By Jessica Diebold, Boston
Last winter, my husband fell on some ice. Instead of landing on his backside, he landed on his left hip. He was in a great deal of pain in both the hip and lower back, and went to an ER for X-rays, which came back negative. The pain persisted for the following two weeks, and eventually he was referred to an orthopedic surgeon, who did MRIs and a bone scan (both negative). After a round of PT with no decrease in pain, he was referred to a physiatrist, who diagnosed traumatic facet syndrome.
After another round of PT and injections to numb the spinal nerves, my husband is still in pain. He was referred to another physiatrist, who still insists it is facet joint syndrome and prescribed daily light stretching. The pain is getting worse, not better, and even taking a pain medication like Percocet does not totally relieve his pain. Is there anything else this could be? Do we go for a fourth opinion?
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
I often encourage patients to seek a second or even a third opinion. It is important that every patient find a physician that he or she can have a good rapport with, especially when dealing with something that can be difficult to treat. Low back pain is one such condition. The patient with low back pain might consider seeing physicians of different specialties such as a neurologist, an orthopedic surgeon and a physiatrist, also known as a rehabilitation doctor.
What you describe is also called lumbosacral facet syndrome or Z-joint mediated low back pain. This is a common cause of low back pain. It can be due to small damage to spinal bone and soft tissue, arthritic degeneration of bone or overgrowth with remolding of the bone and joint structure. In either case, the nerve leaving the spine is impinged upon, and this causes the pain. The pain can be isolated to the back, or it can radiate down the leg.
The pain is often exacerbated by twisting the back, stretching or lateral bending. Many describe their pain as worse in the morning. It seems aggravated by rest and relieved by repeated motion. Unlike many other causes of back pain, this pain usually does not worsen with an increase in intra-abdominal pressure. Therefore, coughing, laughing and straining to have a bowel movement do not worsen the pain.
This condition is difficult to diagnose because the findings are nonspecific on physical examination, and all imaging studies such as MRI or CT of the spine and bone scan are usually normal. Occasionally, electromyography, a study of electrical conduction of the nerves, will be abnormal. This can be the only objective abnormal finding. These examination and imaging studies are useful in ruling out other causes of pain such as a fracture of a spinal disc or disc herniation. Disease of the spinal discs is often misdiagnosed as lumbosacral facet syndrome.
There are three phases to facet syndrome. They are referred to as acute, recovery and maintenance.
The initial treatment plan for facet syndrome in the acute phase is a day or two of bed rest, pain relief with non-steroidal anti-inflammatories, application of heat and cold to relax the muscles and positioning to provide comfort and some limited exercise. Physical therapy includes instruction on proper posture and body mechanics in activities of daily living that protect the injured joint, reduce symptoms and prevent further injury. One should avoid activities and positions that cause pain.
There are a number of treatments that have been used in severe cases of facet syndrome where the pain of the acute phase will not remit. Most patients have disappointing outcomes, but a few get significant relief. These treatments include injection of the nerve with anesthetics and/or steroids, radiofrequency ablation of the nerve and median branch blocks. Some report success with acupuncture or transcutaneous electrical nerve stimulation. Some patients do find comfort in chiropractic spinal manipulation and mobilization beginning in the acute phase. Surgical intervention is not commonly used for the acute phase of facet syndrome.
The recovery phase begins once the painful symptoms are controlled. At this point, stretching and strengthening exercises of the muscles of lower back and trunk are started. Because the facet syndrome pain tends to be worse with extension, strengthening and conditioning exercises should typically be performed with a flexed trunk. Strengthening maneuvers must emphasize flexion, neutral postures and pelvic tilt. A great deal of emphasis is placed on strengthening muscles using pelvic tilt. This is all in an effort to reduce compression on the nerves coming out of the spine.
In the maintenance phase, more dynamic conditioning exercises are done on a long-term basis to maintain a neutral spine with symmetrical flexibility of the trunk. It is not uncommon for the patient to have future bouts of low back pain.
Many physicians are hesitant to prescribe narcotics for a long term to a patient with chronic low back pain. There is fear of causing an addiction. Most physicians are comfortable giving a limited amount of narcotics for a limited period of treatment, especially during a period of severe pain.
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