title: Lumbar zygapophyseal pain during extension-based stabilization protocol following lumbar transdiscal biacuplasty.
abstract: BACKGROUND
  Transdiscal biacuplasty (TDB) is a minimally invasive procedure for the treatment of lumbar discogenic pain. Theoretically, TDB ablates the aberrant ingrowth of nerve fibers beyond the outer third of the annulus fibrosis of the lumbar intervertebral disk and treats annular tears via collagen reformation. Typically, recovery involves a robust rehabilitation protocol that emphasizes lumbar stabilization exercises, focusing on extension maneuvers while also strengthening the multifidi and transverse abdominus. New-onset postprocedural pain during recovery may occur; evaluation of nondiscogenic causes should be considered. We report 3 of 12 patients who developed zygapophyseal-mediated pain during the recovery period.
  
  
  METHODS
  Three of 12 patients who underwent TDB over a 1-year period, developed zygapophyseal-mediated back pain at the level of the original discogenic pathology. All three underwent unilateral intra-articular zygapophyseal injections with resolution of their new-onset symptoms.
  
  
  CONCLUSIONS
  Novel postprocedural low back pain should provoke re-evaluation of potential etiologies such as persistent discogenic pathology, zygapophyseal or sacroiliac joint involvement, and other mechanical sources of pain. We postulate that extension maneuvers during rehabilitation, combined with lumbar bracing in extension, inadvertently triggered and potentially exacerbated pre-existing zygapophyseal irritation. The clinical implication of this scenario is novel distracting pain, caused by an alternative etiology to the original discogenic pain, and may present a confounder to the assessment of the efficacy of TDB.
authors.affiliation: Pain Medicine & Non-Operative Spine Services, The George Washington University Medical Center, Washington, District of Columbia, U.S.A.
authors.forename: Puneet K
authors.initials: PK
authors.lastname: Sayal
authors.forename: Mehul J
authors.initials: MJ
authors.lastname: Desai
mesh_terms: D000328:Adult; D000700:Analgesics / Q000627:therapeutic use; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000209:etiology* / Q000601:surgery* / Q000628:therapy; D008159:Lumbar Vertebrae / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects*; D019637:Orthopedic Procedures / Q000009:adverse effects*; D010149:Postoperative Pain / Q000628:therapy; D026741:Physical Therapy Modalities; D016896:Treatment Outcome; D021801:Zygapophyseal Joint
chemical_list: D000700:Analgesics
keywords: facet joint; low back pain; mechanical; postprocedural pain; transdiscal biacuplasty