S1 root compression
This root is fixed to the dural sac at the level of the L5-S1 intervertebral disc. This is the spinal segment that bears the greatest functional load.
If the mobility between the vertebrae Lm and Ljy is on average 12°, between L4-L5 - 16°, then at the level of L5-S1 it is 20° (Brocher J., 1958). The L5-S1 disc wears out more often in those with the so-called first type of pelvis, in which the Lrv-v disc is located high above the level of the iliac crests.
At the level of L5-S1, the posterior longitudinal ligament extends only 3/4 of the diameter of the wall of the spinal canal, its width here does not exceed 1-4 mm (Magnuson W., 1944; Khevsuriani S.O., 1961). In this case, disc prolapses are often not median or paramedian, as in the overlying segments, but due to the presence on the sides of the ligament of a free path for a hernia, they are posterolateral.
With such a localization of the hernia, it has a deforming effect on the L5 root, heading towards the L5-S intervertebral foramen. In those rarer cases, when the hernia is median or paramedian, the first sacral root is stretched over it. It emerges here from the dural sac at an acute angle of 30° (Hanraets P., 1959). The overlying roots emerge more shallowly, at more obtuse angles. Heading towards the first sacral foramen, the Si root with disc pathology finds itself in a very disadvantageous position. It runs in the bony canal of the sacrum, intimately fused with the dura mater and limited in its mobility.
According to D. Petit Dutaillis (1945), this root insufficiency is aggravated when it is pulled over the L5-S1 disc herniation, which often results in a protective tilt of the body to the affected side. It is necessary to take into account the greater mobility of the lumbosacral segment and the need for corresponding significant excursions of the root stretched over the hernia. These movements turn out to be especially traumatic because... the root, as mentioned above, is sufficiently fixed in the bone. And yet, the Si root is infringed by a hernia less often than the L5 root: the S1 root most often passes medially from the articular processes of the sacrum in a wide canal (Rutenburg M.D., 1973; see Fig. 4.34).
Because a disc herniation is not held for a long time by the narrow and thin posterior longitudinal ligament at this level; the disease often begins immediately with radicular pathology. The period of lumbago and lumbalgia, if it precedes radicular pain, is short. Among those undergoing surgery, isolated compression occurs in 25% according to M.K. Brotman (1972) and B.V. Drivotinov (1972). In our clinic, among patients with lumbar radicular syndromes, they were diagnosed in 49.7%. It should be taken into account that the symptoms of damage to this root are very often associated not with a herniated Ly-Si disc or with isolated compression, but with intradural dislocation in a herniated L4-5 disc. Such symptoms from the Si root were noted by M.K. Brotman (1975) in 61%.
Compression of the root by the sequestration of the herniated disc, which descends to the S1 foramen, is especially difficult. In these cases, in addition to the symptoms of loss and irritation of the root, pain is detected in the area of the well-palpable opening Si. Currently, MP tomography helps clarify the diagnosis, but in the past such pictures seemed clinically very clear.
Patient Sh., 43 years old, was brought to the clinic and suffered for two weeks from unbearable pain and excruciating paresthesia in the right heel and along the outer edge of the right leg. There was no pain in the lower back. In the dermatome Si there was mild hypoalgesia, the Achilles reflex on the right was reduced. The hole Si on the spondylogram on the right turned out to be a horizontal gap between the transverse process of L5 and the sacrum. Dipping the pad of the finger into the area of this depression caused a sharp (recognizable) pain in the leg. The adjacent areas of the sacrum remained painless. After injecting 5 ml of a 1% novocaine solution into this gap, the pain went away, and the patient fell asleep peacefully for the first time in a week. One repeated novocaine blockade, and then lidase electrophoresis on the S1 zone on the right and decongestant drug treatment significantly alleviated the course of the disease. The pain and paresthesia became less intense, and after 3 weeks she was discharged for outpatient follow-up treatment. I already walked without the help of a stick.
Symptoms of S1 root compression are as follows. The pain radiates from the buttock or lower back and buttock along the posterior outer edge of the thigh, along the outer edge of the lower leg to the outer edge of the foot and the last toes, sometimes only to the little toe.
Often the pain extends only to the heel, more to its outer edge. Tingling sensations and other paresthesias are sometimes experienced in these same areas. Pain from the “hernial point” can also be felt here when causing the phenomenon of the intervertebral foramen, when coughing and sneezing, or with intense palpation of the first sacral foramen. In the same dermatome, especially in the distal parts, hypoalgesia is determined. Not always, as with damage to the Ls root, deep sensitivity is reduced in the corresponding fingers, but vibration sensitivity is often reduced (Farber M.A., 1984).
February 3, 2011
Spine C4(disc and intervertebral foramen C3-C4). Rare localization. Pain in the shoulder girdle, clavicle, atrophy of the posterior neck muscles (trapezius, splenius, levator scapulae, longissimus capitis and neck). A decrease in the tone of these muscles and, as a result, an increase in the air cushion in the lung area. In cases of irritation of the C3-C4 roots, an increase in the tone of the diaphragm usually leads to a downward displacement of the liver; Possible pain simulating angina pectoris. When prolapse occurs, the diaphragm relaxes.
C5 root (disc and intervertebral foramen C4-C5). Relatively uncommon localization. The pain radiates from the neck to the shoulder girdle and to the outer surface of the shoulder; weakness and wasting of the deltoid muscle.
In practice, a neurologist most often encounters damage to the C6 and C7 roots. Chronic degenerative-dystrophic changes (osteophytes, disc herniation) at this level occasionally cause dysphagia (Fig. 2.101).
Spine C6(disc and intervertebral foramen C5 - C6). Pain spreading from the neck and shoulder blade to the shoulder girdle, along the outer surface of the shoulder, to the radial edge of the forearm and to the first finger, paresthesia in the distal parts of this zone. All these subjective phenomena are intensified or provoked by inducing the phenomenon of the intervertebral foramen or by voluntary movements of the head. Hypalgesia in the C6 dermatome, weakness and hypotrophy of the biceps muscle, and decreased or absent reflex from the tendon of this muscle are noted.
Spine C7(disc and intervertebral foramen C6-C7). Pain spreading from the neck and scapula along the posterior surface of the shoulder and dorsal surface of the forearm to the II and III fingers, paresthesia in the distal part of this zone, hypalgesia in the C7 zone, weakness and wasting of the triceps muscle, decreased or absent reflex from the tendon of this muscle.
Spine C8(disc and intervertebral foramen C7-Th1). Pain spreading from the neck to the ulnar edge of the forearm and to the fifth finger, paresthesia in the distal parts of this area. Hypalgesia in zone C8 according to Kigen, decrease or loss of styloradial and supinator reflexes.
Radicular manifestations at the thoracic level are reduced to a girdling, sharp or dull pain in the area of the affected root. Because the roots are in close connection with the capsules of the joints of the heads and tubercles of the ribs, the pain intensifies with intense inhalation and coughing.
I would like to dwell in more detail on lumbar hernias, because They are the most common cause of discogenic lumboischialgia. Progressive spondylosis, recurrent episodes of acute low back pain, or chronic stress aggravate the injury and possible annulus weakness. Initially, under the influence of normal loads, small cracks appear in the latter. They arise in the center and spread to the periphery, thus weakening the annulus fibrosus. With a sudden increase in intradiscal pressure, the central nucleus may bulge and cause compression of the nerve root (Fig. 2.102)
The incidence of acute symptomatic hernias is highest in individuals aged 30-50 years. The nucleus pulposus at this time is voluminous and has greater turgor than the drier and fibrotic nucleus in older people.
A herniated disc usually forms gradually as the posterior longitudinal ligament, which holds the nucleus pulposus of the intervertebral disc in its normal state, weakens. A fragment of the latter can also move up, down or sideways into the intervertebral foramen. In rare cases, extensive nuclear prolapse occurs with sudden compression of the nerve. Hernia can also penetrate the cartilaginous plates of the upper or lower vertebral body. The disc material breaks through the defect of the cartilaginous plate into the cancellous bone. The hernia usually has an indeterminate size and shape, and on an x-ray it appears surrounded by a ring of sclerotic bone, called the Schmorl node (Fig. 2.102).
Upper lumbar roots L1, L2, L3 respectively, discs and intervertebral foramina L1-L2, L2-L3 and L3-L4. Relatively rare localization. L1-L2 disc herniation also affects the conus spinal cord. The onset of radicular syndrome is manifested by pain and loss of sensitivity in the corresponding dermatomes, and more often in the skin of the inner and anterior thighs. With median hernias, symptoms of damage to the cauda equina appear early. As a rule, symptoms of lower lumbar radicular lesions are also detected as a result of tension of the dura mater by an upper lumbar hernia. In elderly people, cruralgia with paresthesia occurs in a wide area above and below the knee due to compression of the upper lumbar roots. Weakness, hypotrophy and hypotonia of the quadriceps femoris muscle, decreased or loss of the knee reflex and sensory disturbances in the L3, L4 dermatomes are determined. Swelling of the roots can cause symptoms in the external cutaneous nerve of the thigh.
Spine L4(disk L3-L4). Infrequent localization; a mild pain occurs that radiates along the anterior inner thigh, sometimes to the knee and a little lower. In the same area there are also paresthesias; motor disturbances appear almost only in the quadriceps muscle: mild weakness and malnutrition with a preserved (often even increased) knee reflex (Fig. 2.103).
Spine L5(disk L4-L5). Frequent localization. The L5 root is compressed by a herniated L4-L5 disc, usually after a long period of lumbar pain, and the picture of the radicular lesion turns out to be very severe. During this long time, the nucleus pulposus manages to break through the fibrous ring, and often the posterior longitudinal ligament. The pain radiates from the lower back to the buttock, along the outer edge of the thigh, along the anterior outer surface of the leg to the inner edge of the foot and the first toes, often to just the first toe. The patient experiences a feeling of tingling and chilliness. Pain from the hernial point may also come here when coughing and sneezing. In the same zone, especially in the distal parts of the dermatome, hypalgesia is detected. A decrease in the strength of the extensor of the first finger (a muscle innervated only by the L5 root), a decrease in the reflex from the tendon of this muscle, hypotonia and hypotrophy of the tibialis anterior muscle are determined. The patient experiences difficulty standing on his heel with the foot extended (Fig. 2.104).
Spine S1(disk L5-S1). Frequent localization. Because a disc herniation cannot be held for long by the narrow and thin posterior longitudinal ligament at this level; the disease often begins immediately with radicular pathology. The period of lumbago and lumbalgia, if it precedes radicular pain, is short. The pain radiates from the buttock or from the lower back and buttock along the posterior outer edge of the thigh, along the outer edge of the lower leg to the outer edge of the foot and the last fingers (sometimes only up to the fifth finger). 
Often the pain extends only to the heel, more to its outer edge. In these same areas, only sometimes the patient experiences a tingling sensation and other paresthesias. Pain from the “hernial point” can also radiate here when causing the phenomenon of the intervertebral foramen (when coughing and sneezing). In the same zone, especially in the distal parts of the dermatome, hypalgesia is determined. A decrease in the strength of the triceps surae muscle and the flexors of the toes (especially the flexor of the fifth finger), hypotension and hypotrophy of the gastrocnemius muscle are determined. The patient has difficulty standing on his toes, and there is a decrease or absence of the Achilles reflex (Fig. 2.105).
When the S1 root is compressed, scoliosis is observed, more often heterolateral - tilting the body to the affected side (which reduces the tension of the relatively short root above the hernia). When the L5 root is compressed, scoliosis is often homolateral (which increases the height of the corresponding intervertebral foramen).
The result of large central hernias can be compression of several nerve roots - cauda equina syndrome.
E.V. Podchufarova
MMA named after I.M. Sechenov Moscow
Among pain syndromes lower back pain occupies a leading position. Acute pain in the back of varying intensity are observed in 80-100% of the population. 20% of adults experience periodic, recurrent pain in the back lasting 3 days or more. Analysis of social, individual and professional factors showed that there is a connection between pain in the back, level of education, lack of physical activity, intensity of smoking and frequency of bending and lifting heavy objects during work.
Depending on the reason pain distinguish vertebrogenic (pathogenetically associated with changes in the spine) and non-vertebrogenic painful syndromes. In this case, vertebrogenic disorders include lesions lumbar and sacral roots in case of intervertebral disc herniation, stenosis of the central and lateral spinal canal, spondylolisthesis and instability, arthropathic syndrome in case of degenerative lesions of the facet joints. To vertebrogenic causes pain in the back there are also relatively rare malignant neoplasms of the spine (primary tumors and metastases), inflammatory (spondyloarthropathies, including ankylosing spondylitis) and infectious lesions (osteomyelitis, epidural abscess, tuberculosis 0.7, 0.3 and 0, 01% of cases of acute pain in the back, respectively), as well as compression fractures of the vertebral bodies due to osteoporosis (3.10|.
Examples of nonvertebrogenic painful syndromes may include diseases of internal organs (gynecological, renal and other retroperitoneal pathologies). The main causes of radiculopathy not associated with dystrophic changes in the spine (less than 1% of cases) pain in the back with irradiation to the leg), are primary and metastatic tumors, meningeal carcinomatosis; congenital anomalies (arachnoid and synovial cysts); infections (osteomyelitis, epidural abscess, tuberculosis, herpes zoster, Lyme disease, HIV infection); inflammatory diseases: (sarcoidosis, vasculitis); endocrine and metabolic disorders: (diabetes mellitus, Paget's disease. acromegaly: arteriovenous malformations).
Among the structural damage associated with lower back pain, the following can be distinguished: hernia of the nucleus pulposus; narrow spinal canal (central canal stenosis, lateral canal stenosis); instability due to disc (intervertebral disc degeneration) or extradiscal (facet joints, spondylolisthesis) pathology; myofascial painful syndrome (MFPS). Clinically, the listed factors make it possible to identify compression radiculopathy, the progression of which leads to disability. and musculoskeletal painful syndromes (lumbodynia, lumbar ischialgia), mainly worsening the quality of life of patients.
Local pain in the lumbosacral region usually referred to as “lumbodynia”; pain, reflected in the leg - “lumboischialgia” and radiating pain associated with vertebrogenic lesions lumbar and/or sacral roots - “compression radiculopathy”.
Compression radiculopathies are most often observed with compression lumbar or sacral root herniated intervertebral disc, as well as lumbar stenosis. Radicular (irradiating) pain differs in greater intensity, distal (peripheral) spread to the corresponding dermatomes and the conditions that cause it. The mechanism of this pain consists of stretching, irritation or compression of the root (spinal nerve). Spreading pain almost always occurs in the direction from the spine to some part of the limb. Coughing, sneezing or exercise are common factors that increase pain. The same effect has any movement that causes stretching of the nerve, or conditions that lead to an increase in cerebrospinal fluid pressure (for example, coughing, straining).
Compression by a herniated disc
One of the main causes of compression radiculopathy is a herniated disc. When a disc herniation occurs, the dura mater first suffers, then the perineurium of the spinal ganglia and the roots of the cauda equina. Direct relationship between channel sizes and the appearance of signs
there is no compression of the roots. Men over 40 years of age are more likely to get sick. Pain compression related lumbosacral roots of a herniated intervertebral disc, wears
heterogeneous character. The “classical” picture of compression radiculopathy is the appearance of shooting, rolling, and less often burning pain and paresthesia (“pins and needles”, tingling), combined with decreased sensitivity (hypalgesia) in the area of innervation of the affected root. In addition to sensory disorders, the development of weakness in the so-called “indicator” muscles, mainly innervated by the affected root, is characteristic, as well as a decrease (loss) of the corresponding reflex. Characteristic sensory, motor and reflex disorders during
the most common types of compression radiculopathy lumbosacral roots are shown in Table I. In addition, with radicular compression
there is often an increase in pain with an increase in intra-abdominal pressure (when coughing, sneezing, laughing) in a vertical position and a decrease in a horizontal position. In approximately half of patients with disc pathology, a tilt of the body to the side (scoliosis) develops, which disappears in the supine position, which is mainly due to contraction of the quadratus muscle lower back. The straight leg raise test (Lasegue's sign) with the lift angle limited to 30 -50″ is practically pathognomonic for disc damage [1]. It is important to keep in mind that the clinical picture of root compression (usually L5) at the level of the corresponding intervertebral foramen is different. In such patients pain It is observed both when walking and at rest, does not increase with coughing and sneezing and is monotonous throughout the day. Forward bends are less limited, and painful sensations are most often provoked by extension and rotation.
Narrow spinal canal
In addition to the presence of disc pathology itself, the occurrence of radicular symptoms is facilitated by the relative narrowness of the spinal canal. The syndrome, in which damage to the spinal nerve roots occurs due to degenerative changes in the bone structures and soft tissues of the spinal canal, is clinically different from acute protrusion of the intervertebral disc. The main factors for spinal canal stenosis are hypertrophy of the ligamentum flavum, facet joints, protrusion of intervertebral discs, posterior osteophytes and spondylolisthesis. There is stenosis of the central canal of the spine (central lumbar stenosis) and lateral stenosis with a decrease in the size of the root canal or intervertebral foramen (foraminal stenosis). The smallest permissible anteroposterior diameter of the spinal canal at the lumbar level is 10.5 mm. In some cases, the sagittal diameter of the spinal canal remains normal, and narrowing occurs in the radicular canal, which is limited anteriorly by the posterolateral surface of the vertebral body, and posteriorly by the superior articular process. Lateral stenosis is diagnosed when the sagittal size of the root canal decreases to 3 mm. Compression factors in root canal stenosis are hypertrophy of the superior articular process and thickening of the ligamentum flavum. In 20-30% of cases there is a combination of central and lateral lumbar stenosis The L5 root suffers more often than others, which is explained by the significant severity of degenerative changes and the greater length of the lateral canals at the LV-SI level. Root entrapment can also occur in the central canal; this is more likely when it has a small diameter in combination with degenerative changes in the intervertebral discs, joints, and ligaments. The development of radicular compression can be caused not only by degenerative changes, but also by the presence of thickening of the veins (edema or fibrosis), epidural fibrosis (due to trauma, surgery with subsequent hematoma, infectious process, reaction to a foreign body). The absolute size of the root ropes cannot indicate the presence or absence of compression: what matters is its relationship with the size spinal ganglion or root
| Spine |
Radiation of pain |
Sensory disorders | Weakness | Reflex change |
| LI | Groin area | Groin area | Hip flexion | Cremasteric |
| L2 | Groin area, anterior thigh | Anterior thigh | Hip flexion, hip adduction |
Adductor |
| L3 | Front thigh surface knee-joint |
Distal sections anteromedial surface hips, knee joint area |
Shin extension Shin Hip flexion and adduction |
Knee adductor |
| L4 | Posterolateral thigh surface lateral surface of the shin, medial edge of the foot to I-II toes |
Medial surface of the leg | shin extension, hip flexion and adduction | Knee |
| Dorsiflexion of the foot | ||||
| L5 | - | Lateral surface of the tibia dorsum of the foot, toes I and II |
and big finger, hip extension |
No |
| Rear surface thighs and shins lateral edge feet |
Posterolateral surface of the leg, lateral edge of the foot |
Plantar flexion of the foot and fingers bending shins and thighs |
Achilles |
A characteristic manifestation
stenosis is neurogenic (caudogenic) intermittent claudication (claudication). It is most often observed in men aged 40-45 years engaged in physical labor.
occurs in one or both legs when walking, usually located above or below the knee, sometimes spreading to the entire limb. At rest
not expressed. Neurogenic intermittent claudication is characterized by an increase in paresis, weakening of tendon reflexes and a decrease in somatosensory evoked potentials of the spinal cord and brain from the legs after walking (“march test”). Passed before occurrence
sensations, the distance usually does not exceed 500 m. A decrease in
when leaning forward. Extension and rotation reduce the available space, compressing the root and its vessels, which explains the limitation of both types of movement in patients with this pathology. The basis of the disease is a metabolic disorder in the roots of the cauda equina due to their ischemia during physical activity. The presence of spinal stenosis at one level or narrowing of the lateral canals is not sufficient to cause claudication. More often, multilevel stenosis is observed in combination with a decrease in the size of the root canals. It should be noted that in patients with a narrow spinal canal, an isolated increase in intensity
when walking, often atypical for a radicular lesion of localization, is usually caused by musculoskeletal disorders accompanying lumbar stenosis and degenerative damage to the joints of the spine and legs. Therefore, it is necessary to differentiate caudogenic claudica syndrome from other causes of vertebrogenic
Which may accompany clinically insignificant
stenosis. If a narrowing of the spinal canal is suspected, it is necessary to carry out
(sometimes in combination with myelography)
department of the spine. The presence of a wide spinal canal excludes the diagnosis of neurogenic claudication. Electrophysiological methods - somatosensory evoked potentials and
The most common musculoskeletal disorders encountered in clinical practice are
syndromes not associated with lesions
roots (about 85% of patients with
in back). They are caused by irritation of the receptors of the fibrous ring, muscle-articular structures of the spine, as a rule, are not accompanied by a neurological defect, but may also be present in the picture of radicular lesions (reflex
syndromes).
At the moment of physical stress or during awkward movement, sharp, often shooting lumbago often occurs.
lasting from minutes to hours. The patient, as a rule, freezes in an uncomfortable position and cannot change his body position if the attack occurs while lifting something heavy.
the spine remains fixed (natural immobilization) even when trying to passively move the leg (extended at the knee joint) in the hip joint,
may not occur.
Lumbodynia
It is now generally accepted that localized
pain in the back (lumbodynia) is most often caused by damage to muscles, ligaments and degenerative changes in the spine. The cause of localized myogenic
pain in the lumbar and sacral region may be
MFBS of quadratus muscle lower back, muscles. erector spinae, multifidus and rotator cuff muscles lower back. MFBS is characterized by the formation
trigger points (TP) - areas of local pain in the affected muscle, upon palpation of which a tight cord is revealed, an area of local compaction located along the direction of the muscle fibers. Mechanical pressure on the CT causes not only intense local, but also reflected pain |2|.
MFBS of quadratus muscle lower back often causes deep aching pain in the lower back, which, in the presence of superficially located TTs, irradiates into the area sacro- iliac joints and in the gluteal region, and with TT in the depths of the muscle in the thigh, region iliac crest and inguinal region. In the quadratus muscle lower back Most often, active TTs are formed during forced movements, accompanied by bending and turning the body, lifting a load, as well as during postural stress associated with gardening, cleaning premises or driving a car. Pain usually localized in the area bounded above by the costal arch, below by the iliac crest, medial spinous processes of the lumbar vertebrae, and laterally by the posterior axillary line. Painful sensations arise or intensify when walking, bending, turning in bed, getting up from a chair, coughing and sneezing. There is often intense pain at rest, disrupting sleep. Since the quadratus muscle lies under the erector spinae muscle, deep palpation is necessary to identify the TT in it with the patient lying on the healthy side. As a rule, there is a limitation of lateroflexion in lumbar part of the spine in the direction opposite to the localization of the spasmed muscle. MFBS of the erector spinae muscle. Another common myogenic source pain in the back is the MFBS muscle that straightens the spine. Pain associated with it is localized in the paravertebral region and significantly limits movements in lumbar department of the spine. Typically, the TT in this muscle activates the “unprepared” movement with bending and rotation in the lumbar region.
Degenerative spondylolisthesis (displacement of the vertebrae relative to each other) most often occurs at the LIV-LV level. which is due to a weaker ligamentous apparatus, a high disc height, and a predominantly sagittal orientation of the articular surfaces of the facet joints. The formation of degenerative spondylolisthesis is also facilitated by: 1) a decrease in the mechanical strength of the subchondral bone (microfractures due to osteoporosis lead to changes in the relationship of the articular surfaces); 2) reducing the resistance to the load of the intervertebral disc, damaged by the degenerative process, and, as a result, increasing the load on the facet joints to withstand the force of the anterior shear; 3) strengthening of lumbar lordosis due to changes in the ligamentous apparatus; 4) weakness of the trunk muscles; 5) obesity. Degenerative spondylolisthesis can be combined with manifestations of segmental instability of the spine. The appearance of neurological disorders in this condition is associated with narrowing and deformation of the central and radicular canals and intervertebral foramina. It is possible to develop symptoms similar to neurogenic claudication, compression of the roots and spinal nerves, more often at the level of I.IV-LV.
Segmental instability of the spine (mixing of the vertebral bodies in relation to each other, the magnitude of which changes with movements of the spine) manifests itself pain in the back, aggravated by prolonged exercise or standing; Often there is a feeling of fatigue, causing the need to rest while lying down. The development of instability is typical in middle-aged women suffering from moderate obesity, with episodes pain in the back in the anamnesis, first noted during pregnancy. The presence of neurological symptoms is not necessary. Flexion is not limited. When extending, patients often resort to using their hands, “climbing up on themselves.” To establish a final diagnosis, radiography with functional tests (flexion, extension) is required.
Sciatica
The cause of lumbar ischialgia may be arthropathic disorders (dysfunction of the facet joints and sacral-iliac joints), as well as muscular-tonic and MFBS of the gluteus maximus and gluteus medius, piriformis, iliocostal muscles and ilio- lumbar muscles.
Arthropathic syndrome. Facet (facet, apophyseal) joints can be a source of both local and reflected pain in back. Frequency of facet joint pathology in patients with pain in the lumbosacral region ranges from 15 to 40%. There are no pathognomonic symptoms of their damage. Pain, caused by pathology of the facet joints, can radiate to the groin area, along the back and outer surface of the thigh, to the tailbone. Clinical features of diagnostic significance are pain in the lumbar department, increasing with extension and rotation with localized pain in the projection of the facet joint, as well as the positive effect of blockades with local anesthetics in the projection of the joint)
