Can mild right‑sided lumbar scoliosis, slight upper‑lumbar retrolisthesis, and mild facet joint arthropathy at the lumbosacral junction cause chronic low‑back pain?

Can Mild Dextroscoliosis, Upper Lumbar Retrolisthesis, and Mild Facet Arthropathy Cause Chronic Pain?

Yes, these findings can cause chronic low back pain, but they are not the primary pain generator in the majority of cases—facet joints are responsible for pain in only 9-42% of patients with degenerative lumbar disease, and imaging findings alone do not reliably predict pain. 1, 2

Understanding the Pain Generators

Facet Joint Arthropathy as a Pain Source

• Facet-mediated pain accounts for only 9-42% of chronic low back pain in patients with degenerative lumbar disease, meaning in 58-91% of cases, the facet joints are NOT the primary source despite their appearance on imaging 1, 2
• No physical examination findings or radiographic changes consistently correlate with facet-mediated pain—the diagnosis requires controlled diagnostic blocks, not imaging alone 1, 2
• Pain from lower lumbar facet joints (L4-5, L5-S1) typically refers to the groin and deep posterior thigh, while upper lumbar facets cause flank, hip, and upper lateral thigh pain; pain below the knee is highly questionable for facet origin 1, 3

Scoliosis and Facet Degeneration

• Moderate scoliosis significantly increases the odds of severe facet arthropathy, with a 6.72-fold increase at L3-L4 and 5.57-fold increase at L5-S1 4
• Even mild scoliosis poses notable risk, with a threefold increase in facet degeneration at L4-L5 and twofold increase at L5-S1 4
• Degeneration is more severe on the concave side of the scoliotic curve, suggesting asymmetric loading as a mechanical contributor 4

Retrolisthesis Contribution

• Retrolisthesis at L5-S1 was NOT associated with increased preoperative low back pain or physical dysfunction in patients with disc herniation 5
• The presence of retrolisthesis does not increase the incidence of having degenerative disc disease, posterior degenerative changes, or vertebral endplate changes 5
• Retrolisthesis is relatively rare (23.2% prevalence in one study) and when present, its pain contribution may be overshadowed by other pathology 5

Critical Diagnostic Approach

What Imaging Cannot Tell You

• Imaging findings of mild facet arthropathy, scoliosis, and retrolisthesis do NOT establish these as the pain source—90% of patients with facet joint changes on imaging do not have facet-mediated pain 2, 6
• The presence of structural changes on MRI lacks specificity for identifying the actual pain generator 1

Establishing the True Pain Source

• The gold standard for diagnosing facet-mediated pain requires controlled comparative local anesthetic blocks (double-injection technique) with ≥80% pain relief threshold 2, 3
• The double-block technique uses anesthetics with different durations of action on two separate occasions to confirm facet origin 2, 3
• Single diagnostic blocks have high false-positive rates and limited diagnostic value 2, 7

Alternative Pain Generators to Consider

• Discogenic pain or annular tears should be evaluated, particularly if pain is worse with flexion rather than extension 2, 8
• Sacroiliac joint pathology must be considered given typical radiation patterns to hip and buttocks 2, 8
• Myofascial pain is a common contributor that may coexist with structural changes 8

Treatment Algorithm

First-Line Conservative Management (Minimum 6 Weeks)

• Physical therapy focusing on extension exercises combined with NSAIDs is the recommended first-line treatment before considering any interventional procedures 2, 6
• For spondylolisthesis specifically, flexion exercises (abdominal strengthening, posterior pelvic tilts) show better outcomes than extension exercises, with only 19% having moderate-severe pain at 3-year follow-up versus 67% in extension groups 9
• Conservative treatment must be attempted for at least 6 weeks before interventional procedures are considered medically necessary 2

If Conservative Treatment Fails After 6 Weeks

• Proceed with diagnostic medial branch blocks (NOT intraarticular facet injections) using >50% pain relief threshold as initial confirmation 2, 3, 6
• Medial branch blocks show superior diagnostic accuracy and therapeutic efficacy compared to intraarticular facet injections 2, 3
• Each medial branch block provides an average of 15 weeks of pain relief 2, 6

Definitive Treatment for Confirmed Facet Pain

• Radiofrequency ablation of the medial branch nerves is the gold standard for confirmed facet-mediated pain, with 66% success rate versus 38% in control groups 3, 6
• RFA provides moderate evidence for both short-term and long-term pain relief 2, 6
• Do NOT perform repeated intraarticular facet injections—guidelines state these are considered experimental with no proven long-term benefit 2, 3

Critical Pitfalls to Avoid

Common Diagnostic Errors

• Do not assume imaging findings equal pain source—only 7.7% of patients selected for facet injection based on clinical criteria and imaging achieve complete relief 2, 6
• Do not rely on single diagnostic blocks due to high false-positive rates (up to 40%) 1, 7
• Do not proceed with therapeutic interventions without proper diagnostic confirmation 2

Treatment Mistakes

• Intraarticular facet joint injections with steroids are no more effective than placebo for long-term pain relief and disability 2, 3
• Repeated intraarticular injections at the same level are not supported by evidence and should not be performed 3, 6
• Epidural steroid injections provide limited evidence for chronic low back pain without radiculopathy (less than 2 weeks relief) 1

Clinical Bottom Line

Your imaging findings CAN contribute to chronic pain, but they are NOT sufficient to establish causation. The mild nature of these findings (mild facet arthropathy, slight retrolisthesis, mild scoliosis) makes them even less likely to be the primary pain generator. Begin with 6 weeks of physical therapy and NSAIDs. If this fails, pursue diagnostic medial branch blocks—not imaging-guided treatment decisions—to identify the true pain source before considering any interventional procedures. 2, 6 If facet-mediated pain is confirmed with proper diagnostic blocks showing ≥80% relief, proceed directly to radiofrequency ablation rather than repeated injections. 2, 3, 6