PAIN® 147 (2009) 17-19 "AIN’ Topical review On the definitions and physiology of back pain, referred pain, and radicular pain Nikolai Bogduk* Lives of Neate Newent Boe a at ty, 1. Ineroduction Despite the efforts ofthe Imernational Association for the study of Pain [621], confusion sil persists amongst clinicians about the definitions of back pain, referred pain, radicular pain, and radicu- apathy. Basic scientists now stand to ert this confusion as they {develop animal models of back pain {7} Pivotal to the definition of these entities are seminal studies ‘undertaken 50,60, and 70 years ago. Te legacy of this pioneering ‘work has not properly permeated medical education, publications cor clinical practice, 2. Nociceptive back pain By definition, nociceptive back pain must be pain thats evoked by noxious stimulation of structures in the fumbar spine, The ual ity of pain so evoked has been determined ia studies of nesta vol- lunteers, in whom discrete noxious stimuli were delivered t0 Selected lumbar structures, In the original studies, muscles of the back [17] oF the interspinous ligaments [18] were stimlated, using injections of hypertonic saline. Others replicate these scud- {es [2,13 Later, the lumbar zygapophysial joints [22.23] and the sacroiliac joints [14] were stimulated with injections of contrat ‘medium chat evoked pain by distending these joints. The dura ma {er has been stimulated mechanically |27) and chemically (10), Surgeons wha have operated on patients under local anaesthesia, have probed various structures mechanically, and showed that the posterior surface of the lumbar intervertebral dises are the ‘most potent source of experimentally-induced back pain (12,2029), Uniformly, shese experimental studies showed that roxious stimulation causes dul, aching pain in the back, Conse- quently, when it occurs clinically, this type of pain that shold be inferred to be nocicepeive back pain. 3, Somatic referred pain Noxious stimulation of structures i the lumbar spine can pro- «duce referred pain in addition to back pain. The pain spreads into the lower limbs, and i perceived in regions innervated by nerves other than those that innervate the site of noxious stimulation = ‘the core of the definition of referred pain (21. Since the source of spinal referred pain lies in the somate tissues of the lumbar Tels 2 4820950 fon 63 248 558 ‘Emad edie michele pie cevesee ads, 0 018) pn.2008 8420 ena Cet, PO By 8, Newest, NSH 250, Asta spine thas been named somatic referred pain [3,5 order to dis- ‘inguish it both from visceral referred pain an radicular pain. So- matic referred pain does not involve stimulation af nerve coo. eis preduced by noxious stimulation of nerve endings within spinal Structures such as dises, zygapophystal joints, oF sacraliae joins The proposed mechanistn of referal fs convergence of nociceptive afferents on second-order neurons inthe spinal cord that happen also o subtend regions ofthe lower limb [21]. Asa general rule, so- ‘matic referred pai is perceived in regions that share the ame sex ‘mental innervation a the source. Since somatic referre pain isnot ‘caused by compression of nerve roets,thete are no neurological signs ‘Somatic referred pain is dull, aching and gnawing, and is some- times described as an expanding pressure. it expands into wide areas that can be dificult to localize [2.13.18]. Once established i tends tobe fixed in leation. Subjects often find it dificult to de> fine the boundaries ofthe affected area, but can confidently iden- tify its centre of core, The earliest studies depicted segmental ‘maps of the referred pain pattems [13.18} (Fig 1). However, although pain from eifferent segments inthe lumbar spine refers to different regions in the lower limb, patterns are not consistent amongst subjects or between studies. Mast significantly, however, the pattem is not dermatomal. If anything, the pattern corresponds to the segmental innervation of deep tissues in the lower limb, such as muscles and joints. Moreover, although somatic referred pain tends most often to centre over the gluteal region and proxt- mal thigh, it ean also extend as fa a the foot (Fig 1) Such distri= butions have been evoked in normal volunteers and patients by stimulating the urnbar zygapophy/sial joins [2223] or interverte, bral discs (25), and relieved in patients by anaesthetizing their _ygapoplysal joints (11,23,26), To be consistent with these exper- imental data, when dull aching pain that spreads into the lower limi and settles into relatively feed location occurs in patients, it should be recognized as somatic referred pain, when it occurs ‘inpatients. ae 4. Radicular pain Radicular pain difers from somatic referred pain both in mech- anism and clinical features. Physiologically, itis pain evoked by e<- ‘opie discharges emanating ftom a dorsal roa o ts ganglion (21 Dise herniation is the most common cause, and inflammation of the affected nerve seems tobe the-ritieal pathophysiological pro- ess [3]. The clinical features of radicular pain were established in, studles of patients who underwent surgery for dise herniation In 3880 © 208 tematonl Asotin forthe Say of al Pushes by ever BY ll igh reservedu begat PAN 19 (208) 17-19 Hig. 1. Pattee of somite refer pln eve by nos Inersinous Tgaments a the septs ate. aed on Kel | ‘one study, he affected nerves and adjacent nerves were challenged by squeezing them with forceps in awake patients [24), In anther study, sutures were placed around the nerves, duting surgery. and {ed out through the wound, so chat they could be pulled on the fol- Towing day [27) The pain evoked was distnccve. had a lancinat- {ng quality, and traveled along the length of the lower limb, in 3 band no more than 2-3 inches wide (see Fig. 2) This és the only {ype of pain that has been produced by stimulating nerve roots. So, reciprocally, it is only this type of pain that should be énter- preted as radicular pa, ‘Significanty. squeezing or pulling normal nerve roots does not produce radicular pain. Only if nerve roots have previously been Inflamed does mechanical stimulation evoke radieular pain (27) For compression alone tobe painful, it seems that it must involve ‘the dorsal root ganglion. Although this has not been verified in experiments on human volunteers, itis borne out in animal studies, Studies in laboratory animals have provided a neurophysiologic corvelate of radicular pain. Squeezing normal nerve roots evokes only & momentary discharge, but squeezing a dorsal root ganglion, fr squeezing an inflamed dorsal root, evokes discharges in AB as well as AB and C fibers (15.16), Radicular pain, therefore, is not ddue to a discharge exclusively in nociceptive afferents; itis due oa heterospecifc discharge inthe affected nerve. The evoked sen sation is very unpleasant but is rot exactly pain ina classical, oci- ceptive sense, The qualities of lancinating, shocking, o electric are consonant with more than nociceptive afferents discharging, Since the English language lacks a more precise word, tis sensation is, nevertheless, by default, called pain, vb Pig 2. An sation of he acnating aly eraser ple Cave othe Yor ln ing marr nd ‘The cerm ~ sciatica, is arcane. It stems from an era when the mechanisms of refered pain were not understood, ad any re= ferred pain was attributed to iritation of the peripheral nerve that passed through the region of pain. The taxonomy ofthe IASP rec- ‘ommend replacement by the term = radieular pan (21) 5. Radiculopathy Racliculopathy is yet another, distinc entity {21). Its a neuro- logical state in which conduction is biocked along 2 spinal nerve for its roots. When sensory fibers are blocked, numbness Is the symptom and sign, When motor flbers are blocked weakness en- sues, Diminished reflexes occur asa result f either sensory or mo- tor block. The oumbness is dermatomal in distribution snd the ‘weakness is myotomal. However, radiculopathy is not defined by pain. tis defined by objective neurological signs, Although radici Topathy and radicular commonly occu together, radiculopathy can ‘cea in the absence of pain, ad radicular pain can occur in the ab- sence of radiculopathy. Careful clinical examination remains the best tool for diagnos ing @ radiculopathy. Flectrophysioiogieal testing should rarely be necessary. The indications and validity of electrophysiological test ing ate beyond the scope if this review, bur they have been ad- dressed elsewhere [1,49 ‘A-common maxim is chat the segmental origin of radicular pain can be determined trom its distribution, This isnot true. The patterns of 14,15, and St radicular pain cannot be distin- guished from one ancther [24,28]. Segments can be estimated ‘only when radiculopathy occurs in combination with radicular pain, In that event its the dermatomal distribution of rumbness = nat the distribution of pain ~ that allows the segment of erigin to be determined, 6. Discussion Foilure co distinguish radicular pain from somatic referred pain ‘ay lead to misdiagnosis and thereby mismanagement. Back pain and somatic referred pain are common, but radiouae pan isnot. ‘When radicular pain has been strictly defined, its prevalence is only about 12% of less (8), Mistaking somatic referred pain for radicular pain creates the erroneous impression tha radicular pain is more common. Because ofthe sttong possibilty that somatic re ferred pain has been mistaken for radicular pain inthe past, studies of the prevalence of radicular pain are not reliable (18) With respect to clinical management, imaging is justified for ‘he investigation of radicular pain and radiculopathy: because ‘maging can often establish the causative lesion. The same does ‘hot apply for somatic referred pain. Plain radiographs, MRI scan, ‘oF CT scan are unable co reveal the eause of somatic palit. in the majority of cases. Moreover, they carry the tsk of false-post tive interpretations. Finding. degenerative changes, dist bulges and possible nerve root compression is immaterial to the diagno- sis if the patient has somatic referred pain, but can lea to uinec- essary surgery if somatic referred pains mustaken for radicular pain Since nociceptive back pain and somatic referred pain do not Involve nerve injury there are no grounds for expecting neurolog- ical symptoms or signs. In particular, allodynia should not be a feanure; and, indeed, allodynia has never been tecorded in cases of nociceptive back pain, In contrast, since radicular pain and radiculopathy do involve pathology of a nerve trunk, allodynia is a theoretical possibilty, provided that the nerve sullers an appropriate injury. However, allodynia Is nota types! feature of Tadicular pain os radiculopathy, unless there is true netve damage and neuropathy rather than simply compression of inflammation. ovBega PAN 1 (008) 1-19 ” Clinical practice is straightforward when presentations are ‘unambiguous. A patient whois distressed by pain shooting down the lower limb, cannot lie comfortably, and on examination has ‘numbness or weakness in the leg clearly as radicular pain and radiculopathy. A patient with aching pain in the back, which spreads into the buttock ané thigh, but no lancinating pain and ‘no neurological symptoms, has nociceptive back pain and somatic refersed pain, Difficulties arise when patients have combinations. I js possi ble for a patient to have nociceptive back pain, due to internal disc disruption, for instance. This pain may be referred into the Tower limb, in which case itis somatic referred pain, However, the disc may also herniate, or leak inflammatory ehemicals onto the nearby nerve root. Chemical ivtaion of the nerve root will ‘cause racicular pain, Radiculopathy may ensue as the nerve r00t, becomes swollen and conduction block oceurs. Each feature, then, has a separate cause ard separate mechanism; and invites sep: arate investigation and treatment. Disceccomy inight remove the dise herniation and relieve the radicular pain: but it will not re= lieve the back pain and any somatic referreé pain, indeed, this is the commen experience of surgeons: discectomy is highly suc= ‘cessful for leg pain, but patients are left with their back pain Certain terms are misleading and unhelpful, There is no singu- Jar condition called “iow back pain ~ sciatica" This term implies that the patient has a single condition that causes both symp= toms, which is not correct. Patients can have back pain; they ‘an also have sclatca; but the two symproms have separate ‘mechanisms and causes. Features, causes, and mechanisms. of ‘one entity cannot be attributed to the other. Thus, although disc herniation is the most common cause of radicular pain, it i not ‘common cause of back pain. The vast majority of patients with nociceptive back pain does not have radicular pain, and do not have a dise herniation. Nor is it necessary to Invoke terms such, _38 pseudo-scatca or pseudo-radicular pain. There is nothing false ‘about these symptoms. These terms are superfuous synonyms for ‘somatic refered pain o, a times, peripheral nerve entrapment distal to the spine, nether of which has anything in common ‘with radicular pain, otner than being perceived inthe lover limb. Indeed, because somatic referred pain is far more common than ‘radicular pain, radicular pain should be regarded as the exception rather than somatic refered pain being relegated to some irregu= larity of radicular pain. If clinicians ceased to confuse somatic refered pain and radic- ular pai, fewer patients would he mismanaged, and fewer would sustain iatrogenic problems If basic scientist understand the dis- Xinction, animal models of nociceptive back pain would be devel- ‘ped that do not include neurological abnormalities Conflict of interest ‘The author has no conflets of interest regarding this article. 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