Posterior Rami Syndrome
Encyclopedia
Posterior Ramus Syndrome, also referred to as Thoracolumbar Junction Syndrome, Maigne Syndrome and Dorsal Ramus Syndrome is caused by the unexplained activation of the primary division of a posterior ramus
of a spinal nerve (Dorsal ramus of spinal nerve). This nerve
irritation causes referred pain
in a well described tri-branched pattern. The diagnosis is made clinically with the variable presence of four criteria.
Descriptions of clinical involvement of posterior rami were found as early as 1893, but not until 1980 that LDRS was so precisely described. While any (or all) of the three branches may present themselves, their constancy of location is what allows this to be defined as a distinct syndrome
. One branch sets off anteriorly to the groin
or pubic region. A second branch remains posterior, innervating the lower back
and upper gluteal region. Thirdly a lateral take-off passed down the anterolateral thigh
or trochanter region. The term sclerotome, distinct from dermatome for anterior rami involvement, has been proposed to describe the pattern of pain produced from posterior rami.
Secondly the patient will not usually have spontaneous pain at the offending spinal level. Pain can be provoked by palpation of the facet joints, or the level can remain veiled, with only the referred pain as evidence of the defect. Usually unilateral, bilateral cases have been described as we present here. Patients will not have pain radiating below the knee, which is more typical of anterior ramus involvement.
Third, radiographic evidence is non-contributory. MRI, CT
and myelography
are all ineffective at localizing the at-fault level. The typical degenerative changes seen on most images may lead to unnecessary surgery or false diagnosis. The posterior ramus is far removed from herniating or bulging discs.
The fourth criterion clinches the diagnosis: pain relieved by injection of local anesthetic into the correct facet joint. This diagnostic procedure can also be therapeutic; the injection of steroids or radiofrequency denervation of the medial branch can be added for refractory cases. Essential to remember is that the pattern of referred pain in no way hints at the spinal level involved. Multiple studies confirm that there is considerable overlap in the distribution of pain stemming from the zygapophyseal joints, including anterior, lateral or posterior thigh, groin, lumbar spine region, and trochanter region. This overlap of innervation is poorly handled by the standard dermatome map which physicians rely on to trace pain back to its source.
Ramus
Ramus can refer to:* A branch* A portion of a bone , as in the Ramus of the mandible or Superior pubic ramus* A nerve ramus such as the Dorsal ramus of spinal nerve* Petrus Ramus...
of a spinal nerve (Dorsal ramus of spinal nerve). This nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
irritation causes referred pain
Referred pain
Referred pain is pain perceived at a location other than the site of the painful stimulus. An example is the case of ischemia brought on by a myocardial infarction , where pain is often felt in the neck, shoulders, and back rather than in the chest, the site of the injury...
in a well described tri-branched pattern. The diagnosis is made clinically with the variable presence of four criteria.
Descriptions of clinical involvement of posterior rami were found as early as 1893, but not until 1980 that LDRS was so precisely described. While any (or all) of the three branches may present themselves, their constancy of location is what allows this to be defined as a distinct syndrome
Syndrome
In medicine and psychology, a syndrome is the association of several clinically recognizable features, signs , symptoms , phenomena or characteristics that often occur together, so that the presence of one or more features alerts the physician to the possible presence of the others...
. One branch sets off anteriorly to the groin
Groin
In human anatomy, the groin areas are the two creases at the junction of the torso with the legs, on either side of the pubic area. This is also known as the medial compartment of the thigh. A pulled groin muscle usually refers to a painful injury sustained by straining the hip adductor muscles...
or pubic region. A second branch remains posterior, innervating the lower back
Back
- People :* Adam Back, British cryptographer* Charles Back, South African winemaker* Chris Back , Australian politician* Ernst Emil Alexander Back , German physicist* Frédéric Back , Canadian animator...
and upper gluteal region. Thirdly a lateral take-off passed down the anterolateral thigh
Thigh
In humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...
or trochanter region. The term sclerotome, distinct from dermatome for anterior rami involvement, has been proposed to describe the pattern of pain produced from posterior rami.
Diagnosis
The affected posterior ramus ends cutaneously causing trophic changes of the skin referred to as cellulalgia. Neuropathic pain is found in three well described regions and serves as the principal clinical component in diagnosing Lumbar Dorsal Ramus Syndrome (LDRS). Typical neuropathic skin changes are present: a thickening or nodularity of the skin, hair loss or even a swollen puffy appearance. Patients with pain in any of these three regions should have a complete physical exam of the entire spinal column including palpation of the facets and spinous processes in hopes of determining the level of origin.Secondly the patient will not usually have spontaneous pain at the offending spinal level. Pain can be provoked by palpation of the facet joints, or the level can remain veiled, with only the referred pain as evidence of the defect. Usually unilateral, bilateral cases have been described as we present here. Patients will not have pain radiating below the knee, which is more typical of anterior ramus involvement.
Third, radiographic evidence is non-contributory. MRI, CT
Computed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
and myelography
Myelography
Myelography is a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors...
are all ineffective at localizing the at-fault level. The typical degenerative changes seen on most images may lead to unnecessary surgery or false diagnosis. The posterior ramus is far removed from herniating or bulging discs.
The fourth criterion clinches the diagnosis: pain relieved by injection of local anesthetic into the correct facet joint. This diagnostic procedure can also be therapeutic; the injection of steroids or radiofrequency denervation of the medial branch can be added for refractory cases. Essential to remember is that the pattern of referred pain in no way hints at the spinal level involved. Multiple studies confirm that there is considerable overlap in the distribution of pain stemming from the zygapophyseal joints, including anterior, lateral or posterior thigh, groin, lumbar spine region, and trochanter region. This overlap of innervation is poorly handled by the standard dermatome map which physicians rely on to trace pain back to its source.