Posterior Branches of Lumbar Spinal Nerves - Part III: Spinal Dorsal Ramus Mediated Back Pain - Pathomechanism, Symptomatology and Diagnostic Work-up.

Spinal Dorsal Ramus Mediated Back Pain is the second most frequently described condition (the first one being Lumbar Facet Syndrome) originating from pathology involving posterior branches of lumbar spinal nerves. Spinal Dorsal Ramus Mediated Back Pain was described as "thoracolumbar junction syndrome" by Maigne in 1989. As a rule, Spinal Dorsal Ramus Mediated Back Pain presents unilaterally within posterior branches at the levels Th11-12 and L1-2. The pain is triggered by extension and/or rotation. Typical symptoms include pain that may radiate towards the gluteal area and posterior iliac crest and does not cross the body midline. Clinical symptoms may correlate with the area supplied by the whole spinal nerve of the given segment, including both the posterior and anterior branch. For this reason, patients may report not only low back pain, but also pseudovisceral pain in the hypogastric area, false sciatic neuralgia, tenderness of the pubic symphysis and hypersensitivity of the intestines. The above symptoms may lead to diagnostic difficulties. Diagnostic work-up may benefit from performance of the Kibler Fold Test to determine sensitivity of the tissues surrounding the iliac crest. Patients with Spinal Dorsal Ramus Mediated Back Pain respond well to manual manipulative techniques if these are delivered in a technically correct manner and address the appropriate segment. A recommended approach for patients with absolute contraindications to manipulation, i.e. advanced osteoporosis or osteogenesis imperfecta, is a block of the po-sterior branch of the spinal nerve involved.