Optimal Noninvasive Imaging for Suspected Zygapophyseal (Facet)‐Mediated Low Back Pain

Abstract

A 46-year-old healthy man presents with an 8-week history of axial low back pain without precipitating trauma. He was initially seen in the physiatry spine clinic, and at that time he described right lower back pain without radiation into the legs. Clinical examination was positive for sharp, localized right lower back pain that was exacerbated with lumbar extension and right quadrant loading and relieved with lumbar flexion. Pertinent negative findings included a normal neurologic examination and no neural tension signs, including the straight leg raise and slump test. Flexion/extension radiographs revealed mild disk height loss at L4-L5, no pars interarticularis fractures, and no evidence of dynamic instability. The patient was prescribed nonsteroidal antiinflammatory drugs (meloxicam, 15 mg) and muscle relaxants (cyclobenzaprine, 5 mg) at night to help with sleep. He has since completed 8 weeks of physical therapy with a combination of Williams flexion exercises, deep tissue massage, and pelvic traction; however, his pain persists. He presents to discuss further diagnostic imaging and possible interventional treatments. What imaging examination is most appropriate to identify the likely pain generator? Dr Jason Talbott will take the position that functional nuclear medicine imaging is the appropriate examination. Dr J. Levi Chazen will take the position that magnetic resonance imaging is most appropriate at this stage.