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Anesth Pain Med 2011; 6: 101~108 종설 근골격계통증의 radiculopathic pain 의진단을위한이학적검사 차의과대학교만성통증센터 안 강 Segmental palpation for radiculopathy Kang Ahn Chronic Pain Center, CHA University, Seoul, Korea The success of intramuscular stimulation relies heavily on a thorough physical examination by a competent practitioner, trained to recognize the physical signs of segmental changes according to segmental innervations of the spinal nerve. These segmental changes are influenced by descending pathways from higher centers of the CNS and/or ascending pathways from peripherally innervated areas. These changes are actual phenomena but are frequently unrecognized by imaging studies such as X-rays, CT scans and MRI. To find abnormal segmental changes, a physical examination with exact palpation is essential. Therefore, in this chapter, we introduce the segmental changes in view of a physical examination and target areas according to dermatomes of the spinal nerve from the cervical and lumbosacral regions. (Anesth Pain Med 2011; 6: 101 108) Key Words: Palpation, Physical examination, Segmental changes. 서 신경뿌리에대한자극은해당신경의지배를받는조직에있는통증수용체를포함한말초의여러수용체의과민화를가져오며정방향활성 (orthodromic activation) 뿐아니라특히역방향활성 (antodromic activation) 이보다현저하게발생한다 [1]. 이는일시적인문제일수도있고지속되는신경손상이나마찰에의한것일수도있다. 실제로디스크에의한포획보다이러한신경의장기적인손상에의한문제가훨씬더많을수있으나검사상에잘나타나지않을수도있다. Received: January 25, 2011. Accepted: March 20, 2011. Corresponding author: Kang Ahn, M.D., Chronic Pain Center, Medical College of CHA University, 605, Yeoksamdong, Kangnamku, Seoul 135-060, Korea. Tel: 82-2-3468-3099, Fax: 82-2-3468-3344, E-mail: fmriver@netsgo.com 론 신경근병성통증, 혹은다발성신경병과근근막통증증후군은 신경근이나말초신경에존재하는신경학적인이상 과신경전도나근전도의이상이존재하는가에의하여구별될수있다 [2]. 하지만이러한이상이존재하지않아도신경병이아니라고말할수는없다는상반된이견이존재한다 [3-5]. 신경병증에있어서도압통점은신경의지배를받는모든경추혹은요추의신경분절내에존재하는것이고, 근육내에서발생한것이라도종국은분절의변화를유발한다 [6]. 그러므로결국근육내에존재하는유발점혹은압통점문제이던혹은신경근병의문제이던간에분절성검사를진행하는것은분명한의미가존재하고치료의방향을결정하는데많은도움을준다 [7-10]. 이러한변화를 segmental vertebral cellulotenoperiosteaomyalgic syndrome[11] 이라고표현할수있으며또한척추분절의이상에따른연부조직의분절성과민화 (segmental facilitation or facilitated segment) 라고표현할수있다 [12]. 이러한과민화된분절에대한이학적검사는자극이역방향활성 (antidromic activation), 혹은정방향활성 (orthodromic activity) 이던혹은대부분의경우처럼이두가지가함께존재하던간에조직내수용체의과민화에의하여분명한조직의변화가발생한다. 이를이학적검사로확인하는것이정확한만성통증의진단에필요할것이다. 근골격계통증치료를위한이학적검사근골격계통증을평가하기위한이학적검사는순서대로시행하는것을권장하며 (Table 1), 항상신경근병의존재유무와문제가되는국소적인부위와척추분절의연관성을확인하고, 종합적인평가에의해이환된분절을결정해야한다 [12]. 이학적검사는크게척추에대한검사와해당신경지배분절근육의운동점이나, 유발점혹은압통점의확인, 그리고 cellulalgia에대한검사를포함하게되며, 촉진을통하여피부, 근육, 건, 인대, 그리고관절간격에대한평가를하게된다 (Table 2). 101

102 Anesth Pain Med Vol. 6, No. 2, 2011 Table 1. Sequence of Physical Examination for Musculoskeletal Pain 1) History taking including event, duration, worsening factor, relieving factor. 2) Check posture, gait 3) Palpation on painful soft tissue and joint. 4) Palpation on spine, inter-spinous process, transverse process 5) Range of motion of spine. 6) Neurologic examination 7) Segmental diagnosis (peripheral change on palpation which innervated by same spinal nerve+ spine changes on palpation of the same segment) 경추와경추신경지배분절의검사경추의검사경추관절의촉진은경추관절에엄지나검지를고정하고전방, 측방으로경추를굴곡시키면서압통이나움직임의저항을확인하거나혹은관절에고정된엄지나검지를관절앞뒤로비비는방법에의하여진단하는것이좀더정확한방법이지만, 일반적으로극돌기간 (interspinous space) Table 2. Considerations for Palpation of Pathologic Changes Palpation of spine The examination is usually nonpainful in normal segment. If pain is provoked, this suggests abnormal pathology of the segment. 1) Axial pressure on interspinous ligament with thumb or index finger. 2) Friction-pressure over the facet joint with thumb or index finger 3) Transverse pressure on spinous process Palpation of skin 1) A fold of skin is pinched firmly between the thumb and index finger. 2) Rolled between the fingers in one direction and then in the other. Skin And subcutaneous tissue irritability is characterized by increased texture thickness with tenderness. 3) This examination should be performed bilaterally and segmentally. 4) Often there is excess fluid in the subcutaneous tissues, as in Trophedema. 5) Orange peel appearance when skin rolling. Palpation of muscle, ligament, tendon 1) Trigger points are most localized to the same part of the same muscles, tendons, and ligaments for the same spinal segment. 2) The pathologic muscles present as one or several taut band that are very tender when pressed a point or rubbed transversely on muscle bands with thumb or index finger. 3) Thickened or tendered tendons or ligaments are present especially on insertion or joint which they pass. Fig. 1. (A) Palpation of the posterior tubercle with the patient s neck side-flexed at 15 degrees to the opposite side. Notice the SCM muscle in front of it. To facilitate the palpation, draw an imaginary line along the transverse processes and trace the locations of the posterior tubercles. Palpation of the splenius muscle which is as thick as a pencile at the back of the transverse tubercles and palpation of the lateral surface of zygopophyseal joints at the back of the splenius. (B) Palpation of the cervical zygopophyseal joints with an examiner s index finger at the sides of the semispinal muscles while the patient is lying on the back maintaining the natural C-curve of the neck.

안강 : 근골격계통증의 radiculopathic pain 의진단을위한이학적검사 103 을만지거나환자를바로누운상태에서면관절을촉진하는것이편한방법이다 [11,13]. 외측에서횡돌기나면관절의촉진을먼저시행하고이후목의후방에서면관절을촉진하는방법을사용한다. 외측에서촉진하는경우보다쉽게만져지며후방에서촉진하는경우압력을가해야한다. 압력을가한후에근육이긴장되어촉진이어려울수있다 (Fig. 1). 횡돌기나면관절의촉진은손가락을가볍게횡돌기나면관절에눌러횡돌기나관절면이만져지는정도에서앞뒤로비비게되는데이때압통의정도에따라 4단계로나뉘는데, 1단계는촉진시압통이느껴지는정도, 2단계는촉진시압통이심해몸을피하거나얼굴을찡그리는것, 3단계는통증이심하여몸을피하는현상, 그리고 4단계는횡돌기나관절면을비비지않아도돌기나관절이닿는순간아파서몸을피하는현상이나타나는것을말한다. 보통 1 2단계는진단이확실하지않으므로반대편관절에같은정도의촉진을하여양측을비교하도록하여야한다. 하지만 3, 4단계의현상이나타난다면이는횡돌기나관절면의압통이존재하는것이며분절성과민화가존재할가능성을보여준다. 목의외측에서 C2-3번후관절에서부터 C3-4, C4-5, C5-6, C6-7, C7-T1관절까지촉진이가능하다. 또한 Maigne의극돌기간촉지방법에의하여 C2-3번극돌기부터시작하여 T1-2 번극돌기까지촉진이가능하다. 또한마른사람의경우극돌기간극1센티미터측방, 즉목의후부에서후관절면을촉진할수도있다 [13]. 경우삼차신경이나안면신경지배부위의피부가두꺼워지며그러인하여피부를집어비비는검사만으로충분할수있다. 후관절이나횡돌기에비정상적으로과민한통증이존재하면서 cellulalgia가존재하는경우그치료대상은피부가아니라경추부위가되며 [11,12], cellulalgia는피부와근막을같이검사하는것이므로단순한피부분절과는다르다는것을명심해야한다. 경추 2번신경지배의분절검사 : 눈썹위의통증이나얼굴, 귀뒤의통증, 후두부, 특히 90도목을후굴하였을때증상이심해지는양상, 그리고승모근의통증은경추 2, 3번신경지배의지배영역이다. 환자가호소하는통증부위의피부를양쪽에서집어비비면서더과민한것을확인한다 (Fig. 2). 경추 3번신경지배의분절성검사 : 앞목의근육과피부, 근막은경추 3번신경의지배가흔하다. 환자의통증부위를 경신경지배부위 facilitated segment 의검사 Maigne은 [11] cellulalgia라고하는신경지배분절에대한검사를피부와근막을촉진하여표현하였는데이는상당한진단적가치가있다. 검사는피부를집어서비비는 pinch roll test라는것에의존한다. 일반적으로이검사와함께근육의검사를같이시행해야하지만, C 2-3번의문제가있는 Fig. 3. Cellulalgia at C3 innervation. Fig. 2. Cellulalgia at C2 innervation. The dark area is where the patient has pain. The hypersensitized skin is painful when pinched and rolled. (A) lateral view, (B) posterior view.

104 Anesth Pain Med Vol. 6, No. 2, 2011 Fig. 4. Cellulalgia at C4 and C5 innervation. Fig. 5. The pain along the inner margin of the scapular and over the infraspinatus may be associated with the pathology of C6, 7, 8 nerve roots as well as C5. The over the infraspinatus, deltoid and acromion is often associated with the cellulalgia at C5 innervation. 집어비비는검사를시행하여통각과민 (hyperalgesia) 된통증부위를찾는다 (Fig. 3). 이것은 C3-4, 혹은 C2-3 관절의통각과민혹은 C3 횡돌기의통각과민과함께한다. 이때검사하여야하는부위는 C3-4 혹은 C2-3이다. 통각과민이더심한쪽을촉진하지만양쪽을같이촉진하는것도필요하다. 경추 4번신경지배의분절성검사 : C4의신경지배는견갑골상부혹은쇄골부위에나타난다. 이곳의이상이존재하면서 C4-5 관절의통각과민이나타나거나 C4 횡돌기의통각과민이나타나는지확인한다 (Fig. 4). 경추 5번신경지배의분절성검사 : C5 신경지배의분절성 Fig. 6. Cellulalgia and trigger point in the back and the arm innervated by C6 nerve root. The muscles related with C6 to be tested with a thrust back and forth are marked by black lines. The upper; biceps, the middle; the extensors of the wrist and fingers and the lower; the extensor of the thumb. 검사는견갑골내측부와어깨, 극하근부위에해당한다. 이때근육은극하근의운동점혹은유발점에대한근육을눌러좌우로문지르는검사 (transverse friction) 를같이시행하면도움을얻는다 (Fig. 5). 경추 6번신경지배의분절성검사 : C6 신경지배의분절성검사는견갑골내측과팔의외측부위의통각과민을주증상으로하며, 이두박근힘줄의긴장이나팔목에위치하는손가락과손목의외측신전근에대한근육을눌러좌우로문지르는검사를같이시행한다 (Fig. 6).

안강 : 근골격계통증의 radiculopathic pain 의진단을위한이학적검사 105 Fig. 7. Cellulalgia at C7 innervation. The black lines represent the area-upper 1/3 of the pronator teres and the transverse carpal ligamentin which the transverse friction test is performed. The referred pain along the medial side of scapular is the same as that of C6 nerve root. Fig. 8. Cellulalgia at C8 innervation. The black lines indicate the areas for the physical examination. At 3cm below from the origin of the flexor carpi ulnaris, the transverse friction test is undertaken (in the upper right). The pinch and roll test is performed at the thenar area (in the lower right). 경추 7번신경지배의분절성검사 : C7 신경지배의분절성검사는견갑골내측부위와팔목의원회내근상부 1/3부위를눌러좌우로문지르는검사를시행하거나피부를집어서비비는검사를시행한다. 손목횡단인대 (transverse carpal ligament) 위를살짝누르며좌우로문지르는검사를시행하여도도움이된다 (Fig. 7). 경추 8번신경지배의분절성검사 : C8 신경지배의분절성검사는내상과 (medial epicondyle) 아래부위와손바닥내측부위의피부를집어문지르는것이유용하다. 이와더불어척골수근굴근 (flexor carpi ulnaris) 의기시부에서 3센티미터아래에서근육을눌러좌우로문지르는검사를시행하여진단한다 (Fig. 8). 요추와요추신경지배분절의검사하지의분절성검사를위하여우선척추에대한검사를시행한다. 척추에대한검사에서는베개를깔고배를바닥에닿게누워서척추의극돌기를만지는검사나허리를 45 도앞으로굽혀서극돌기를만지면서하는검사가통증을유발하거나척추의불안정을확인하는데중요하다 [14,15]. 극돌기간의촉진은척추질환의진단에유용한방법이며, 극돌기사이가느슨한경우눌러서통증이쉽게야기된다. 극돌기간에간극이만져져척추전방전위증 (spondylolisthesis) 이의심되는상황이면반드시허리굴전-신전촬영 (Flexion-extension view) 을하여미세한전위가있는지확인하여야한다. 전위가되었다하더라도극돌기간의압통이동반되지않으면그것이통증을일으키는원인이아닐가 능성이높아진다. 흉-요추경계부흉-요추경계부의통증은두가지양상으로나타나게되는데하나는흉-요추경계부나허리에나타나는통증이고, 다른하나는전지를통해나타나는하복부와서혜부의통증과후지의피하가지를따라존재하는고관절부위와외측허벅지의통증이다 [16]. 이는하부요추의병변과흔히혼돈되며주의깊게관찰하지않으면밝혀내기가어렵다. 흉-요추경계부의통증과요-천추경계부의통증을구분하는것은다음세가지에의한다. 첫째, 흉-요추경계부의통증은무릎이하의분절성이상을초래하지않으며, 둘째, 흉-요추경계부의통증은 L2를제외하고는천장관절의내측부의분절성이상을동반하지않는다. 셋째, 대전자첨부의압통을초래하는경우가드물다. 흉요추경계부피하분절의통증은둔부, 대퇴측면, 서혜부에나타나게되며이들은단독으로나타날수도있고함께나타날수도있다. 흔히흉요추의통증은호소하지않은채나타나지만극돌기간사이를눌러압통을확인하거나극돌기간의사이가다른극돌기간과비교하여현저히늘어져있으면서그림에나타나는형태의 cellulagia를나타내면분명한의의가있다 (Fig. 9). 요신경과천신경의분절성이상몇개의공통되는몇개의근육을검사하고척추혹은척추주위의이상을검사하여평가하는방법을따른다. L4-5극돌기간의통증이나, 굽혔을때다른극돌기간에비

106 Anesth Pain Med Vol. 6, No. 2, 2011 해벌어짐이존재한다면이것은척추분절의문제뿐아니라척추영상검사상나오지않는불안정성을의미할수있다. 따라서, 사진상의이상여부를확인하기위해허리굴전과신전사진 (flexion and extension view) 를찍어사소한불안정성의가능성도찾아내도록하여야한다. 극돌기간압통이나척추의불안정성이나타나면일단불안정한관절의통증이있는지확인하여야하며, 그관절을지배하는신경과 Fig. 9. Cellulalgia at T12 and L1 innervation. The dysfunction in the thoracolumbar junction is associated with the pain in the dermatome of the posterior primary ramus(1) and that of the anterior primary ramus(2,3) as well as the back pain. This is confirmed by the pinch and roll test with the affected skin and the existence of tenderness at the interspinous space in the thoracolumbar junction. Palpation at the interspinous space is performed from T10/11 to L2/3 with the patient bending forward or lying on the chest on the bed with the feet on the ground. The transverse friction test on the skin 7-8cm apart from the midline over the iliac crestup and down or side to side -can reproduce the pain that the patient presents with by irritating cluneal nerve. 그관절을지나는경막관 (dural tube) 의가장바깥에존재하는신경의이상을확인하여야한다. 예를들어 L2와 L3 극돌기간의이상이나타난다면그관절을지배하는 L2, 특히 L3신경과그관절에서경막관의가장바깥쪽에위치하는 L4신경의이상이존재할가능성이큰것이며, 마찬가지로 L3와 L4 극돌기간에서 L3, 특히 L4신경이나 L5신경, L4와 L5 극돌기간은 L4, 특히 L5신경이나 S1신경의이상을내포할가능성이크다. L5와 S1 극돌기간의문제이면마찬가지로 L5, 특히 S1 과 S2 신경의문제가많다. L2, L3 신경분절의검사 : L1-2혹은 L2-3척추분절극돌기간의압통이있으면 L2, L2-3 혹은 L3-4척추극돌기간의압통이있으면 L3신경의문제를먼저생각할수있다. 뒷가지신경 (dorsal rami) 의통증양상이나후관절에의하여나타나는통증양상에대하여이미잘알려져있다 [17]. 신경앞가지 (ventral rami) 에대한이학적검사에서환자가호소하는통증양상의확인과함께근육의검사와 cellulalgia 유무를검사한다. 이때주의해야할사항은, 현재환자의통증이척추신경근병증통증이나방산통의양상이아니더라도해당척추분절내의관절이나힘줄등의문제가존재하는경우에는척추의검사상척추관절이나신경의이상이강력하게의심되는경우가많다는점이다. 예를들어무릎내측의통증이라면 L3신경, 무릎후내측의통증이라면 S1신경, 무릎외측의통증이라면 L5신경의문제가척추에대한검사에서흔하게나타난다는것이다. L2와 L3신경의검사에서는근육검사가도움이된다. 가장대표적인것이요방형근 (quadratus lumborum), 장요근 (iliopsoas), 골반내전근 (hip adductors) 등이다. 이학적검사상으로는골반내전근의단축에의하여누운상태에서 90 도골반굴전 (hip flexion) 시킨자세를만들어양쪽무릎을 Fig. 10. Cellulalgia at L2 and L3 innervation and the related back pain area. Cellulalgia is clearly detected by the pinch and roll test. The problem in the iliolumbar ligament can be confused with that of L5 nerve root. So the muscle test for adductors is necessary unless there is the sensory dysfunction associated with L2.

안강 : 근골격계통증의 radiculopathic pain 의진단을위한이학적검사 107 Fig. 11. The pain from the dorsal ramus of L4 or zygopophyseal joint between L3 and L4. The cellulalgia and the severe pain are identified by the pinch roll test on the skin below the knee innervated by the saphenous nerve. Fig. 12. Cellulalgia and pain from the dosal ramus of L5. The pinch and roll test on the skin over the anterior tibialis is easy to diagnose it. 잡고골반외전 (hip abduction) 시키면 60도가이르기전에내전근부위의통증이나타나는경우가상기신경에해당되며, 이신경분절에서 cellulagia를확인할수있다 (Fig. 10). L4신경분절의검사 : L4신경은흔히생각하지않는부분이다. L4신경의경우뒷가지의이상은잘나타나는반면앞가지의이상은잘나타나지않는경우가많다. 뒷가지는천장관절바깥쪽의통증이잘나타나며앞가지신경지배부위의 cellulalgia는특징적으로복재신경 (saphenous nerve) 의아랫가지 (inferior branch) 신경지배부위에서정확하게포착된다 (Fig. 11). Fig. 13. Cellulalgia and pain from the dosal ramus of S1. Palpation of muscles at the motor point, trigger points and tender points of lateral head of the gastrocnemius is important in the segmental diagnosis of S1 by way of transverse friction. The pinch and roll test is performed for detecting cellulalgia at the upper 1/3 of the gastrocnemius. L5신경분절의검사 : L5신경의분절의검사에서뒷가지의신경지배부위인 L4와 L5번극돌기간통증이동반되는경우가가장많다. 이때척추협착증이아니더라도 S1신경의분절성이상이함께동반되는경우가흔하다. 흔히노인에서 L4/5디스크가퇴화되고, 척추사이가거의움직이지않거나 L4와 L5번척추간의퇴행성변화가심하게나타나허리의다열근 (multifidus) 등의긴장이심해지게된다. 이와함께 L3와 L4 척추체사이의불안정성이나타나는경우가

108 Anesth Pain Med Vol. 6, No. 2, 2011 흔하다. 허리를굽히고검사할때 L3과 L4극돌기간이너무많이벌어지거나, 계단처럼층이지는경우는불안정성을뜻하는경우가많다 (Fig. 12). 중둔근 (gluteus medius) 의압통점은 L5신경의문제를흔히내포한다. 중둔근의약화는이보다더욱강력한 L5신경지배근육의약화를표현하는데, 흔히한발로서있지못하거나, 걸으면서다리를벌리고몸을굽히며걷게된다. 노인들에게는매우흔한증상이다. S1신경지배분절의검사 : L4와 L5 요추의극돌기간압통이존재하거나, 극돌기간간격이느슨하면서세게누르면극심한압통을호소하는경우, 혹은불안정성이존재하는경우에는 S1신경의이상이흔하게발생한다. 또한 S1신경의이상은 L5신경이나 S2신경지배분절의신경근병증성통증, 방산통그리고이학적검사상의 cellulalgia를흔히함께동반한다 (Fig. 13). 특히 L4/5 디스크탈출증이나척추협착증, 척추전방전위증등의분명한문제가발견되는경우도있지만, 이러한문제없이증상이나타나는경우도흔하다. 그러나이학적검사에서는분명한이상이발견된다. 척추검사상 L5신경과 S1신경의이상이단독으로존재하는경우도있지만 L4와 L5 척추간에비하여흔하지는않다. 보통은 L4와 L5 척추극돌기간압통과함께동반된다. 다만, L4-5 척추간에비하여더많이아픈경우는요천추접합부의문제가주된것이라고예상할수있다. 종아리뿐만아니라, 뒷무릎, 뒷발꿈치와발바닥의문제가있을시에는이학적검사상흔히 S1 과 S2 신경의이상이동반되는경우가많다. 참고문헌 1. Xavier AV, Farrell CE, McDanal J, Kissin I. Does antidromic activation of nociceptors play a role in sciatic radicular pain? Pain 1990; 40: 77-9. 2. Travell JG, Simons DG. Myofascial pain and dysfunction. In: The trigger point manual. Baltimore, Williams & Wilkins. 1983. 3. Dalton PA, Jull GA. The distribution and characteristics of neck-arm pain in patients with and without a neurological deficit. Aust J Physiother 1989; 35: 3-8. 4. Lindblom U. Neuralgia: mechanisms and therapeutic prospects. In: Advances in pain research and therapy: Recent advances in the management of pain. 7th ed. Edited by Benedetti C, Chapman CR, Moricca G: New York: aven Press. 1984, pp 427-38. 5. Dyck PJ. Invited review: limitations in predicting pathological abnormality of nerves from the EMG examination. Muscle Nerve 1990; 13: 371-5. 6. Srbely JZ, Dickey JP, Bent LR, Lee D, Lowerison M. Capsaicininduced central sensitization evokes segmental Increases in Trigger Point Sensitivity in Humans. J Pain 2010; 11: 636-43 7. Fischer AA. Treatment of Myofascial Pain. J Musculoskeletal Pain 1999; 7: 131-42 8. Gunn CC. Radiculopathic pain: diagnosis and treatment of segmental irritation or sensitization. J Musculoskeletal Pain 1997; 5: 119-34. 9. Gunn CC. "Prespondylosis" and some pain syndromes following denervation supersensitivity. Spine (Phila Pa 1976) 1980; 5: 185-92. 10. Ochoa JL, Torebjdrk E, Marchettini P, Sivak M. Mechanisms of neuropathic pain: cumulative observations, new experiments and further speculation. In: Advances in pain research and therapy: Proceedings of the fourth world congress on pain, Seattle. 9th ed. Edited by Fields HL, Dubner R, Cervero F, Jones LE: New York, Raven Press. 1985, pp 431-50. 11. Maigne R. Diagnosis and treatment of pain of vertebral origin, 2nd ed. L, CRC Press. 2006, pp 133-61. 12. Ahn K, Lee SC. Segmental radiculopathic model and chronic musculoskeletal pain. Korean J Anesthesiol 2002; 43: 535-41. 13. Fligg B. Lower cervical spine motion palpation (C2-7). J Can Chiropr Assoc 1984; 28: 219-21. 14. Johnston WL, Allan BR, Hendra JL, Neff DR, Rosen ME, Sills LD, et al. Interexaminer study of palpation in detecting location of spinal segmental dysfunction. J Am Osteopath Assoc 1983; 82: 839-45. 15. Schneider M, Erhard R, Brach J, Tellin W, Imbarlina F, Delitto A. Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study. J Manipulative Physiol Ther 2008; 31: 465-73. 16. Maigne R. Diagnosis and treatment of pain of vertebral origin, 2nd Edition, L, CRC Press. 2006, pp 103-32. 17. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord 2004; 28: 5-15.