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1 Focused Issue of This Month Causes and Diagnostic Strategies for Chronic Low Back Pain Hyoung Ihl Kim, MDDongGyu Shin, MD Department of Neurosurgery, Presbyterian Medical Center hyoungihl@hotmail.comsdh8262@hanmail.net J Korean Med Assoc 2007; 50(6): Abstract Chronic low back pain (CLBP) has become more prominent with globally increasing life expectancy. Its cause is more attributable to degenerative changes than to traumatic lesions. Although the diagnosis of CLBP is recently on higher demand, lack of clinical features and non-informative imaging findings in patients with CLBP are challenging to clinicians to establish the diagnosis. Therefore, understanding of the new concept of pathogenesis, elimination of prejudice, and evidencebased diagnostic steps are required to resolve the question of pain source. Analysis of pain distribution patterns and careful history taking can be utilized as an initial guide to divide CLBP into somatic and radicular pain. Zygapophyseal joint pain and sacroiliac joint pain representing somatic pain can be further investigated using medial branch and sacroiliac joint blocks. However, comparative blocks are essential to decreased false positive rate. Infiltration of a small volume of local anesthetics can increase the specificity of the procedures. Discogenic pain stemming from internal disk derangement can be confirmed by pressurecontrolled discography. Automated discography is recommended to provide the constant rate of dye injection with obviating the fluctuation of intradiscal pressure. Evidence based concept and diagnostic procedures can provide more accurate and efficient methods to establish the diagnosis of CLBP. Keywords : Low back pain; Nerve block; Discography; Evidencebased medicine 482

2 Causes and Diagnostic Strategies for CLBP Table 1. Causes of spinal pain and their representative examples Causes Representing diseases or conditions Degenerative Intervertebral disk, Zjoint arthropathy, SI joint arthropathy Traumatic Fracture Congenital Lumbarization, diastomatomyelia Metabolic Senile osteoporosis, estrogen deficiency, chronic steroid use Inflammatory Systemic infection, ankylosing spondylitis Neoplastic Osteid osteoma, giant cell tumor, hemangioma, metastasis Vascular Abdominal aortic aneurysm Mechanical Obesity, poor posture, low mobility, chronic sedentary work Psychogenic Traumarelated compensation *zjoint: zygapophyseal joint, SI:sacroiliac 483

Kim HIShin DG Sympathetic trunk Sinuvertebral Nerve Dorsal Ramus Ventral Ramus L5 dorsal ramus IOL SLB SN Lateral Branch Medial Branch SIJ Figure 1.

3 Kim HIShin DG Sympathetic trunk Sinuvertebral Nerve Dorsal Ramus Ventral Ramus L5 dorsal ramus IOL SLB SN Lateral Branch Medial Branch SIJ Figure 1. Schematic drawing of lumbar vertebral area demonstrating the nerves and their innervated structures. IOL: interosseous ligament, SLB: sacral lateral branch, SN: sacral nerve, SIJ: sacroiliac joint Figure 2. Schematic drawing of sacroiliac joint demonstrating the innervating nerves. 484

4 Causes and Diagnostic Strategies for CLBP Table 2. Differential diagnosis of somatic versus radicular pain Somatic Pain Radicular Pain Origin Muscles and ligaments DRG Neurological Sign No Numbness, Myotomal weakness, Lost reflex Distribution Diffuse Quasilinear Quality Deep aching Lancinating, *DRG: dorsal root ganglion 485

5 Kim HIShin DG Type A Type B1 Type B2 Type B3 Figure 3. Pain distribution patterns in lumbar zygapophyseal joint dysfunction. Type E (undetermined type) is not depicted here. 486

6 Causes and Diagnostic Strategies for CLBP Type A Type B Type C Type D Figure 4. Pain distribution patterns in sacroiliac joint dysfunction. Type E (undetermined type) is not depicted here. 487

7 Kim HIShin DG Type A Type B Figure 5. Pain distribution patterns of discogenic pain. 488

8 Causes and Diagnostic Strategies for CLBP Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Figure 6. Modified Dallas discogram classification. Note that disk degeneration is confined inside the disk in Grade 1, 2, and 3. Disk herniations are demonstrated in Grade 4 and

9 Kim HIShin DG Figure 7. Computer screen of automated discography device demonstrating the increase of intradiscal pressure (A) with change of pain severity (B). 490

10 Causes and Diagnostic Strategies for CLBP Zjoint: zygapophyseal joint, Exam: examination, SI: sacroiliac, MBB: medial branch block, IOL: interosseous ligament Figure 8. Algorithm for the management of chronic low back pain. 491

11 Kim HIShin DG Table 3. Change of pain intensity and neurological signs depending upon the sources of pain Symptoms and signs Zjoint SI joint HNP stenosis Pain on sitting Pain on walking Pain on transition / SLRT Motor change ++ + Sensory change Limited flexion Limited extension Patrick's test + + +/ Zjoint: zygapophyseal joint, SI: sacroiliac, HNP: herniated nucleus pulposus SLRT: straight leg raising test (modified from Ray CD, Percutaneous radiofrequency facet nerve block: treatment of the mechanical low back syndrome. Procedure technique Series, Radionics, PP: 11) 11. Merskey H, Bogduk N, eds. Classification of chronic pain: description of chronic pain syndromes and definition of pain terms,. 2nd ed. Seattle: IASP Press, 1994: Andersson GBJ. Epidemiological features of chronic low back pain. Lancet 1999; 354: Haldeman S. Low back pain: current physiologic concepts. Neurol Clin 1999; 17: Borenstein D. Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol 1996; 8: Adams MA, Bogduk N, Burton K, Dolan P. Epidemiology of low back trouble. The biomechanics of back pain. London: Churchill Livingstone, 2002: Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: Schwarzer AC, Wang SC, Bogduk N. Prevalence and clinical feature of lumbar zygapophysial joint pain: A study in an Australian population with chronic low back pain. Ann Rheum Dis 1995; 54: Schwarzer AC, April CN, Derby R. The prevalence and clinical features of internal disc disruption in patients with chronic back pain. Spine 1995; 20: Bogduk N, Willson A, Tynan W. The human lumbar dorsal rami. J Anat 1982; 134: Green G, Baljet B, Drukker J. Nerves and nerve plexuses of the human vertebral column. Am J Anat 1990;188: Yin W, Willard F, Carreiro J, Drey fuss P HB, Pauza K, Joshi A, Mclarty J, Bogduk N. Sensory stimulationguided sacroiliac joint radiofrequency neurotomy: Technique based on neuroanatomy of the dorsal sacral plexus. Spine 2003; 28: Nachemson A, Wadell G, Norlund A. Epidemiology of neck and low back pain. In: Nachemson A, Jonsson E, eds. Neck and back pain: the scientific evidence of causes, diagnosis, treatment. Philadelphia: Lippincott, Williams & Wilkins, 2000: Bogduk N, Govind J, eds. Medical management of acute lumbar radicular pain: an evidencebased approach. Newcastle: Newcastle Bone and Joint Institute, 1999: Osti OL, Fraser RD. MRI and discography of annular tears and intervertebral disc degeneration. A prospective clinical comparison. J Bone Joint Surg Br 1992; 74: Boos N, Rieder R, Schade V, Psych D, Spratt KF, Semmer N, Psych D, Aebi M. The diagnostic accuracy of magnetic resonance imaging, work perception and psychosocial factors in identifying symptomatic disk herniations. Spine 1995; 20: Grant PA. Electrodiagnostic medical consultation in lumbar spine problems. Occup Med 1998; 13: LomenHoerth C, Aminoff MJ. Clinical neurophysiologic studies: which test is useful and when? Neurol Clin 1999; 17: 492

12 Causes and Diagnostic Strategies for CLBP Peng B, Wu W, Li Z, Guo J, Wang X. Chemical radiculitis. Pain 2007; 127: Piperno M, Graverand M, Reboul P, Mathieu P, Tron A, Perrin G, Peschard M, Richard M, Vignon E. Phospholipase A2 activity in herniated lumbar discs. Spine 1997; 22: Freemont AJ, Watkins A, Le Maitre C, Jeziorska M, Hoyland JA. Current understanding of cellular and molecular events in intervertebral disc degeneration: implications for therapy. J Pathol 2002; 196: Ozaktay AC, Kallakuri S, Cavanaugh JM. Phospholipase A2 sensitivity of the dorsal root and dorsal root ganglion. Spine 1998; 23: Bogduk N. Low back pain. In: Bogduk N, ed. Clinical anatomy of the lumbar spine and sacrum. London: Churchill Livingstone, 2002: Schwarzer AC, Aprill C, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: Kim HI, Shin DG, Shin DA, Lee JO. Pain evaluation for decision making for management of spinal pain. J of the Kor Soc of Ster and Func Neurosurg 2005; 1: Kim HJ, Shin DG, Kim HI, Shin DA. Selective neurotomy of sacral lateral branches for pain of sacroiliac joint dysfunction. J Korean Neurosurg Soc 2005; 38: Mixter WJ, Barr JS. Rupture of intervertebral disc with involvement of the spinal canal. New Engl J Med 1934; 211: Shin DA, Kim HI, Jung JH, Shin DG, Lee JO. Diagnostic relevance of pressurecontrolled discography. J Korean Med Sci 2006; 21: Derby R, Howard MW, Grant JM, Lettice JJ, Van Peteghem PK, Ryan DP. The ability of pressurecontrolled discography to predict surgical and nonsurgical outcomes. Spine 1999; 24: Peer Reviewer Commentary 493

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical