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Pseudoradicular and radicular low-back pain: How to diagnose clinically?

Article  in  Pain · May 2008

DOI: 10.1016/j.pain.2008.02.003 · Source: PubMed

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 Pain 135 (2008) 311–316
Letters to the Editor
Pseudoradicular and radicular low-back pain: How to
diagnose clinically?
We want to congratulate colleagues Freynhagen et al.
on their impressive work on the use of quantitative
sensory testing for trying to differentiate between
pseudoradicular and radicular low-back pain [4]. It is
interesting to see that both disease entities show [11]
differences in vibration detection. Therefore it seems
that quantitative sensory testing may be indicative of a
potential differentiation between radicular and pseudo-
radicular pain. This is in line with the observations that
QST can potentially be used as predictive parameter to
select patients who will respond to epidural steroid injec-
tions [8].
The diagnosis of radicular and pseudoradicular low-
back pain remains, however in our opinion a problem,
mainly because of the lack of a golden standard [11].
The diagnostic value of anamnesis and physical exami-
nation has not been well documented [10]. As Freynha-
gen et al. also mention, there is a poor correlation
between radiologic imaging and clinical symptoms.
Besides, other (neurophysiologic) tests lack specificity.
The inclusion criteria handled in the QST study
define radicular pain as pain radiating beyond the knee.
Others [1,7,9] reported distribution of zygapophyseal
joint pain beyond the knee. Additionally the Laségue
test was used and this test has indeed a pooled sensitivity
of 0.91 but a specificity of only 0.26 [5]. These observa-
tions may shed doubt over the accuracy of the selection
criteria used to identify patients with pain of radicular
etiology.
Hence the outcome of the current study where QST
measurements is used to subdiagnose radicular and
pseudoradical pain are difficult to validate, which can
be considered as a weakness of the study.
Efforts should be made to identify and fine-tune clin-
ical tests that specifically try to evoke nerve-root tension
signs or dural irritation, through combinations of
manipulations. It has been established that a cervical
flexion by itself provokes a displacement of lumbar
roots [2] and that an additional flexion of the hip
increases this effect [6]. We therefore propose a triad
of clinical tests to be investigated in the future: active
www.elsevier.com/locate/pain
flexion in standing position with a passive cervical flex-
ion, a straight-leg raising test with a passive dorsiflexion
of the foot [3] and a straight-leg raising test with a pas-
sive cervical flexion.
References
[1] Bous R. Facet joint injections. In: Stanton-Hicks M, Bous R,
editors. Chronic Low Back Pain. New York: Raven Press; 1982.
p. 199–211.
[2] Breig A, Marions O. Biomechanics of the lumbosacral nerve roots.
Acta Radiol Diagn (Stockh) 1963;1:1141–60.
[3] Breig A, Troup JD. Biomechanical considerations in the straight-
leg-raising test. Cadaveric and clinical studies of the effects of
medial hip rotation. Spine 1979;4:242–50.
[4] Freynhagen R, Rolke R, Baron R, Tolle TR, Rutjes AK, Schu S,
et al. Pseudoradicular and radicular low-back pain – A disease
continuum rather than different entities? Answers from quantitative
sensory testing. Pain 2007.
[5] Hoving JL, de Vet HC, Twisk JW, Deville WL, van der Windt D,
Koes BW, et al. Prognostic factors for neck pain in general
practice. Pain 2004;110:639–45.
[6] Lew PC, Morrow CJ, Lew AM. The effect of neck and leg flexion
and their sequence on the lumbar spinal cord. Implications in low
back pain and sciatica. Spine 1994;19:2421–4. [discussion 5].
[7] Marks R. Distribution of pain provoked from lumbar facet joints
and related structures during diagnostic spinal infiltration. Pain
1989;39:37–40.
[8] Schiff E, Eisenberg E. Can quantitative sensory testing predict the
outcome of epidural steroid injections in sciatica? A preliminary
study. Anesth Analg 2003;97:828–32.
[9] Sowa G. Facet-mediated pain. Dis Mon 2005;51:18–33.
[10] Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of
history and physical examination in patients suspected of sciatica
due to disc herniation: a systematic review. J Neurol
1999;246:899–906.
[11] Wolff A, Wilder-Smith O. Diagnosis in patients with chronic
radiating low back pain without overt focal neurological deficits:
What is the value of segmental nerve root blocks? Therapy
2005;2:577–85.
Koen Van Boxem *
Department of Anesthesiology and Pain Centre,
Sint Josefziekenhuis Bornem and Willebroek,
Kasteelstraat 23, 2880 Bornem, Belgium
E-mail address: koenleenvb@scarlet.be
Jan Van Zundert
Department of Anesthesiology and Multidisciplinary
Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
312 Letters to the Editor / Pain 135 (2008) 311–316
Jacob Patijn
Maarten van Kleef
Department of Anesthesiology and Pain Therapy,
Academic Hospital Maastricht,
Maastricht, The Netherlands
* marized previous suggestions (e.g., [1,3,7]) that sensory
Corresponding author. Tel.: +32 474978635.
0304-3959/$34.00 Ó 2008 International Association for the Study of
Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2008.02.003
Letter to the Editor of Pain on Freynhagen et al.:
Pseudoradicular and radicular low-back pain – A disease
continuum rather than different entities? Answers from
quantitative sensory testing. Pain 2007;135:65–74
Low-back pain with leg pain is one of the more chal-
lenging and prevalent pain patterns in individuals from
industrialized countries. Therefore, studies aimed at
unravelling details of the clinical phenomenology of
these conditions are most welcome. Importantly, both
neuropathic (projected) and referred phenomena may
arise in the leg in patients with low-back pain and hence
differential diagnostic issues related to this are impor-
tant. Spread of pain and other sensory symptoms in a
non-dermatomal fashion to the leg in subgroups of pa-
tients with low-back pain following increased focal pain
intensity is the hallmark of referred sensory compo-
nents, complaints that usually co-vary with the pain in
the low-back. Neuropathic radicular components, on
the other hand, are distributed in a neuroanatomically
correlated fashion with respect to affected root/roots.
The study by Freynhagen et al. (2007) addresses impor-
tant aspects of combined low-back pain and leg pain.
We feel, however, that the study rationale is relatively
weak and that the study has some methodological short-
comings, which make us question the foundation for the
interpretation of the results.
Our main concern with the aims of the study is that
there is no practical clinically warranted need to further
evaluate the QST (quantitative sensory testing) status of
the L5 dermatome only in the foot in a low-back pain
patient with a non-dermatomal leg pain confined to
the thigh and with the characteristics of a referred symp-
tomatology. The pain treatment strategy of such a
patient is still to target plausible nociceptive mechanisms
related to the pain in the focal pain area. In addition, the
rationale for the choice of the L5 dermatome for
detailed QST is not revealed. Since the authors
embarked on this endeavour with the possibility of
finding sensory aberrations in the foot of patients with
pseudoradicular pain in the thigh, and actually found
that on a group level, one may ask whether referred
sensations in the leg only, without concomitant radicu-
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lopathy, are never to be expected by the authors in
subgroups of pseudoradicular pain patients?
The inclusion of patients with ‘‘chronic” (no informa-
tion is given about the duration of pain) low-back pain
and radicular pain in combination was based mainly on
medical histories, pain drawings and bedside neurologi-
cal examinations. A recent consensus paper [9] has sum-
aberrations in the distribution of the affected nervous
structure are a diagnostic prerequisite in neuropathic
pain conditions. From Table 1 in the paper by Freynha-
gen et al. it is reported that 5 out of 12 of the patients
classified with painful radiculopathy had normal out-
come of the bedside examination of sensory function.
The methodological details of that examination (modal-
ities examined and equipment used; confirmation of
sensory abnormalities confined to the proper innerva-
tion territory) are not touched upon anywhere in the
paper and the number of altered modalities is not
reported. The lack of a high-resolution report of the
outcome of bedside testing contrasts markedly to the
presentation of exhaustive QST data from the feet. Also,
out of the several tests used for diagnostic purposes
(Table 1, page 3), 4 patients demonstrated only one to
be altered and in one patient all test outcomes were nor-
mal. Still, all 5 were classified as ‘‘radicular”. In light of
this, the used inclusion criteria may have resulted in
recruitment of patients without radicular pain to this
group. It also deserves to be mentioned that the text is
not entirely consistent about that the correspondent
dermatome of the foot in the patients with L5/S1 painful
radiculopathy was examined (see page 3, right column,
line 5, and compare with discussion page 6, right
column, line 1). Also, where were patients with L4 radic-
ulopathy examined?
Patients with pseudoradicular pain were included if
they in addition to low-back pain reported a non-derma-
tomal pain pattern (presumably) confined to the thigh,
although the latter is not clearly expressed in the method
section. In light of contemporary clinical knowledge
such an approach may be questioned. Classical experi-
ments from 1954 by Feinstein et al. [4] have demon-
strated that pain induced by injection of hypertonic
saline into paravertebral structures at the lumbar or
sacral level resulted in referred pain and other sensory
symptoms as far as the ankle joint but not reaching into
the foot. Therefore, non-dermatomal distribution of
such symptoms as far as the ankle is best classified as
referred. In addition, such symptoms are usually vari-
able in distribution and transitory and often positively
correlated concerning presence and content to the inten-
sity of the ongoing low-back pain [2,5,6]. They may even
be lacking when the back pain is of low intensity. A fur-
ther important aspect of the differential diagnostic ap-
proach is the demonstration of sensory abnormalities
confined to one of the three dermatomes in the lower