed. The result must be interpreted in its clinical context: it does not guarantee treatment success.
The former targets the small nerves carrying pain signals from the facet joints; the latter targets the joint itself. The purpose, target and interpretation of any diagnostic procedure should be explained beforehand.
The first step: restoring movement and function
The pathway includes education, adapted activity and exercise, physiotherapy when indicated and individualised medication where appropriate. An interventional procedure may be considered if pain continues to limit daily life despite an adequate course of conservative care.
Radiofrequency: which technique for which pain?
Thermal medial branch radiofrequency
Thermal radiofrequency aims to interrupt pain transmission through the medial branches supplying the facet joints. It is an option for selected patients with suspected facet joint pain and a favourable response to diagnostic assessment.
At PONOS, the procedure is performed in an operating theatre as day surgery, using fluoroscopic guidance and checks of needle position. It does not correct osteoarthritis or spinal deformity.
How lumbar radiofrequency is performedPRF and radicular pain
Pulsed radiofrequency (PRF) is used for neuromodulation and is not interchangeable with thermal facet denervation. The treatment target depends on the pain mechanism.
Radicular pain, for example, requires a different assessment pathway: read about sciatica and lumbar radiculopathy. Low back pain alone is not sufficient to indicate either RF or PRF.
What do the guidelines say?
The 2020 NASS low back pain guideline gives thermal radiofrequency for lumbar facet joint pain a grade B recommendation. It highlights the importance of diagnostic selection; the studies reviewed reported benefit lasting at least six months. This does not predict the duration of relief for an individual patient.
NICE recommends a positive response to a diagnostic medial branch block before denervation. The number of tests and response criteria should be established by the clinician within the individual assessment pathway.
Results, limitations and follow-up
The aim is to reduce pain and improve independence, sleep and tolerance of movement. Benefit may develop over the following weeks and may be partial or temporary. Persistent pain calls for reassessment of other possible contributing sources.
Possible adverse effects include temporary local pain, nerve irritation, bleeding and infection; neurological injury is rare. The consultation and informed consent process cover risks, alternatives and individual circumstances.
Frequently asked questions
Can MRI alone diagnose facet joint pain?
No. Degenerative changes can be present without pain. Imaging, clinical assessment and the response to any diagnostic blocks need to be considered together.
Does radiofrequency cure osteoarthritis?
No. It acts on pain transmission without rebuilding the joint. Functional rehabilitation remains part of treatment.
Does leg pain always come from the facet joints?
No. Referred facet pain and radicular pain may overlap, but their mechanisms and assessment pathways differ. Weakness or loss of sensation require particular attention.
Can the procedure be repeated?
Repeat treatment may be considered when a meaningful benefit wears off, following a fresh clinical assessment. It is not automatic and there is no fixed interval suitable for everyone.
New or progressive weakness, loss of sensation around the perineum, or new problems with bladder or bowel control require urgent assessment. Fever or pain following trauma, particularly in someone with osteoporosis, also requires prompt medical advice.
Further reading and sources
Causes of low back painLumbar RF: the pathwayPONOS clinical cases
- NASS, Diagnosis and Treatment of Low Back Pain, 2020 — evidence reviewed up to February 2016.
- NICE NG59, recommendations 1.3.2–1.3.3.
- Cohen and colleagues, consensus practice guidelines on interventions for lumbar facet joint pain, 2020.
A targeted assessment of low back pain
The pathway starts with identifying the source of pain and setting realistic goals for the individual.
Dr Evangelos Panagiotakos • PONOS
Contact and appointmentsAbout the doctor