Look Beyond the Disk: A Case of MRI–Symptom Mismatch Leading to Missed Lumbar Facet Joint Pain Generators

Abstract Magnetic resonance imaging (MRI) is routinely used to assess chronic low back pain (LBP); however, important pain generators, especially lumbar facet joints often under-reported/poorly visualized. Overdependence on imaging may divert clinical attention, possibly resulting in misdiagnosis. A 72-year-old Retired Army man with a history of three L4–L5 laminectomies/discectomies, followed by dorsal root ganglion pulsed radiofrequency, now presents with LBP and right thigh pain. MRI comments were postoperative laminectomy changes, multilevel disk bulges, foraminal narrowing, and an L5–S1 annular tear, without commenting on facet joints. Clinically, Kemp’s and facet loading tests indicated facet arthropathy. Fluoroscopy-guided right L4–L5, L5–S1 medial branches diagnostic blocks resulted in 50%–80% pain relief, confirming facetogenic pain according to the American Society of Interventional Pain Physicians criteria. Medial branch radiofrequency ablation with caudal neuroplasty was performed. Clinical examination and diagnostic blocks may be needed if MRI findings do not match the symptoms. This integration can prevent misdiagnosis and inappropriate interventions.