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Back Pain - facet joint pain: Part 1
Case History & Clinical Presentation:
A 50 year old man (Patient A) presented with a 5 year story of back pain, which had been getting slowly worse. The pain was in the low part of the back, and was much worse on the left side. The pain then spread into the buttock and the back of the thigh (into the hamstring). The pain was aggravated by bending, lifting, walking and rolling in bed. Sitting was variably sore. The intensity of pain in the back was worse than the leg pain. The leg pain was a general aching sensation. The back pain was similar, but at times it was sharp. He could walk without much pain: indeed, walking helped to relieve the pain. |
| He has tried both physical therapy and chiropractic care over those years. Earlier on physical treatment had helped. He had been through a few periods of exercise. These included stretching exercises, which he was still doing three times a week, and strengthening exercises, which he had ceased doing.
He was still working, in a job that did involve a moderate amount of bending and some lifting. He said that he did feel more pain when working than when taking it easier on a weekend, but the aggravation was not all that much.
He scored his pain on a pain score chart at generally about 5/10, with flare ups reaching 7/10. He always had some back pain, with 3/10 being about the best. He had tried some medication, but it had not helped enough and he had decided just to put up with the pain.
Examination of the back showed that he could touch his toes without pain. However, backwards bending was restricted and produced the back pain. The hips moved well and without pain. Tests on nerve function in the lower legs did not reveal any problem.
He had had a CT scan. It showed a small L5/S1 spondylolisthesis and with moderate disc space narrowing. There was no disc prolapse. However, there was bulging of the lower two discs.
Comments on the clinical presentation:
- He had gone for 5 years without getting any sustained relief. It was apparent that the back condition was unlikely to get better left untreated.
- It is a moot point as to whether or not a lighter job would help him much. It is quite common for back pain to persist and even get worse when swapping to a job that involves less activity. He wanted to keep working in the same job if he could. It was felt that it was reasonable for him to continue on with his job. He was advised to try to find a happy balance between activity and rest. That is, he needed to make sure that he worked at the right pace.
- The presence of leg pain does not mean that there is nerve pressure. In this instance it was thought that the pain was a referred pain, that is, pain traveling from a specific structure in the low back, rather than from nerve damage.
- It is not possible to work out what back structure hurts by performing a medical examination. However, the fact that bending backwards hurt points to a diagnosis of facet joint pain.
- The CT is not all that helpful in the diagnosis of what causes the pain. Here the CT revealed changes, including a small slip of one bone on another (spondylolisthesis), and some disc bulging with degeneration. These findings are sometimes called osteoarthritis. However, these changes can be considered to be not unusual for any person at the age of 50. People without pain can have these changes. Thus, it was considered that the changes were not of concern.
- The problem here was to decide if he should just put up with the pain, or do something about it. He did obtain general information on how to live with back pain. This involved advice on exercise, efficient lifting and use of the core muscles, pacing and general health matters. After discussion he decided to proceed to a medial branch block to determine whether or not he had facet joint pain.
- If these blocks lead to a diagnosis of primary facet joint pain, then radiofrequency neurotomy would follow.
- If the block proved negative then there may have been nothing else to do. At that stage consideration could be given to disc investigation and treatment.
Results: Medial Branch Block Investigation
Find out about the resulting outcome and discussion from the first Medial Branch Block performed on Patient A.
Next Page
[This Case History will be continued in the next Lowbackpain.TV Guide.]
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