society.

One estimate is that this condi-

tion affects 15% of the US population.3
The impact on overall cost of healthcare
Using Image-Guided is staggering when considering the dis-
Techniques for Chronic abling influence of LBP on the working
Low Back Pain population. According to Manchikanti’s
epidemiologic review,4 probable risk fac-
Stephen S. Boyajian, DO tors for LBP include genetic factors as
well as age and smoking; however, none
was convincingly causal. Possible risk
factors include a history of back pain,
job dissatisfaction, heavy physical work,
obesity, static work posture, and psy-
chosocial factors. Because LBP is the
most common symptom seen by inter-
ventional pain management physicians
and is a common symptom seen by pri-
mary care physicians, this review article
Image-guided spine intervention is used primarily for its precise diagnostic focuses considerably on diagnosis of LBP
capabilities. This article reviews basic principles of the more common image- and treatment of patients with this con-
guided diagnostic techniques specifically as they relate to patients with low dition.
back pain. It also includes discussion of advanced modes of therapy, including The symptomatology of LBP is non-
spinal cord stimulation and intrathecal therapy, providing primary care physi- specific with many possible etiologies.
cians with an understanding of the primary indications for these therapeutic The lumbar spine is a complex structure,
modalities. Two illustrative case presentations have been added to “refresh” this and for many years, treatment of patients
article, which was originally published in a supplement to the September 2005 with LBP was based on speculation. Lim-
issue of the JAOA and to further enhance primary care physicians’ under- ited understanding of lumbar spine
standing of spinal intervention. anatomy, specifically neuroanatomy, and
J Am Osteopath Assoc. 2007;107(suppl 6):ES3-ES9 a lack of knowledge of functional
anatomy contributed to this approach to
treatment.
Fortunately, the dedicated, diligent,
ment physicians. This situation changed and unparalleled work of Nikolai
A lthough the variety of specialists
caring for patients with chronic
pain is broad, anesthesiology is the spe-
in 2001 as the result of the establishment
of guidelines set forth by the American
Bogduk did much to change treatment.
His text Clinical Anatomy of the Lumbar
cialty that represents the majority of Society of Interventional Pain Physicians1 Spine and Sacrum5 contains knowledge
physicians who use interventional and more comprehensive practice guide- and science essential to more complete
approaches in the treatment of these lines recently published by the Interna- comprehension of pathology, diagnosis,
patients. Anesthesiologists who consider tional Spine Intervention Society (ISIS).2 and treatment. This greater awareness
themselves as interventional pain man- As these standards become more com- of anatomy and function resulted in con-
agement specialists agree that the spec- monplace in this specialty, the gap of siderable research data generated by
trum varies widely from those who use varied skill levels and training will many quality double-blind controlled
only epidural steroid injections in a narrow with the expectation of trials. These data were translated into
recovery room setting to those who are improved outcomes based on random- precise diagnostics that further enhanced
fellowship-trained and exclusively pro- ized control trials that are ongoing to appreciation of complex issues in LBP
vide image-guided spine intervention. further delineate more accurate guide- and dramatically changed the specialty of
Training and skill level among such lines for each specific procedure. interventional pain management. Scien-
anesthesiologists vary widely, mainly tific advances coupled with the ever-
because until recently, no common com- Low Back Pain developing art of medicine will undoubt-
prehensive standards or guidelines Low back pain (LBP) is a common edly translate into less suffering with
existed for interventional pain manage- problem that has an enormous clinical, greater function and productivity for
social, and economic impact on our those who have chronic pain.

Dr Boyajian has no conflicts of interest to disclose.

Address correspondence to Stephen S. Boya-
This continuing medical education publication is supported by
jian, DO, Advanced Pain Consultants, PA, 805
Cooper Rd, Suite 2, Voorhees, NJ 08043-3814. an unrestricted educational grant from Purdue Pharma LP.
E-mail: sboyajian@comcast.net

Boyajian • Using Image-Guided Techniques for Chronic Low Back Pain JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES3
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 Given these fortuitous advances,
there is no longer a place for the routine
“series of three” injections. Spinal injec-
tion procedures are primarily diagnostic
and, to a lesser degree, potentially ther-
apeutic. Repeated injections should be
considered only in regard to response of
previous ones. A poor response pre-
cludes repeating the same spinal injec-
tion procedure. Furthermore, precise
needle placement, an absolute require-
ment for diagnostic injections, cannot be
accomplished unless fluoroscopy and
contrast are used. Even for a potentially
therapeutic injection such as a conven-
tional (interlaminar) epidural steroid
injection, the needle tip (and the desired
delivery of corticosteroid) may not con-
sistently reach its target when fluo-
roscopy is omitted.6,7
The concept of precisely diagnosing
a potential anatomic structure respon-
sible for generating LBP rests on the idea
that for a structure to be a source of pain,
it must have a nerve supply. Hence, a
diagnostic nerve block can be adminis-
tered to test this hypothesis.8
Based on several studies by
Schwarzer et al,9-14 Bogduk15 postulated
that precision diagnostic injections can
assist in formulating a specific diagnosis
in 70% to 80% of those who suffer from
LBP.
With respect to the relative contri-
butions of various structures in chronic
LBP, Manchikanti et al16 evaluated 120
patients with a chief complaint of LBP
by administering precision diagnostic
injections. These injections targeted facet
joints via medial branch blocks, inter-
vertebral disks via provocation diskog-
raphy, and sacroiliac joints (SIJs) via intra-
articular injections. They concluded that
the facet joint contributed to chronic LBP
in 40% of the population, the interverte-
bral disk in 26%, and the SIJ in 27%.
Anecdotal experience among physicians
at Advanced Pain Consultants, PA, in
Voorhees, NJ, indicates that the inter-
vertebral disk is the more frequent clin-
ically significant source of chronic LBP
than are lumbar facet joints.
Facet Joint Pain
Facet joints (zygapophyseal joints) are
paired synovial joints formed by articu-
lation of the inferior articular process of
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one vertebra with the superior articular
process of the subjacent one. These joints
allow the spine to move in flexion, exten-
sion, and rotation.
Innervated by the medial branch
originating from the dorsal ramus of the
spinal nerve, facet joints can be identi-
fied as a source of pain either by placing
a needle tip within the joint or by
blocking the medial branch nerve that
lies outside the joint.
Osteoarthritis and trauma are
among the most common conditions
leading to pain emanating from facet
joints. The primary symptom of pain
emanating from this site is that of LBP. By
injecting a solution of 10% hypertonic
saline solution in the region of the facet
joints, Hirsch and colleagues17 demon-
strated that pain can be created in the
upper back and thigh regions. Pain fre-
quently is also referred into the groin,
buttocks, hip, or lateral and posterior
thigh regions (or a combination of these
sites). Pain is often described as a “deep,
dull ache” and may be either unilateral or
bilateral.
On physical examination, there may
frequently be increased pain with exten-
sion, tenderness to palpation over the
affected joints, and normal findings on
neurologic examination. Electrical stim-
ulation of the medial branch nerves has
also assisted in identifying referral pain
patterns.18
Facet joint injections or medial
branch nerve blocks are primarily diag-
nostic tools. An intra-articular facet injec-
tion usually includes use of a steroid such
as methylprednisolone, which theoreti-
cally reduces inflammation within the
joint, thereby potentially reducing pain.
However, injecting steroid into the facet
joint does not usually provide lasting
relief.
The interventional pain manage-
ment specialists at Advanced Pain Con-
sultants, PA, routinely administer con-
trolled diagnostic blocks of the lumbar
medial branches to determine if a given
patient may be a candidate for radiofre-
quency neurotomy. Dreyfuss et al19 have
demonstrated that clinically significant
and prolonged relief from back pain can
be achieved with radiofrequency neuro-
tomy of the lumbar medial branches.
Patients’ pain must be carefully diag-
Boyajian • Using Image-Guided Techniques for Chronic Low Back Pain
nosed with controlled diagnostic blocks
of the lumbar medial branches.
Sacroiliac Joint Pain
Like the facet joint, the SIJ is also a
diarthrodial synovial joint with a cap-
sule. Unlike the facet joint, which has a
clearly defined innervation, the SIJ has
a nerve supply that is not clearly defined
and is probably complex. The lack of a
clearly defined innervation precludes use
of a nerve block as a diagnostic tool for
identifying pain emanating from this site.
The SIJ can be the source of LBP in
a substantial percentage of cases.
Schwarzer et al 14 suggest that this
causality may be true in 13% of cases.
Using controlled diagnostic injections,
Maigne et al20 suggest the incidence of SIJ
dysfunction causing LBP may be as high
as 19%.
Because there is no scientific evi-
dence that history or physical examina-
tion can accurately identify the SIJ as a
source of pain, controlled intra-articular
injections are the only available means
of identifying this site as causing such
discomfort.21,22 Because innervation of
the SIJ is poorly defined and most likely
complex, pain emanating from here
cannot be diagnosed using nerve blocks.
Intra-articular injection of a local anes-
thetic (eg, lidocaine or bupivacaine
hydrochloride) into the SIJ is the tech-
nique of choice used to prove or disprove
that it is the etiologic factor.
Based on the experience of
Advanced Pain Consultants, patients in
whom emanation of pain is suspected—
and subsequently confirmed by intra-
articular injection—to be from the SIJ,
usually present with pain in the lower
back, groin, or buttocks (or a combination
of these sites). Referred lower extremity
pain may also be present.
Fortin et al,23 using asymptomatic
volunteers, created a map suggesting
that the characteristic location from which
SIJ pain may be referred is an area of
approximately 3 cm ⫻ 10 cm just inferior
to the posterior inferior iliac spine. Unfor-
tunately, this same referral pattern is not
unique to the SI joint; it is also common
to the facet joint and lumbar interverte-
bral disk. Therefore, intra-articular injec-
tions of a local anesthetic are necessary
for diagnosis.
 Diskogenic Pain
Because different structures in the lumbar
spine share similar innervation, pain pat-
terns do not assist in distinguishing the
exact pain generator. Without use of pre-
cision diagnostic injection techniques,
pain originating from the intervertebral
disk, facet, or SIJs is indistinguishable.
Provocation diskography involves
injection of contrast medium into the
disk nucleus to define its morphology;
this increase in intradiskal pressure
allows simultaneous evaluation of the
patient’s response to pain reproduction.
Therefore, provocation diskography can
determine if this anatomic location is a
pain source. It is based on the concept
that if a particular disk is the source of
pain, stressing it should result in repro-
duction of that pain. Furthermore, if the
disk is not the source of pain, then when
stressed, it should either not cause pain
or it may produce pain that is atypical
(disconcordant) of the underlying pain.
Immediately following provocation
diskography, computed tomography
(CT) scanning is done to obtain a static
axial view of the intervertebral disk to
evaluate the degree of annular disrup-
tion. Sachs et al24 developed the Dallas
diskogram scale, which grades disrup-
tion of the annulus on a four-point scale.
A normal nucleogram, one in which con-
trast is entirely contained within the
nucleus, is considered a grade 0 disk.
Grades 1 to 3 describe extension of the
contrast medium to the inner third,
middle third, and outer third of the
annulus fibrosis, respectively. Examples
include a posterior radial fissure at L4-5
with contrast extravasating into the ante-
rior epidural space (Figure 1) and a
grade 3 posterolateral annular disrup-
tion on the postdiskography CT scan
(Figure 2).
Provocation diskography with post-
diskography CT imaging can be used to
assist patients in making decisions
regarding surgical intervention with
either conventional spinal fusion tech-
niques or disk replacement surgery. This
diagnostic study can also serve to iden-
tify patients who may want to consider
the less-invasive options such as
intradiskal electrothermal annuloplasty
(IDET) or other percutaneous disk inter-
ventions.
Boyajian • Using Image-Guided Techniques for Chronic Low Back Pain
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Figure 1. Lumbar diskogram demonstrating
L4-5 posterior annular tear with contrast
extravasating into the anterior epidural space.
Epidural Steroid Injections
Undoubtedly, the epidural steroid injec-
tion (ESI) is the precursor of the more
specific spinal injection procedures done
today and the most familiar to primary
care physicians. Historically, the ESI has
been administered primarily as a thera-
peutic procedure. With widespread use
of fluoroscopy and contrast medium,
epidural injections into the anterior
epidural space (transforaminal approach)
also now have substantial diagnostic
value.
Anatomically, the epidural space is
divided into an anterior and posterior
compartment. The posterior aspect of the
vertebral body, intervertebral disk, and
posterior longitudinal ligament anteri-
orly border the anterior epidural space.
The posterior confine of the anterior
epidural space is the thecal sac. The pos-
terior epidural space is bordered by the
thecal sac anteriorly and the ligamentum
flavum posteriorly.
Three approaches to the epidural
space are, historically, the more conven-
tional interlaminar and caudal proce-
dures and the more target-specific trans-
foraminal method.
Despite ESI’s widespread use since
first described in 1953,25 most early
studies on its efficacy have been criti-
cized because of the use of the blind (ie,
without fluoroscopy) technique and
hence, the lack of target specificity. Even
in the hands of experienced clinicians,
an epidural needle placed without using
fluoroscopy will result in approximately
25% incorrect placements.7,26 Therefore,
JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES5
Figure 2. L4-5 postdiskography computed
tomography scan demonstrating a radial tear
from the central nuclear zone extending into
a large circumferential outer annular fissure.
the fluoroscopically guided approach
has become standard of care among
interventional pain management physi-
cians, not only for all spinal diagnostic
injections, but also for the more conven-
tional caudal and interlaminar epidural
steroid injections.
When an intervertebral disk is her-
niated, a host of inflammatory media-
tors may affect lumbar nerve roots and
result in clinical symptoms of radicu-
lopathy or radicular pain. Inflammatory
mediators identified in disk material
which may irritate the dorsal root gan-
glion or dural sleeve include nitric oxide,
phospholipase A2, phospholipase E2,
tumor necrosis factor, interleukins, met-
alloproteinases, and immunoglobulins.27
Corticosteroids such as methylpred-
nisolone or betamethasone decrease
inflammation by inhibiting phospholi-
pase A2 activity.28,29 Other mediators of
inflammation are also most likely inhib-
ited by corticosteroid therapy.
Precisely placing a corticosteroid at
the site of the pathologic process and
inflammatory cascade should provide
improved clinical outcomes. Unlike the
more conventional interlaminar and
caudal techniques, the transforaminal
approach to the epidural space delivers
drug very close, if not directly, to the
site of the pathologic process. Under
fluoroscopic guidance, a transforaminal
needle is positioned within the inter-
vertebral foramen just below the pedicle
(Figures 3-5). Contrast traverses the
regional epidural space and outlines the
dorsal root ganglion (Figure 6). This more

Figure 3. Oblique image of the lumbar spine
demonstrating a needle placed under the
pedicle for a transforaminal injection.
Figure 4. Lateral fluoroscopic image of
needle in the L4-5 foramen.
Figure 5. Frontal fluoroscopic image of
needle in the L4-5 foramen.
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Figure 6. Contrast spreading into the
regional anterior epidural space demon-
strating left L4-5 foraminal patency.
target-specific method is used for diag-
nostic as well as therapeutic purposes.
Additionally, Derby and col-
leagues30 demonstrated prognostic value
by reporting that patients not responding
to relief of radicular pain following trans-
foraminal injections were less likely to
benefit from surgical intervention. Riew
et al31 demonstrated that transforaminal
steroids, as opposed to local anesthetics
alone, may decrease the need for surgery,
ie, 67% of patients treated with trans-
foraminal local anesthetics alone required
an operation, but this rate was reduced to
29% when steroids were given.
Advanced Therapies
Spinal cord stimulation and intrathecal
therapy are advanced therapeutic
modalities used for treating patients with
chronic intractable pain. They are essen-
tially reserved for patients in whom con-
tinuing pain is not the symptom, but
rather the disease. Together, these
modalities consist of technology that is
considered “neuromodulatory.”
Neuromodulation is electric or chem-
ical alteration of the central nervous
system to significantly reduce chronic pain
or improve neurologic function by pre-
cise delivery of small doses of electricity or
drugs directly to targeted nerve sites.
Electricity to treat pain dates back
hundreds of years and was usually met
with considerable skepticism. However,
in 1967, Shealy and associates32 reintro-
duced the use of electricity in treatment
of patients in pain based on the Melzack
Boyajian • Using Image-Guided Techniques for Chronic Low Back Pain
and Walls publication of the gate control
theory.33
In the early 1970s, spinal cord stim-
ulation technology lost enthusiasm as
technical failures and poor patient selec-
tion resulted in limited success in treating
patients with chronic pain. During the
past 30 years, however, many well-con-
trolled studies have provided a substan-
tial level of clinical experience. Subse-
quently, more specific patient selection
criteria (Figure 7) and technologic changes
have resulted in successful utilization of
electricity in management of chronic
pain. Many common chronic pain con-
ditions such as chronic radiculopathy,
neuralgia, peripheral ischemia pain, and
phantom limb pain respond to electrical
neuromodulation (Figure 8).
Currently, the drugs approved by
the US Food and Drug Administration
for intrathecal use include morphine sul-
fate, baclofen, and, most recently,
ziconotide. Other drugs commonly
administered by physicians experienced
with this technology include other opi-
oids such as hydromorphone, as well as
agents such as bupivacaine and cloni-
dine hydrochloride. Intrathecal therapy
is used for malignant and nonmalignant
pain as well as for spasticity not relieved
with oral agents.
Systemic analgesics administered
either orally or transdermally, as well as
other conservative modes of therapy, are
usually effective in reducing symptoms
in most patients with malignant and in
those with nonmalignant pain. However,
for patients with chronic pain not
responding to more conventional treat-
ment modalities, intrathecal therapy may
be an option. It is reserved for those who
failed all of the more conservative
approaches, including systemic delivery
of analgesic medications such as the
many sustained-release opioids that are
now available. Intrathecal therapy is con-
sidered a last-resort therapy. When deliv-
ered intrathecally, opioids exert a potent
analgesic effect via spinal and
supraspinal receptors, without signifi-
cantly affecting motor, sensory, and sym-
pathetic reflexes.
The most recent advance in intra-
thecal therapy is the now marketed
ziconotide, a synthetic equivalent of a
conotoxin derived from a marine snail.

Checklist
䡺 All more conservative modes of
therapy have failed
䡺 Psychological evaluation and
clearance
䡺 Further surgical intervention not
indicated
䡺 Successful trial screening
䡺 No history of drug seeking,
habituation, or addiction
䡺 No contraindication to implant
exists
䡺 Pain complaint is consistent with
an observable pathologic process
Figure 7. Patient selection criteria for
advanced pain therapies.
Checklist
䡺 Failed back surgery syndrome
䡺 Arachnoiditis
䡺 Chronic radiculopathies
䡺 Neuralgias
䡺 Complex regional pain syndrome
䡺 Peripheral ischemia pain
䡺 Peripheral neuropathies
䡺 Postherpetic neuralgia
䡺 Phantom limb pain
Figure 8. Most common chronic pain condi-
tions that respond to spinal cord stimulation.
Ziconotide selectively and reversibly
blocks N-type voltage-sensitive calcium
channels, thereby inhibiting the release of
neurotransmitters from primary afferent
nociceptors located in the dorsal horn of
the spinal cord. Although slow titration
is required to minimize the occurrence of
adverse effects, tolerance to ziconotide
does not appear to develop. Early clinical
experience suggests that individual
response can differ markedly. 34
Ziconotide is currently not being used
as a first-line intrathecal medication.
Boyajian • Using Image-Guided Techniques for Chronic Low Back Pain
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Percutaneous Disk Decompression
A wide variety of new percutaneous pro-
cedures directed to the intervertebral disk
(eg, percutaneous endoscopic laser
diskectomy and percutaneous diskec-
tomy) has been developed to provide
patients with a minimally invasive pro-
cedure that may serve to avoid conven-
tional open surgical techniques. These
percutaneous techniques hold several
theoretical advantages over their more
aggressive surgical counterparts. How-
ever, widespread acceptance of these
newer modalities remains limited pri-
marily because of the lack of random-
ized controlled trials.
Case Presentations
Spinal injection procedures for LBP have
evolved from potentially therapeutic
blind epidural steroid injections to the
more current and precise image-guided
injections . Unlike blind injections, image-
guided spine injections are used for diag-
nostic as well as therapeutic purposes.
As a result of these more advanced treat-
ment and diagnostic interventions, there
has been a trend to initially refer patients
to an interventional pain management
specialist before consideration for
surgery.
The following anecdotal case
vignettes demonstrate how two of the
more common interventions are used in
the diagnosis and treatment of LBP.
Case Presentation 1
Jason, aged 34 years, sought treatment
because of a 4-week history of right-sided LBP
associated with pain and numbness into the
right lower extremity and foot. He said that
his symptoms began gradually with back pain
progressing to involve the right lower
extremity. He did not improve with 4 weeks
of rehabilitation. Jason had no history of
trauma or injury precipitating the onset of
symptoms. However, a similar episode of back
pain 3 years earlier occurred following an
altercation during his employment as an
inner-city police officer. He had no leg pain
associated with this prior episode, and the
back pain resolved completely after 3 weeks of
physical therapy.
On physical examination, range of
motion demonstrated marked decreased
flexion. Neurosensory evaluation revealed a
positive straight leg–raising test on the right
JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES7
and weakness in the right anterior tibialis
muscle group.
Magnetic resonance imaging (MRI)
revealed a small right foraminal disk hernia-
tion at L4-5 and a large right paracentral L5-
S1 herniation. Additionally, there was marked
decrease in lumbar lordosis.
Transforaminal injections on the right at
L4 and L5 were administered and revealed
foraminal patency at both levels as demon-
strated by contrast spread in the anteropos-
terior view. The lateral fluoroscopic image
demonstrated the needle tips in the superior
posterior aspects of the respective root canals.
Following a single transforaminal injec-
tion of both local anesthetic and corticosteroid,
Jason was 90% improved subjectively. Neu-
rosensory examination at follow-up demon-
strated a negative straight leg–raising test;
however, motor examination continued to
demonstrate slight weakness. Jason under-
went another 6 weeks of rehabilitation with
complete resolution of symptoms and normal
findings on neurologic examination.
Case Presentation 2
Lisa, aged 40 years, was referred by a spine
surgeon for a spinal diagnostics evaluation to
determine if she may benefit from spinal
fusion. She has a long history of LBP and
referred pain involving the lower extremi-
ties. The back pain is much more clinically sig-
nificant than the lower extremity symptoms.
Lisa had been employed as an executive
secretary, but due to an inability to sit for
longer than 10 minutes without severe back
pain, she stopped working 10 months before
evaluation via diskography. Two months of
physical therapy including aquatic rehabili-
tation failed to provide her with benefit. Lisa
had undergone several spinal injection pro-
cedures before evaluation via diskography;
however, these procedures failed to provide
her with any sustained benefit. Ibuprofen
gave her minimal relief.
Physical examination revealed moder-
ately decreased flexion and extension due to
pain. Lisa had moderate tenderness over the
L4 spinous process. Neurosensory testing
failed to reveal any focal deficits.
Magnetic resonance imaging demon-
strated decreased signal on the T2-weighted
sagittal images at L4-L5 and L5-S1, as well
as high-intensity zones at both levels. Axial
images demonstrated a right posterolateral
annular tear at L5-S1 and a midline posterior
annular tear at L4-5. Both levels also demon-
 strated small central disk herniations.
Lumbar disk stimulation (diskography)
was carried out using manometry to mea-
sure intradiskal pressures at L3-4, L4-5, and
L5-S1. The anteroposterior view showed con-
trast extending to the far right lateral annular
margin of the L4-5 disk. The lateral view
showed a normal L3-4 nucleogram. The L4-
5 nucleogram demonstrated a posterior
annular tear. No contrast was seen in the
L5-S1 disk. Postdiskography CT scanning
demonstrated a normal nucleogram at L3-4,
a right posterior lateral radial fissure at L4-5
which reproduced clinically significant back
and leg pain at low pressures, and diffuse
annular disruption at L5-S1 which also repro-
duced back and leg pain at moderately high
pressures.
Following diskography, Lisa was sent
back to her referring surgeon to discuss her
surgical options. Apart from any corrective
spine surgery, other options for treatment
would include a pharmacologic approach to
control the symptoms of pain with further
attempts at rehabilitation. Should these non-
surgical or surgical approaches fail, a trial of
spinal cord stimulation would be indicated.
Discussion
Divergent in the precise etiology of pain,
these two case studies demonstrate that
patterns of pain can be identical in their
clinical presentation yet originate from
entirely different and distinct sources.
When evaluating spine-related pain, it
is crucial to differentiate between somatic
versus radicular pain. This delineation
is critical in the application of appropriate
management and treatment modalities.
Stimulation of nerve endings in
muscle, bone, ligaments, or joints will
result in pain. Noxious stimulation of
one of these musculoskeletal structures
can result in somatic pain, which is typ-
ically described as deep, aching pain that
usually is diffuse and difficult to localize.
Often, pain originating in one of the
somatic sites can be referred or perceived
in regions relatively remote from its
origin. This is a common phenomenon in
patients presenting with low back pain
from stimulation of small nerve endings
that innervate intervertebral disks. These
patients frequently present with referred
pain into the lower extremity which is
clearly not radicular pain. Referred pain
can be explained on the neurophysio-
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logic basis of convergences. Nerves from
different sites converge in the dorsal horn
cells of the spinal cord, therefore ren-
dering the higher centers unable to dif-
ferentiate pain arising from anatomically
different locations.
Radicular pain arises from a chem-
ical or mechanical irritation of a spinal
nerve or root. While somatic pain is char-
acteristically difficult to localize, radic-
ular pain is typically shooting and may
follow a dermatomal distribution; her-
niation of an intervertebral disk is the
most common cause.
The two cases presented here rep-
resent the more classic clinical presenta-
tion for radicular pain and for diskogenic
pain, respectively. Typically, the clinical
presentation may not be accompanied
with positive neurologic findings or
imaging techniques that demonstrate an
obvious disk herniation compressing an
exiting nerve root or a high-intensity zone
on the T2-weighted sagittal MRI images
that is diagnostic of painful internal disk
disruption. 35 The important role of
image-guided spine intervention for
diagnostic and therapeutic purposes is
further emphasized by the interventional
pain medicine specialty designation by
Medicare.
Comment
Low back pain usually is self-limiting,
but when it persists and is unresponsive
to rehabilitation and analgesics, precise
determination of the source of pain
becomes key to planning proper treat-
ment. Patients with LBP may demon-
strate varied clinical scenarios, none of
which, unfortunately, helps in deter-
mining the exact source of the pain. A
precise spinal diagnostic evaluation can
identify the correct anatomic site of such
discomfort in most patients. An epidural
steroid injection is one of many tools
used by interventional pain management
physicians. Use of image-guided proce-
dures and contrast medium affords pain
management physicians a methodology
for precision diagnostics.
When patients visit their primary
care physician with a complaint of LBP
and they have no response to conserva-
tive treatment such as analgesics and
physical therapy, it would be appropriate
to obtain MRI scans and refer these
Boyajian • Using Image-Guided Techniques for Chronic Low Back Pain
patients to a pain management physi-
cian. The interventional pain specialist
will be able to precisely diagnose the eti-
ology of the pain and determine whether
further rehabilitation, therapeutic injec-
tions, or a surgical evaluation would be
prudent.
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JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES9