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Causes and Diagnostic Strategies for Chronic Low Back Pain

Article information

J Korean Med Assoc. 2007;50(6):482-493
Publication date (electronic) : 2007 June 30
doi : https://doi.org/10.5124/jkma.2007.50.6.482
Hyoung Ihl Kim, MD, Dong-Gyu Shin, MD
Department of Neurosurgery, Presbyterian Medical Center, Korea. hyoungihl@hotmail.com, sdh8262@hanmail.net

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 evidence-based 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 pressure-controlled 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; Evidence-based medicine

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Article information Continued

Copyright © 2007 Korean Medical Association

Figure 1

Figure 1

Schematic drawing of lumbar vertebral area demonstrating the nerves and their innervated structures.

Figure 2

Figure 2

Schematic drawing of sacroiliac joint demonstrating the innervating nerves.

IOL: interosseous ligament, SLB: sacral lateral branch, SN: sacral nerve, SIJ: sacroiliac joint

Figure 3

Figure 3

Pain distribution patterns in lumbar zygapophyseal joint dysfunction. Type E (undetermined type) is not depicted here.

Figure 4

Figure 4

Pain distribution patterns in sacroiliac joint dysfunction. Type E (undetermined type) is not depicted here.

Figure 5

Figure 5

Pain distribution patterns of discogenic pain.

Figure 6

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 5.

Figure 7

Figure 7

Computer screen of automated discography device demonstrating the increase of intradiscal pressure (A) with change of pain severity (B).

Figure 8

Figure 8

Algorithm for the management of chronic low back pain.

Z-joint: zygapophyseal joint, Exam: examination, SI: sacroiliac, MBB: medial branch block, IOL: interosseous ligament

Table 1

Causes of spinal pain and their representative examples

Table 1

*z-joint: zygapophyseal joint, S-I:sacroiliac

Table 2

Differential diagnosis of somatic versus radicular pain

Table 2

*DRG: dorsal root ganglion

Table 3

Change of pain intensity and neurological signs depending upon the sources of pain

Table 3

Z-joint: 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)