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Tell Me Where it Hurts?
March 05, 2011 by Dr Matthew D. Long
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Tell Me Where it Hurts?
March 05, 2011 by Dr Matthew D. Long
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Tell Me Where it Hurts?
March 05, 2011 by Dr Matthew D. Long
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One of the great challenges of clinical practice is determining the origin of pain. Indeed, the chronic uncertainty that pervades spinal diagnosis has lead to a sort of 'diagnostic paralysis' that affects clinicians of all persuasions. The conventional wisdom seems to be that "Diagnosing spinal pain through physical examination is impossible - so why even try?" This has lead to the development of a number of pragmatic approaches to the question of spinal derangement, including the development of conceptual 'models' to give some sort of theoretical framework, but avoid nailing down a finite diagnosis. For example, physiotherapist Robin McKenzie OBE suggested that the most efficient way to handle the question is to classify back pain patients into 3 broad categories and vary the treatment according to this classification. However, such approaches don't rely upon making a specific tissue diagnosis. Rather, they create a model of what's going on underneath to give some structure to your management.
But models have limitations, not the least of which being that they don't actually represent reality. So wouldn't it be useful if we could find some diagnostic clues that are reliable enough to help us make a tissue diagnosis? After all, the huge benefit of making a diagnosis is that it gives you a prognosis - and this will directly alter your management, your advice to the patient and your expectations about how much treatment is enough. After all, if you knew that a patient with simple lower back pain (but no leg referral) actually has symptomatic internal disc disruption, wouldn't this alter your approach?
But can it be done? Can we accurately identify a tissue source of pain using in-office clinical examination?
The answer to this question increasingly seems to be "Yes".
There have been a number of recent high quality studies that have challenged our everyday clinical observations in an effort to determine whether they are truly reliable indicators of anything useful. In this age of high-tech imaging and invasive diagnostic blocks it might seem counterintuitive that similar progress is being made in understanding how something as basic as pointing to where it hurts might be very helpful. But it seems to be...
A recent paper in PM&R (1) asked the question "Does the location of low back pain predict its source?".
We are all confronted on a daily basis by patients who map out their area of pain in the hope that it might help us tell them what's wrong. The authors of this study wanted to know whether the precise location of a patient's discomfort correlated with a specific diagnosis. So they asked their patients to “Show me with one finger where your most painful low back pain is.” Their responses were then grouped into two categories:
1. Midline - localised to the spinous processes
2. Paramidline - more than one finger-breadth lateral to the midline
After this, they underwent a rigorous process of evaluation using precision, fluoroscopically guided, contrast-confirmed diagnostic blocks. The procedures were designed to identify either discogenic pain (internal disc disruption), zygapophysial joint pain or sacroiliac pain and the results were compared to the patient's pain map.
As expected, the prevalence of these three diagnoses correlated well with established data. Intervertebral disc pain was present in 41.8% of patients, zygapophysial pain in 30.6% and sacroiliac pain in 18.2%. However, it is the localisation of the pain that was most interesting.
According to DePalma et al, "If a LBP patient has lumbar internal disc disruption (IDD), there is a 96% chance (sensitivity) the patient will report midline LBP; reciprocally, if a patient does not have lumbar IDD, there is 75% chance (specificity) the patient will not report midline LBP... In effect, the spine clinician can “rule in” IDD and “rule out” FJP and SIJP in patients who experience midline LBP."
In addition,
"If a patient has FJP or SIJP, there is a 95% and 96% chance (sensitivity), respectively, the patient will report paramidline LBP as compared with a 67% chance an IDD patient will report paramidline LBP... If a patient reports paramidline LBP especially in the absence of midline LBP, FJP and/or SIJ are more likely to be the source of the individual’s LBP."
It appears that the presence of midline (spinous process) lower back pain is a strong indicator that the ultimate source of pain will prove to be a deranged annulus.
But be careful. Paramidline pain can also occur in the presence of a torn disc, and if so, the pain may actually originate from the opposite side! A study by Slipman and colleagues (2) demonstrated that the side of an annular tear does not correlate with the side of symptoms - and this may be due to the fact that each side of the posterior annulus can receive innervation from the contralateral sinuvertebral nerve.
So it appears that midline lower back pain is a great indicator of internal disc disruption - something to give a bit of clarity to the diagnostic process.
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
But models have limitations, not the least of which being that they don't actually represent reality. So wouldn't it be useful if we could find some diagnostic clues that are reliable enough to help us make a tissue diagnosis? After all, the huge benefit of making a diagnosis is that it gives you a prognosis - and this will directly alter your management, your advice to the patient and your expectations about how much treatment is enough. After all, if you knew that a patient with simple lower back pain (but no leg referral) actually has symptomatic internal disc disruption, wouldn't this alter your approach?
But can it be done? Can we accurately identify a tissue source of pain using in-office clinical examination?
The answer to this question increasingly seems to be "Yes".
There have been a number of recent high quality studies that have challenged our everyday clinical observations in an effort to determine whether they are truly reliable indicators of anything useful. In this age of high-tech imaging and invasive diagnostic blocks it might seem counterintuitive that similar progress is being made in understanding how something as basic as pointing to where it hurts might be very helpful. But it seems to be...
A recent paper in PM&R (1) asked the question "Does the location of low back pain predict its source?".
We are all confronted on a daily basis by patients who map out their area of pain in the hope that it might help us tell them what's wrong. The authors of this study wanted to know whether the precise location of a patient's discomfort correlated with a specific diagnosis. So they asked their patients to “Show me with one finger where your most painful low back pain is.” Their responses were then grouped into two categories:
1. Midline - localised to the spinous processes
2. Paramidline - more than one finger-breadth lateral to the midline
After this, they underwent a rigorous process of evaluation using precision, fluoroscopically guided, contrast-confirmed diagnostic blocks. The procedures were designed to identify either discogenic pain (internal disc disruption), zygapophysial joint pain or sacroiliac pain and the results were compared to the patient's pain map.
As expected, the prevalence of these three diagnoses correlated well with established data. Intervertebral disc pain was present in 41.8% of patients, zygapophysial pain in 30.6% and sacroiliac pain in 18.2%. However, it is the localisation of the pain that was most interesting.
According to DePalma et al, "If a LBP patient has lumbar internal disc disruption (IDD), there is a 96% chance (sensitivity) the patient will report midline LBP; reciprocally, if a patient does not have lumbar IDD, there is 75% chance (specificity) the patient will not report midline LBP... In effect, the spine clinician can “rule in” IDD and “rule out” FJP and SIJP in patients who experience midline LBP."
In addition,
"If a patient has FJP or SIJP, there is a 95% and 96% chance (sensitivity), respectively, the patient will report paramidline LBP as compared with a 67% chance an IDD patient will report paramidline LBP... If a patient reports paramidline LBP especially in the absence of midline LBP, FJP and/or SIJ are more likely to be the source of the individual’s LBP."
It appears that the presence of midline (spinous process) lower back pain is a strong indicator that the ultimate source of pain will prove to be a deranged annulus.
But be careful. Paramidline pain can also occur in the presence of a torn disc, and if so, the pain may actually originate from the opposite side! A study by Slipman and colleagues (2) demonstrated that the side of an annular tear does not correlate with the side of symptoms - and this may be due to the fact that each side of the posterior annulus can receive innervation from the contralateral sinuvertebral nerve.
So it appears that midline lower back pain is a great indicator of internal disc disruption - something to give a bit of clarity to the diagnostic process.
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. DePalma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the Location of Low Back Pain Predict Its Source? PM&R. 2011 (1) 33-39.
2. Slipman CW, Patel RK, Zhang L, Vresilovic E, Lenrow D, Shin C, Herzog R. Side of Symptomatic Annular Tear and Site of Low Back Pain - Is there a Correlation? SPINE 2001. 26 (8) pp E165–E169
1. DePalma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the Location of Low Back Pain Predict Its Source? PM&R. 2011 (1) 33-39.
2. Slipman CW, Patel RK, Zhang L, Vresilovic E, Lenrow D, Shin C, Herzog R. Side of Symptomatic Annular Tear and Site of Low Back Pain - Is there a Correlation? SPINE 2001. 26 (8) pp E165–E169