REVIEW For reprint orders, please contact: [email protected]
Establishing the diagnosis of low back pain: patient selection for interventional pain medicine
Practice Points
Jan Van Zundert*1, Koen Van Boxem2,3, Pascal Vanelderen1,4, Martine Puylaert1, Pieter De Vooght1, Roel Mestrum1, Rene Heylen1, Kris Vissers4 & Maarten van Kleef3 Low back pain forms a considerable burden to the patient, society and the healthcare provider. The variety of possible underlying diseases imposes attempts to fine-tune the diagnosis. It is imperative to exclude the so-called red flags, which point toward a serious underlying pathology,
necessitating causative treatment. Lumbosacral radicular pain is characterized by pain irradiating into the leg, below the knee, according to
a dermatomal distribution. Pain originating from the facet joints has a referral pattern into the buttock and the upper leg. No physical examination is pathognomonic for the diagnosis of lumbar facet pain. The Lasègue and crossed Lasègue tests are most frequently used to identify lumbosacral radicular pain. Medical imaging, including MRI, has low specificity as degenerative changes and herniated discs are
observed in symptomatic, but also asymptomatic patients. The causative structure and level of pain can be confirmed by means of a diagnostic–prognostic block.
SUMMARY Low back pain is one of the most prominent healthcare problems but there is no gold standard for its diagnosis. Aspecific low back pain can be subdivided into radicular and mechanical pain. The diagnosis mainly relies on a combination of elements, such as medical history, physical examination, medical imaging and other possible additional tests. Once a working diagnosis has been established, confirmation of the causative structure and level is sought by means of diagnostic blocks. The use of the different diagnostic tests and blocks should be guided by the balance between the potential benefit (mainly in terms of improved treatment outcome, the possible burden for the patient and the chances of withholding potential effective treatment to patients) with false-negative test results.
Department of Anesthesiology, Critical Care & Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium Department of Anesthesiology & Pain Management, Sint-Jozefkliniek, Bornem en Willebroek, Belgium 3 Department of Anesthesiology & Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands 4 Department of Anesthesiology, Pain & Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands *Author for correspondence: Tel.: +32 89 32 52 40; Fax: +32 89 32 79 47; [email protected] 1 2
10.2217/PMT.13.3 © 2013 Future Medicine Ltd
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Review Van Zundert, Van Boxem, Vanelderen et al. In 1996, Waddell described low back pain as the healthcare enigma of the 20th century [1] . More than 15 years later, low back pain still remains a healthcare and socioeconomic burden. A systematic review on the global prevalence of low back pain found an estimated point prevalence of 11.9% and a 1-month prevalence of 23.2%. The highest prevalence is found among female individuals and those between 40 and 80 years old [2] . Considering the projected aging, the number of patients suffering from low back pain is likely to increase over the coming decades. The first step in the management of patients with low back pain consists of a diagnostic triage to exclude back pain that arises from other structures, such as retroperitoneal structures and the hips, among others [3] . The so-called red flags draw attention to potentially serious underlying diseases (Box 1) . Prior to designing any treatment plan, the clinician will try to exclude inflammatory/metabolic causes (diabetes, ankylosing spondylitis, Paget’s disease, arachnoiditis and sarcoidosis) [4] . Two recent reviews indicated that clinical features, such as age, female gender, major trauma, pain and tenderness, and distracting painful injury, may be predictive for vertebral fractures [5] . Malignancy in the previous year and unexplained weight loss should stimulate the physician to perform further examinations to exclude cancer [6] . These studies concluded that screening patients for serious pathology is difficult. Acute low back pain usually responds well to pharmacologic analgesic treatment. Some patients, however, are refractory to pharmacological treatment, and the low back pain evolves to become a chronic problem. Although it was often stated that only approximately 10% Box 1. Red flags indicating potentially serious underlying diseases. First appearance of back complaints before 20 years or after 55 years Trauma Constant progressive back pain Malignant disorder in the medical history Long-term use of corticosteroids Drug use, immunosupression, HIV (Frequent) general malaise Unexplained weight loss Structural deformities of the spinal column Infectious disorders (e.g., herpes zoster, epidural abscess, HIV and Lyme disease) Neurological loss of function (motor weakness, sensory disturbances and/or micturition disturbances) Reproduced with permission from [57].
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of patients would continue to suffer chronic pain [7] , later studies showed that 62% of patients have recurrent episodes of low back pain at 12 months, 16% are still unable to work 6 months after the first diagnosis and 33% have repeated episodes of incapacity to work during the first year [8] . A recently published systematic review, regarding the clinical course of aspecific low back pain in primary care, found that 65% of the patients still have pain at 1 year after onset [9] . In approximately 5–10% of patients, a specific cause, such as tumor, infection, vertebral fracture or ankylosing spondylitis, among others, can be identified [7] . The remaining 90–95% are considered to be aspecific. Those so-called aspecific types of low back pain are further classified as being of mechanical origin, radicular pain, pain originating from the joints, the ligaments or muscles, or pain of undefined origin. Potential causes of low back pain of mechanical origin are the zygapophyseal (facet) joints, the sacro–illiac joint and the intervertebral disc [7,10–12] . Interventional pain management techniques can be considered when the conservative treatment fails to provide satisfactory pain relief or causes unbearable side effects. The target specificity of the interventional pain management techniques requires identification of the causative structure and the involved level. Since there is no gold standard for establishing the diagnosis of low back pain, a diagnostic procedure consisting of medical history, clinical examination and additional adapted examinations is outlined for the different types of low back pain. The treatment selection is based on the available evidence; however, the potential benefits should be carefully weighed against possible side effects and complications. Although the intervertebral disc has been indicated as a potential source of pain, diagnosis requires invasive techniques [13] and until now there is no convincing evidence for the use of interventional pain management techniques [14] . Two frequently performed interventional pain management techniques are the radiofrequency (RF) facet joint denervation and the epidural administration of corticosteroids [15] . As an example of the diagnostic process leading to the selection of these treatments, this article concentrates on pain originating from the lumbar facet joints and lumbosacral radicular pain. In summary, chronic low back pain forms a major burden for the patient and healthcare
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Establishing the diagnosis of low back pain: patient selection for interventional pain medicine providers, and is documented to consume a large part of the healthcare budget. When conservative treatment fails, interventional management may be considered. Those treatment options are target specific. Treatment success increases with improved patient selection. There is, however, no diagnostic test that is sensitive and specific for the identification of the cause of low back pain. The aim of this article is to provide a proposal for an algorithmic approach to the diagnosis and treatment of low back pain of facetogenic origin and for lumbosacral radicular pain. The authors aim to provide information that has clinical implications and that highlights the different examinations, in order to allow optimal treatment selection.
identifying clinical predictors for facet joint pain, the following criteria were withheld: age >50 years old; the extension–rotation test that is typically considered positive when pain is provoked by extension combined with rotation towards the painful side presumably causing joint compression; the least pain occurs when walking or when sitting; onset pain is paraspinal; and a Modified Somatic Perception Questionnaire score >13 [28] . The role of medical imaging
Low back pain originating from the facet joints The prevalence of lumbar facet joint pain has been reported to vary between 5 and 90%, depending on the diagnostic tests used. However, when selected patient populations were studied, the prevalence ranged between 5 and 15% [14,16] . Osteoarthitis and degenerative diseases are often indicated as causes of facetogenic pain, which also explains the increasing prevalence with age [17,18] . The findings of the provocation studies in volunteers allowed identification of a typical pain distribution pattern (Figure 1) [19–22] .
The primary role of radiological examination is to exclude malignancy, compression fracture or spinal infection [29,30] . Degenerative facet joints can be best visualized with computed tomography examination [31] . MRI is believed to be somewhat less sensitive, although the classification of degenerative facet joints is based on MRI [32] . In half of the studies, abnormal radiological findings correlate with a positive response to diagnostic blocks, while in the other half no correlation could be found. The diagnostic blocks of the articulations that showed hypercaptivity with computed tomography-single-photon emission computed tomography fusion (CT-SPECT) resulted in temporary pain relief in 36 out of the 37 patients [33] . These findings suggest a potential role for CT-SPECT in the diagnosis of lumbar facet joint pain.
Physical examination
Diagnostic–prognostic blocks
No physical examination is pathognomonic for the diagnosis of lumbar facet pain. The wellknown Revel criteria for lumbar facet joint pain were defined based on the correlation between the physical examination and the symptoms with the response to placebo-controlled nerve blocks [23,24] . A systematic review on tests that identify the facet joint as the source of low back pain found that the Revel criteria and CT scan were most often used as the index test. A prospective study, validating the physical examination criteria promoted by Revel with controlled intra-articular or medial branch blocks, demonstrated that the Revel criteria may have use in identifying a small subset (11%) of patients likely to respond to the initial block (specificity 93%) [25] . Another systematic review concluded that none of the seven individual items from the Revel criteria were found to provide positive or negative likelihood information [26] . According to Cohen et al., paravertebral tenderness is the only predictive factor for facet joint pain [27] . In a prospective study, aiming at
A survey among an expert panel, concerning the predictive factors for facet joint pain, resulted in
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Figure 1. Pain distribution pattern of lumbar facet pain. Adapted with permission from [19]. Illustration used with kind permission from Rogier Trompert Medical Art and Jan-Maarten Luursema [101].
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Review Van Zundert, Van Boxem, Vanelderen et al. the establishment of 12 indicators for facet joint pain. Pain relieved by fluoroscopically guided double-anesthetic blocks of the medial branch of the dorsal ramus supplying the facet joint was accepted as a positive indicator by 85% of the experts [34] . Diagnostic–prognostic blocks are recom mended in guidelines prior to performing a RF facet joint denervation, in order to confirm the involvement of the facet joint [35] . There are currently seven randomized controlled trials on RF facet denervation [36–42] . In all these studies, the diagnosis was confirmed by means of a diagnostic block, but the technique, medication used, targeted structure and the interpretation of the outcome of those blocks varied widely. In one study, approximately 10% of the patients were ultimately selected for the RF treatment [42] , while this was the case for 92% of the patients in another study [38] . In this latter study, the RF treatment was not better than sham intervention. The patients were selected with an intra-articular block with local anesthetic and corticosteroid. The block was considered positive if the patient reported ‘significant’ pain relief over 24 h within the first week after the injection. The high inclusion rate may be indicative of a high number of falsepositive blocks. In the studies where patients were selected with diagnostic medial branch blocks, the percentage of patients included in the study was much lower (10–31%), and the outcome of the RF treatment was positive compared with sham intervention [37,42] . Furthermore, in a recently published prospective triple crossover study it was concluded that a single intra-articular facet joint block with local anesthetics was not useful to detect the facet joint responsible for the pain [43] . When local anesthetic is injected at the level of the medial branch of the dorsal ramus, falsepositive and false-negative outcomes may be noted. To increase the accuracy of the diagnostic blocks, controlled blocks have been proposed. This means that the injection is performed twice with two different local anesthetics, each with a different duration of action. To conclude that the injected level is the causative level, the patient should experience pain relief for the duration of action of both local anesthetics [42] . When selecting a treatment, evaluating the balance between the potential benefit and the patient burden is recommended. With controlled diagnostic blocks the rate of false-positive blocks will be reduced, but at the same time the number of false negatives will increase. Increasing the
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number of blocks increases the burden on the patient. Controlled blocks require different sessions and this means at least two appointments in the clinic. Patients who have a false-negative block will not receive RF treatment, even though this treatment was demonstrated to provide pain relief. The patient will continue either conservative treatment or move on to surgery. This reasoning is outlined in [44] and [45] . A randomized controlled trial estimated the cost per successful RF treatment when patients were selected based on clinical examination alone, with one diagnostic block or with two comparative blocks. Radiofrequency treatment of patients selected with clinical examination has the lowest cost per successful treatment, whereas the highest cost per successful RF treatment is generated when performing this procedure after one single diagnostic block [44] . The highest success rate is observed in the group who received two diagnostic blocks. However, 64% of the patients treated after two diagnostic blocks, and 39% of the patients treated after one block, had a successful outcome. This means that for a 25% increase in successful outcome after RF treatment, 100% more diagnostic interventions are needed [44,45] . In a recent publication, it was observed that no optimal threshold for designating a diagnostic block as positive, above 50% pain relief, could be calculated. Employing more stringent selection criteria for lumbar facet RF is likely to result in the omission of a beneficial procedure from a substantial number of patients, without improving success [46] . Summary of the diagnosis of lumbar facet
joint pain
A working diagnosis can be made based on the patient’s medical history, pain distribution and clinical diagnosis. Medical imaging is predominantly used to exclude the red flags, although CT-SPECT may be indicative for the involved level, and could be a valuable tool when envisioning surgical treatment. Based on the available evidence, RF facet denervation can be recommended for the management of chronic facet joint pain. There is evidence that the treatment outcome improves when patient selection is fine-tuned. One positive diagnostic medial branch block that is correctly evaluated improves patient selection and treatment outcome. A cutoff of 50% pain relief after a diagnostic block was documented to be a valuable tool to improve
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Establishing the diagnosis of low back pain: patient selection for interventional pain medicine treatment outcome; there is no reason to select a higher cutoff value for a positive diagnostic block. Lumbosacral radicular pain Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms or symptoms of decreased function. In addition, patients often report paresthesia in the affected dermatome. The distribution of pain along a dermatome helps to determine the level involved; however, there is large variation in radiation patterns [4,47] . The most frequent cause of lumbosacral radicular pain is a herniated disc; however, certainly in patients over 50 years of age, degenerative changes of the spine (e.g., stenosis of the foramen intervertebrale) cause radicular pain [4] . Physical examination
The straight leg raising test, often referred to as the Lasègue test, is the most popular clinical examination for lumbosacral radicular pain. If radicular pain can be elicited with an angle of less than 60–75° in a surgical population, this test is sensitive for the identification of a radiculopathy due to disc herniation [48] . The crossed Lasègue test is the only examination with good specificity, but this comes at the expense of the sensitivity [48] . Both physical tests have wide variation in interobserver agreement and reliability [49] . Most of the physical examinations were studied in a surgical population, so the diagnostic performance of these tests in primary care remains unclear. Furthermore, the diagnostic performance of a single physical test is poor; however, better performance may be obtained when combinations of patient medical history and positive physical tests are evaluated [49] . Neurological signs, such as paresis, sensory loss or loss of reflexes, are not specific [50] . Tarulli and Raynor described the signs that are indicative for the involvement of the different levels: L4 involvement (lessened patellar reflex, foot inversion) or an L5–S1 hernia (Achilles tendon reflex); L5 motor paresis may be accompanied by the ‘stomping foot’ [4] . The role of medical imaging
Medical imaging, primarily MRI, can confirm the presence of a herniated disc; this technique is preferred owing to the better visualization of soft tissues and the lower radiation dose [51] . The
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pooled summary estimate of specificity of MRI and a CT scan is 77 and 73.7%, respectively. Similar to physical tests, diagnostic imaging is troubled by a lack of gold standard and a limited number of studies with a large heterogeneity, limiting the validity of the results [52,53] . Electrophysiological investigation
Electromyography/nerve conduction studies may be used to differentiate lumbar radicular syndrome from peripheral neuropathy [54] . Quantitative sensorial testing was shown to provide predictive information regarding the outcome of epidural corticosteroid injection therapy [55] . Selective segmental nerve blocks
To confirm the presumed causative level, one or more selective nerve root blocks are recommended [56] . To increase the specificity, the use of a limited amount of local anesthetic (maximum 1 ml) is mandatory. When different levels must be tested, this should happen in separate sessions [56] . Summary of the diagnosis of lumbosacral
radicular pain
The radiation pattern of lumbosacral radicular pain is indicative of the involved level. The most frequently used examination is the Lasègue and the crossed Lasègue test. MRI may confirm the presence of disc herniation at the presumed causative level. Medical imaging, as such, is not specific since abnormalities are also noted in asymptomatic patients. Electrophysiological investigation can help to differentiate between lumbar radicular syndrome and peripheral neuropathy. Conclusion & future perspective Since the introduction of evidence-based medicine in the early 1990s, guidelines have proliferated. Unfortunately, some of those guidelines on the same subject provide contradictory recommendations [57–61] . However, those guidelines can be used by healthcare authorities and policy makers when deciding whether to finance a treatment, which provides them an extra dimension above the attempted rationalistic use of the best available treatment for the specific patient. It is not surprising that different interest groups may give another interpretation to the available evidence [58] . For interventional pain management techniques, it is observed that the treatment outcome improves when the patients are more
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Review Van Zundert, Van Boxem, Vanelderen et al. accurately selected [45,62] . Therefore, in the case of low back pain, the pain diagnosis should be fine-tuned to allow identification of the most likely causative structure and level, prior to deciding on an interventional treatment [43] . The incidence of low back pain is likely to increase in parallel with the aging of the population. There is currently a tendency towards ‘mechanism-based treatment’ for the pharmacological as well as for the interventional treatment. This means that translational research is developing fast, and will definitely generate valuable information with regard to the underlying disease mechanism as well as the mechanism of action of pharmacological and interventional treatment options. This knowledge will help select the best treatment for individual patients. However, low back pain is not an ‘isolated’ diagnosis; identifying the cause References 1
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Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
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Website
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www.medical-art.eu
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Establishing the diagnosis of low back pain: patient selection for interventional pain medicine
Practice Points
Jan Van Zundert*1, Koen Van Boxem2,3, Pascal Vanelderen1,4, Martine Puylaert1, Pieter De Vooght1, Roel Mestrum1, Rene Heylen1, Kris Vissers4 & Maarten van Kleef3 Low back pain forms a considerable burden to the patient, society and the healthcare provider. The variety of possible underlying diseases imposes attempts to fine-tune the diagnosis. It is imperative to exclude the so-called red flags, which point toward a serious underlying pathology,
necessitating causative treatment. Lumbosacral radicular pain is characterized by pain irradiating into the leg, below the knee, according to
a dermatomal distribution. Pain originating from the facet joints has a referral pattern into the buttock and the upper leg. No physical examination is pathognomonic for the diagnosis of lumbar facet pain. The Lasègue and crossed Lasègue tests are most frequently used to identify lumbosacral radicular pain. Medical imaging, including MRI, has low specificity as degenerative changes and herniated discs are
observed in symptomatic, but also asymptomatic patients. The causative structure and level of pain can be confirmed by means of a diagnostic–prognostic block.
SUMMARY Low back pain is one of the most prominent healthcare problems but there is no gold standard for its diagnosis. Aspecific low back pain can be subdivided into radicular and mechanical pain. The diagnosis mainly relies on a combination of elements, such as medical history, physical examination, medical imaging and other possible additional tests. Once a working diagnosis has been established, confirmation of the causative structure and level is sought by means of diagnostic blocks. The use of the different diagnostic tests and blocks should be guided by the balance between the potential benefit (mainly in terms of improved treatment outcome, the possible burden for the patient and the chances of withholding potential effective treatment to patients) with false-negative test results.
Department of Anesthesiology, Critical Care & Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium Department of Anesthesiology & Pain Management, Sint-Jozefkliniek, Bornem en Willebroek, Belgium 3 Department of Anesthesiology & Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands 4 Department of Anesthesiology, Pain & Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands *Author for correspondence: Tel.: +32 89 32 52 40; Fax: +32 89 32 79 47; [email protected] 1 2
10.2217/PMT.13.3 © 2013 Future Medicine Ltd
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Review Van Zundert, Van Boxem, Vanelderen et al. In 1996, Waddell described low back pain as the healthcare enigma of the 20th century [1] . More than 15 years later, low back pain still remains a healthcare and socioeconomic burden. A systematic review on the global prevalence of low back pain found an estimated point prevalence of 11.9% and a 1-month prevalence of 23.2%. The highest prevalence is found among female individuals and those between 40 and 80 years old [2] . Considering the projected aging, the number of patients suffering from low back pain is likely to increase over the coming decades. The first step in the management of patients with low back pain consists of a diagnostic triage to exclude back pain that arises from other structures, such as retroperitoneal structures and the hips, among others [3] . The so-called red flags draw attention to potentially serious underlying diseases (Box 1) . Prior to designing any treatment plan, the clinician will try to exclude inflammatory/metabolic causes (diabetes, ankylosing spondylitis, Paget’s disease, arachnoiditis and sarcoidosis) [4] . Two recent reviews indicated that clinical features, such as age, female gender, major trauma, pain and tenderness, and distracting painful injury, may be predictive for vertebral fractures [5] . Malignancy in the previous year and unexplained weight loss should stimulate the physician to perform further examinations to exclude cancer [6] . These studies concluded that screening patients for serious pathology is difficult. Acute low back pain usually responds well to pharmacologic analgesic treatment. Some patients, however, are refractory to pharmacological treatment, and the low back pain evolves to become a chronic problem. Although it was often stated that only approximately 10% Box 1. Red flags indicating potentially serious underlying diseases. First appearance of back complaints before 20 years or after 55 years Trauma Constant progressive back pain Malignant disorder in the medical history Long-term use of corticosteroids Drug use, immunosupression, HIV (Frequent) general malaise Unexplained weight loss Structural deformities of the spinal column Infectious disorders (e.g., herpes zoster, epidural abscess, HIV and Lyme disease) Neurological loss of function (motor weakness, sensory disturbances and/or micturition disturbances) Reproduced with permission from [57].
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of patients would continue to suffer chronic pain [7] , later studies showed that 62% of patients have recurrent episodes of low back pain at 12 months, 16% are still unable to work 6 months after the first diagnosis and 33% have repeated episodes of incapacity to work during the first year [8] . A recently published systematic review, regarding the clinical course of aspecific low back pain in primary care, found that 65% of the patients still have pain at 1 year after onset [9] . In approximately 5–10% of patients, a specific cause, such as tumor, infection, vertebral fracture or ankylosing spondylitis, among others, can be identified [7] . The remaining 90–95% are considered to be aspecific. Those so-called aspecific types of low back pain are further classified as being of mechanical origin, radicular pain, pain originating from the joints, the ligaments or muscles, or pain of undefined origin. Potential causes of low back pain of mechanical origin are the zygapophyseal (facet) joints, the sacro–illiac joint and the intervertebral disc [7,10–12] . Interventional pain management techniques can be considered when the conservative treatment fails to provide satisfactory pain relief or causes unbearable side effects. The target specificity of the interventional pain management techniques requires identification of the causative structure and the involved level. Since there is no gold standard for establishing the diagnosis of low back pain, a diagnostic procedure consisting of medical history, clinical examination and additional adapted examinations is outlined for the different types of low back pain. The treatment selection is based on the available evidence; however, the potential benefits should be carefully weighed against possible side effects and complications. Although the intervertebral disc has been indicated as a potential source of pain, diagnosis requires invasive techniques [13] and until now there is no convincing evidence for the use of interventional pain management techniques [14] . Two frequently performed interventional pain management techniques are the radiofrequency (RF) facet joint denervation and the epidural administration of corticosteroids [15] . As an example of the diagnostic process leading to the selection of these treatments, this article concentrates on pain originating from the lumbar facet joints and lumbosacral radicular pain. In summary, chronic low back pain forms a major burden for the patient and healthcare
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Establishing the diagnosis of low back pain: patient selection for interventional pain medicine providers, and is documented to consume a large part of the healthcare budget. When conservative treatment fails, interventional management may be considered. Those treatment options are target specific. Treatment success increases with improved patient selection. There is, however, no diagnostic test that is sensitive and specific for the identification of the cause of low back pain. The aim of this article is to provide a proposal for an algorithmic approach to the diagnosis and treatment of low back pain of facetogenic origin and for lumbosacral radicular pain. The authors aim to provide information that has clinical implications and that highlights the different examinations, in order to allow optimal treatment selection.
identifying clinical predictors for facet joint pain, the following criteria were withheld: age >50 years old; the extension–rotation test that is typically considered positive when pain is provoked by extension combined with rotation towards the painful side presumably causing joint compression; the least pain occurs when walking or when sitting; onset pain is paraspinal; and a Modified Somatic Perception Questionnaire score >13 [28] . The role of medical imaging
Low back pain originating from the facet joints The prevalence of lumbar facet joint pain has been reported to vary between 5 and 90%, depending on the diagnostic tests used. However, when selected patient populations were studied, the prevalence ranged between 5 and 15% [14,16] . Osteoarthitis and degenerative diseases are often indicated as causes of facetogenic pain, which also explains the increasing prevalence with age [17,18] . The findings of the provocation studies in volunteers allowed identification of a typical pain distribution pattern (Figure 1) [19–22] .
The primary role of radiological examination is to exclude malignancy, compression fracture or spinal infection [29,30] . Degenerative facet joints can be best visualized with computed tomography examination [31] . MRI is believed to be somewhat less sensitive, although the classification of degenerative facet joints is based on MRI [32] . In half of the studies, abnormal radiological findings correlate with a positive response to diagnostic blocks, while in the other half no correlation could be found. The diagnostic blocks of the articulations that showed hypercaptivity with computed tomography-single-photon emission computed tomography fusion (CT-SPECT) resulted in temporary pain relief in 36 out of the 37 patients [33] . These findings suggest a potential role for CT-SPECT in the diagnosis of lumbar facet joint pain.
Physical examination
Diagnostic–prognostic blocks
No physical examination is pathognomonic for the diagnosis of lumbar facet pain. The wellknown Revel criteria for lumbar facet joint pain were defined based on the correlation between the physical examination and the symptoms with the response to placebo-controlled nerve blocks [23,24] . A systematic review on tests that identify the facet joint as the source of low back pain found that the Revel criteria and CT scan were most often used as the index test. A prospective study, validating the physical examination criteria promoted by Revel with controlled intra-articular or medial branch blocks, demonstrated that the Revel criteria may have use in identifying a small subset (11%) of patients likely to respond to the initial block (specificity 93%) [25] . Another systematic review concluded that none of the seven individual items from the Revel criteria were found to provide positive or negative likelihood information [26] . According to Cohen et al., paravertebral tenderness is the only predictive factor for facet joint pain [27] . In a prospective study, aiming at
A survey among an expert panel, concerning the predictive factors for facet joint pain, resulted in
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Figure 1. Pain distribution pattern of lumbar facet pain. Adapted with permission from [19]. Illustration used with kind permission from Rogier Trompert Medical Art and Jan-Maarten Luursema [101].
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Review Van Zundert, Van Boxem, Vanelderen et al. the establishment of 12 indicators for facet joint pain. Pain relieved by fluoroscopically guided double-anesthetic blocks of the medial branch of the dorsal ramus supplying the facet joint was accepted as a positive indicator by 85% of the experts [34] . Diagnostic–prognostic blocks are recom mended in guidelines prior to performing a RF facet joint denervation, in order to confirm the involvement of the facet joint [35] . There are currently seven randomized controlled trials on RF facet denervation [36–42] . In all these studies, the diagnosis was confirmed by means of a diagnostic block, but the technique, medication used, targeted structure and the interpretation of the outcome of those blocks varied widely. In one study, approximately 10% of the patients were ultimately selected for the RF treatment [42] , while this was the case for 92% of the patients in another study [38] . In this latter study, the RF treatment was not better than sham intervention. The patients were selected with an intra-articular block with local anesthetic and corticosteroid. The block was considered positive if the patient reported ‘significant’ pain relief over 24 h within the first week after the injection. The high inclusion rate may be indicative of a high number of falsepositive blocks. In the studies where patients were selected with diagnostic medial branch blocks, the percentage of patients included in the study was much lower (10–31%), and the outcome of the RF treatment was positive compared with sham intervention [37,42] . Furthermore, in a recently published prospective triple crossover study it was concluded that a single intra-articular facet joint block with local anesthetics was not useful to detect the facet joint responsible for the pain [43] . When local anesthetic is injected at the level of the medial branch of the dorsal ramus, falsepositive and false-negative outcomes may be noted. To increase the accuracy of the diagnostic blocks, controlled blocks have been proposed. This means that the injection is performed twice with two different local anesthetics, each with a different duration of action. To conclude that the injected level is the causative level, the patient should experience pain relief for the duration of action of both local anesthetics [42] . When selecting a treatment, evaluating the balance between the potential benefit and the patient burden is recommended. With controlled diagnostic blocks the rate of false-positive blocks will be reduced, but at the same time the number of false negatives will increase. Increasing the
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number of blocks increases the burden on the patient. Controlled blocks require different sessions and this means at least two appointments in the clinic. Patients who have a false-negative block will not receive RF treatment, even though this treatment was demonstrated to provide pain relief. The patient will continue either conservative treatment or move on to surgery. This reasoning is outlined in [44] and [45] . A randomized controlled trial estimated the cost per successful RF treatment when patients were selected based on clinical examination alone, with one diagnostic block or with two comparative blocks. Radiofrequency treatment of patients selected with clinical examination has the lowest cost per successful treatment, whereas the highest cost per successful RF treatment is generated when performing this procedure after one single diagnostic block [44] . The highest success rate is observed in the group who received two diagnostic blocks. However, 64% of the patients treated after two diagnostic blocks, and 39% of the patients treated after one block, had a successful outcome. This means that for a 25% increase in successful outcome after RF treatment, 100% more diagnostic interventions are needed [44,45] . In a recent publication, it was observed that no optimal threshold for designating a diagnostic block as positive, above 50% pain relief, could be calculated. Employing more stringent selection criteria for lumbar facet RF is likely to result in the omission of a beneficial procedure from a substantial number of patients, without improving success [46] . Summary of the diagnosis of lumbar facet
joint pain
A working diagnosis can be made based on the patient’s medical history, pain distribution and clinical diagnosis. Medical imaging is predominantly used to exclude the red flags, although CT-SPECT may be indicative for the involved level, and could be a valuable tool when envisioning surgical treatment. Based on the available evidence, RF facet denervation can be recommended for the management of chronic facet joint pain. There is evidence that the treatment outcome improves when patient selection is fine-tuned. One positive diagnostic medial branch block that is correctly evaluated improves patient selection and treatment outcome. A cutoff of 50% pain relief after a diagnostic block was documented to be a valuable tool to improve
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Establishing the diagnosis of low back pain: patient selection for interventional pain medicine treatment outcome; there is no reason to select a higher cutoff value for a positive diagnostic block. Lumbosacral radicular pain Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms or symptoms of decreased function. In addition, patients often report paresthesia in the affected dermatome. The distribution of pain along a dermatome helps to determine the level involved; however, there is large variation in radiation patterns [4,47] . The most frequent cause of lumbosacral radicular pain is a herniated disc; however, certainly in patients over 50 years of age, degenerative changes of the spine (e.g., stenosis of the foramen intervertebrale) cause radicular pain [4] . Physical examination
The straight leg raising test, often referred to as the Lasègue test, is the most popular clinical examination for lumbosacral radicular pain. If radicular pain can be elicited with an angle of less than 60–75° in a surgical population, this test is sensitive for the identification of a radiculopathy due to disc herniation [48] . The crossed Lasègue test is the only examination with good specificity, but this comes at the expense of the sensitivity [48] . Both physical tests have wide variation in interobserver agreement and reliability [49] . Most of the physical examinations were studied in a surgical population, so the diagnostic performance of these tests in primary care remains unclear. Furthermore, the diagnostic performance of a single physical test is poor; however, better performance may be obtained when combinations of patient medical history and positive physical tests are evaluated [49] . Neurological signs, such as paresis, sensory loss or loss of reflexes, are not specific [50] . Tarulli and Raynor described the signs that are indicative for the involvement of the different levels: L4 involvement (lessened patellar reflex, foot inversion) or an L5–S1 hernia (Achilles tendon reflex); L5 motor paresis may be accompanied by the ‘stomping foot’ [4] . The role of medical imaging
Medical imaging, primarily MRI, can confirm the presence of a herniated disc; this technique is preferred owing to the better visualization of soft tissues and the lower radiation dose [51] . The
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pooled summary estimate of specificity of MRI and a CT scan is 77 and 73.7%, respectively. Similar to physical tests, diagnostic imaging is troubled by a lack of gold standard and a limited number of studies with a large heterogeneity, limiting the validity of the results [52,53] . Electrophysiological investigation
Electromyography/nerve conduction studies may be used to differentiate lumbar radicular syndrome from peripheral neuropathy [54] . Quantitative sensorial testing was shown to provide predictive information regarding the outcome of epidural corticosteroid injection therapy [55] . Selective segmental nerve blocks
To confirm the presumed causative level, one or more selective nerve root blocks are recommended [56] . To increase the specificity, the use of a limited amount of local anesthetic (maximum 1 ml) is mandatory. When different levels must be tested, this should happen in separate sessions [56] . Summary of the diagnosis of lumbosacral
radicular pain
The radiation pattern of lumbosacral radicular pain is indicative of the involved level. The most frequently used examination is the Lasègue and the crossed Lasègue test. MRI may confirm the presence of disc herniation at the presumed causative level. Medical imaging, as such, is not specific since abnormalities are also noted in asymptomatic patients. Electrophysiological investigation can help to differentiate between lumbar radicular syndrome and peripheral neuropathy. Conclusion & future perspective Since the introduction of evidence-based medicine in the early 1990s, guidelines have proliferated. Unfortunately, some of those guidelines on the same subject provide contradictory recommendations [57–61] . However, those guidelines can be used by healthcare authorities and policy makers when deciding whether to finance a treatment, which provides them an extra dimension above the attempted rationalistic use of the best available treatment for the specific patient. It is not surprising that different interest groups may give another interpretation to the available evidence [58] . For interventional pain management techniques, it is observed that the treatment outcome improves when the patients are more
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Review Van Zundert, Van Boxem, Vanelderen et al. accurately selected [45,62] . Therefore, in the case of low back pain, the pain diagnosis should be fine-tuned to allow identification of the most likely causative structure and level, prior to deciding on an interventional treatment [43] . The incidence of low back pain is likely to increase in parallel with the aging of the population. There is currently a tendency towards ‘mechanism-based treatment’ for the pharmacological as well as for the interventional treatment. This means that translational research is developing fast, and will definitely generate valuable information with regard to the underlying disease mechanism as well as the mechanism of action of pharmacological and interventional treatment options. This knowledge will help select the best treatment for individual patients. However, low back pain is not an ‘isolated’ diagnosis; identifying the cause References 1
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