title: Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test The Value of Medical History and Physical Examination in Diagnosing Sacroiliac Joint Pain Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain Clinical predictors of screening lumbar zygapophyseal joint blocks: development of clinical prediction rules. Diagnosis of Symptomatic Disc by Magnetic Resonance Imaging: T2-Weighted and Gadolinium-DTPA-Enhanced T1-Weighted Magnetic Resonance Imaging Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? Capacity of the Clinical Picture to Characterize Low Back Pain Relieved by Facet Joint Anesthesia: Proposed Criteria to Identify Patients With Painful Facet Joints Clinical Features of Patients with Pain Stemming from the Lumbar Zygapophysial Joints: Is the Lumbar Facet Syndrome a Clinical Entity? Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source Painful Lumbar Disk Derangement: Relevance of Endplate Abnormalities at MR Imaging. A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography The Use of a Classification Approach to Identify Subgroups of Patients With Acute Low Back Pain: Interrater Reliability and Short-Term Treatment Outcomes Vibration pain provocation can improve the specificity of MRI in the diagnosis of symptomatic lumbar disc rupture. The Outcome of Posterolateral Fusion in Highly Selected Patients With Discogenic Low Back Pain Prevalence of lumbar facet joint pain in chronic low back pain. Provocative discography in volunteer subjects with mild persistent low back pain. The Value of Radionuclide Imaging in the Diagnosis of Sacroiliac Joint Syndrome A Prospective Study of Centralization of Lumbar and Referred Pain: A Predictor of Symptomatic Discs and Anular Competence Endplate Degeneration Observed on Magnetic Resonance Imaging of the Lumbar Spine: Correlation with Pain Provocation and Disc Changes Observed on Computed Tomography Diskography Correlation of clinical examination characteristics with three sources of chronic low back pain. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power.
abstract: Background Only controlled blocks are capable of confirming the zygapophysial joints ( ZJ ) as the pain generator in LBP patients . However , previous workers have found that a cluster of clinical signs ( " Revel 's criteria ") , may be valuable in predicting the results of an initial screening ZJ block . It was suggested that these clinical findings are unsuitable for diagnosis , but may be of value in selecting patients for diagnostic blocks of the lumbar ZJ 's . To constitute evidence in favour of a clinical management strategy , these results need confirmation . This study evaluates the utility of ' Revel 's criteria ' as a screening tool for selection of chronic low back pain patients for controlled ZJ diagnostic blocks . Methods This study utilized a prospect i ve blinded concurrent reference st and ard related validity design . Consecutive chronic LBP patients completed pain drawings , psychosocial distress and disability question  naires  , received a clinical examination and lumbar zygapophysial blocks . Two reference st and ards were evaluated simultaneously : 1 . 75 % reduction of pain on a visual analogue scale ( replication of previous work ) , and 2 . abolition of the dominant or primary pain . Using " Revel 's criteria " as predictors , logistic regression analyses were used to test the model . Estimates of sensitivity , specificity , predictive values and likelihood ratios for selected variables were calculated for the two proposed clinical strategies . Results Earlier results were not replicated . Sensitivity of " Revel 's criteria " was low sensitivity ( < 17 % ) , and specificity high ( approximately 90 % ) . Absence of pain with cough or sneeze just reached significance ( p = 0.05 ) within one model . Conclusions " Revel 's criteria " are unsuitable as a clinical screening test to select chronic LBP patients for initial ZJ blocks . However , the criteria may have use in identifying a small subset ( 11 % ) of patients likely to respond to the initial block ( specificity 93 % ) Study Design This prospect i ve study evaluated the diagnostic utility of historically accepted sacroiliac joint tests . A multidisciplinary expert panel recommended 12 of the “ best ” sacroiliac joint tests to be evaluated against a criterion st and ard of unequivocal pain relief after an intra‐articular injection of local anesthetic into the sacroiliac joint . Objectives To identify a single sacroiliac joint test or ensemble of tests that are sufficiently useful in diagnosing sacroiliac joint disorders to be clinical ly valuable . Summary of Background Data No previous research has been done to evaluate any physical test of sacroiliac joint pain against an accepted criterion st and ard . Methods Historical data was obtained , and the 12 tests were performed by two examiners on 85 patients who subsequently underwent sacroiliac joint blocks .  Ninety percent or more relief was considered a positive response , and less then 90 % relief was considered a negative response . Results There were 45 positive and 40 negative responses . No historical feature , none of the 12 sacroiliac joint tests , and no ensemble of these 12 tests demonstrated worthwhile diagnostic value . Conclusion Sacroiliac joint pain is resistant to identification by the historical and physical examination data from tests evaluated in this study Abstract A prospect i ve study was performed to compare the results of quantitative radionuclide bone scanning with those of sacroiliac joint anesthetic block in patients with unilateral low back pain . Thirty-four subjects , forming the control group , underwent quantitative radionuclide bone scanning of the sacroiliac joints . The normal values in sacroiliac uptake difference were taken to be between –1.7 % and + 6.2 % . Thirty-two patients with chronic unilateral low back pain underwent sacroiliac bone scanning and sacroiliac joint block . Six of the seven patients with increased uptake > 6.2 % on the painful side had at least 75 % pain reduction in response to the block . The sensitivity , specificity , and positive and negative predictive values of the quantitative bone scanning in the unilateral mechanical sacroiliac joint syndrome were 46.1 % , 89.5 % , 85.7 % , and 72 % , respectively BACKGROUND Only controlled intra-articular zygapophyseal joint ( ZJ ) injections or medial branch blocks can diagnose ZJ-mediated low back pain . The low prevalence of ZJ pain implies that identification of clinical predictors of a positive response to a screening block is needed . PURPOSE To estimate the predictive power of clinical findings in relation to pain reduction after screening ZJ blocks . STUDY DESIGN As part of a wider prospect i ve blinded study investigating diagnostic accuracy of clinical variables , a secondary analysis was carried out to seek evidence of variables potentially valuable as predictors of screening ZJ block outcomes . PATIENT SAMPLE Chronic low back pain patients received screening ZJ blocks ( n=151 ) with 120 patients included in the analysis after exclusions . OUTCOME MEASURES Pain intensity was measured using a 100-mm visual analog scale , and responses were categorized according to 75 % through 95 % or more pain reduction in 5 % increments . METHODS Patients completed pain drawings , question naires , and a clinical examination before screening lumbar ZJ blocks . History , demographic and clinical variables were evaluated in cross tabulation and regression analyses with diagnostic accuracy values calculated for variables and variable clusters in relation to different pain reduction st and ards . RESULTS At the 75 % pain reduction st and ard , 24.5 % responded to screening ZJ blocks and 10.8 % responded at the 95 % st and ard . The central ization phenomenon is not associated with pain reduction using any st and ard . No variables were useful predictors of post-ZJ block pain reduction of less than 90 % . Seven clinical findings were associated with 95 % pain reduction after blocks . Five useful clinical prediction rules ( CPRs ) were found for ruling out a 95 % pain reduction ( 100 % sensitivity ) , and one CPR had a likelihood ratio of 9.7 , producing a fivefold improvement in posttest probability . CONCLUSIONS A negative extension rotation test , the central ization phenomenon , and four CPRs effectively rule out pain ablation after screening ZJ block . One CPR generates a fivefold improvement in posttest probability of a negative or positive response to ZJ block Although radial tear of the annulus fibrosus can be detected on T2-weighted and Gd-DTPA-enhanced magnetic resonance ( MR ) images , the association between the annular tear on MR images and the symptomatic discs is unclear . The purpose of this study was to investigate the relationship between T2-weighted , gadolinium-DTPA-enhanced MR images and pain response through discography in patients with chronic low back pain . A total of 56 lumbar discs from 23 patients with chronic low back pain ( 13 to 47 years old ) underwent MR imaging ( T2-weighted , gadolinium-DTPA-enhanced MR images ) followed by provocative discography . The sensitivity , specificity , positive predictive value , and negative predictive value of T2-weighted and gadolinium-DTPA-enhanced MR images in detecting the symptomatic discs were calculated . The sensitivity , specificity , positive predictive value , and negative predictive value of T2-weighted images in detecting the symptomatic disc were 94 % , 71 % , 59 % , and 97 % , respectively . The sensitivity , specificity , positive predictive value , and negative predictive value of gadolinium-DTPA-enhanced images were 71 % , 75 % , 56 % , and 86 % , respectively . The high sensitivity and the high negative predictive value of T2-weighted MR imaging in detecting the symptomatic disc indicated that MR imaging can be a useful screening tool in avoiding unnecessary discography in patients with chronic low back pain Previous research indicates that physical examination can not diagnose sacroiliac joint ( SIJ ) pathology . Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability . This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations , in relation to an accepted criterion st and ard . In a blinded criterion-related validity design , 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ .  The tests were evaluated singly and in various combinations ( composites ) for diagnostic power . All patients with a positive response to diagnostic injection reported pain with at least one SIJ test . Sensitivity and specificity for three or more of six positive SIJ tests were 94 % and 78 % , respectively . Receiver operator characteristic curves and areas under the curve were constructed for various composites . The greatest area under the curve for any two of the best four tests was 0.842 . In conclusion , composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ . Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections . When all six provocation tests do not provoke familiar pain , the SIJ can be ruled out as a source of current LBP OBJECTIVE To compare the diagnostic accuracy of a multitest regimen of 5 sacroiliac joint ( SIJ ) pain provocation tests with fluoroscopically controlled double SIJ blocks using a short- and long-acting local anesthetic in order to reduce the exposure of patients to unnecessary invasive SIJ procedures . DESIGN Prospect i ve , observational study . SETTING Hospital setting . PARTICIPANTS Sixty patients with chronic low back pain . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Visual analog scale score and receiver operating characteristic ( ROC ) curve . RESULTS Twenty-seven patients responded positively to the blocks , of whom 23 were found positive after the multitest regimen and 4 were negative . For the nonresponders ( n=33 ) , these figures were 7 positive and 26 negative . The calculated sensitivity and specificity were .85 ( 95 % confidence interval [ CI ] , .72-.99 ) and .79 ( 95 % CI , .65-.93 ) , respectively . Positive and negative predictive values were .77 ( 95 % CI , .62-.92 ) and .87 ( 95 % CI , .74-.99 ) , respectively . The positive likelihood ratio was 4.02 ( 95 % CI , 2.04 - 7.89 ) ; the negative likelihood ratio was .19 ( 95 % CI , .07-.47 ) . The area under the ROC curve was .799 . CONCLUSIONS The test regimen with 3 or more positive tests is indicative of SIJ pain . It can be used in early clinical decision making to reduce the number of unnecessary minimally invasive diagnostic SIJ procedures BACKGROUND CONTEXT Lumbar discography has been widely used for evaluating discogenic low back pain ( LBP ) . Comparison of pain responses from suspected symptomatic discs with pain responses from asymptomatic negative discs is routine . However , the ability of discography to distinguish asymptomatic morphologically abnormal discs from those that are symptomatic has been understudied . In addition , the discographic characteristics of negative discs in patients with chronic discogenic LBP have not been reported . Criteria for negative morphologically abnormal discs may be valuable for excluding discs from further treatment and examination . PURPOSE To determine if discography can distinguish asymptomatic discs among morphologically abnormal discs in patients with suspected chronic discogenic LBP and establish the st and ard characteristics of negative discs . STUDY DESIGN / SETTING Prospect i ve , experimental with control group . PATIENT SAMPLE Fifty-five discs from a control group of 16 healthy volunteers without current back pain ( 11 men , 5 women , 32 - 61 years of age , mean age : 47 years ) and 282 discs from a patient group of 90 LBP patients ( 59 men , 31 women , 20 - 70 years of age , mean age : 44.7 years ) were recruited . METHODS Discography was performed using a pressure-controlled manometric technique with an injection rate of 0.05 mL/s and a 3.5 mL restricted total volume . Concordance was rated as none/unfamiliar , or familiar . Pain was rated via a 0 - 10 numerical rating scale ( NRS ) . The pressure and volume at which pain was evoked and NRS pain responses at 15 , 30 , and 50 psi were recorded . Annular disruption grade was rated during the procedure by computed tomography discography and fluoroscopic imaging . Negative discogram required no pain described by the participant as " familiar , " with no pain responses > or=6/10 NRS at pressures < or=50 psi above opening pressure and < or=3.5 mL total injected volume . Patient discs were partitioned into two subgroups based on discographic findings : Neg-D ( negative discs ) and Pos-D ( positive discs ) . Only discs with Grade 3 annular tears ( Dallas Discogram Scale ) were included in the study . RESULTS Among 55 asymptomatic control group discs , 32 ( 58.2 % ) exhibited Grade 3 annular tear . All discs in the asymptomatic control group satisfied negative response criteria . Among 282 patient group discs , 199 ( 70.6 % ) exhibited Grade 3 annular tear . Of 199 discs with Grade 3 annular tears , 104 ( 52.3 % ) satisfied negative response criteria and were categorized as the Neg-D group . The other 95 discs were categorized as a Pos-D group . Patients showed significantly lower pain tolerance relative to control subjects ( p<.05 ) . The control and Neg-D groups showed similar pressures and volumes at which pain was initially evoked . Mean control group pain scores were 0.47 NRS at 15 psi and 1.58 NRS at 50 psi . Mean Neg-D group pain scores were 0.11 NRS at 15 psi and 1.1 NRS at 50 psi . Discographic findings for the Pos-D group were significantly different from those of the control and Neg-D groups ( p<.001 ) . CONCLUSIONS Pain tolerance was significantly lower in patients relative to asymptomatic subjects . Negative patient discs and asymptomatic subject discs showed similar characteristics . Pressure-controlled manometric discography using strict criteria may distinguish asymptomatic discs among morphologically abnormal discs with Grade 3 annular tears in patients with suspected chronic discogenic LBP Study Design . Prospect i ve r and omized study to compare the efficacy of facet joint injection with lidocaine and facet joint injection with saline in two groups of patients with low back pain , with and without clinical criteria that were determined in a previous study to implicate the facet joint as the primary source of the pain . Objectives . To assess the efficacy of single facet joint anesthesia versus placebo ( saline injections ) and to determine clinical criteria that are predictive of significant relief of LBP after injection . Summary of Background Data . There is no syndrome that discriminates between lower back pain caused by facet joint and that caused by other structures . Single or double facet joint anesthesia , and single photon emission computed tomography are expensive and time‐consuming procedures for selecting patients in controlled clinical trials with large population s. Methods . Results of a previous study showed that seven clinical characteristics were more frequent in patients who responded to facet joint anesthesia than in those who did not . In the current study , a group of 43 patients with lower back pain who met at least five criteria were compared with 37 patients who met fewer criteria . Patients r and omly received injection of either lidocaine or saline into the lower facet joints . The result was considered positive if more than 75 % pain relief was determined by visual analog scale . The patient , the radiologist , and the investigator were blinded . An analysis of variance was used to seek an interaction between clinical group effect and injection effect , and logistic regression analysis to select the best set of variables that would be predictive of minimum pain relief of 75 % after the injection . Results . There was a significant interaction between clinical group and injection effect ( P= 0.003 ) . In patients with back pain , lidocaine  provided greater lower‐back pain relief than saline ( P = 0.01 ) . Lidocaine also‐provided greater pain relief in the back pain group than in the the nonpain group ( P = 0.02 ) . The presence of five among seven variables ( age greater than 65 years and pain that was not exacerbated by coughing , not worsened by hyperextension , not worsened by forward flexion , not worsened when rising from flexion , not worsened by extension‐rotation , and well‐relieved by recumbency ) , always including the last item , distinquished 92 % of patients responding to lidocaine injection and 80 % of those not responding in the lidocaine group . Conclusions . A set of five clinical characteristics can be used in r and omized studies to select lower back pain that will be well relieved by facet joint anesthesia . These characteristics should not , however , be considered as definite diagnostic criteria of lower back pain originating from facet joints Study Design This study is a prospect i ve cross-sectional analytic study . Objectives The authors determined the prevalence and clinical features of patients with pain stemming from the lumbar zygapophysial joints . Summary of Background Data Previous studies have demonstrated a wide range of prevalence for zygapophysial joint pain and conflicting results with regard to clinical signs . Methods One hundred and seventy-six consecutive patients with chronic low back pain were investigated with a series of screening zygapophysial joint blocks using lignocaine and confirmatory blocks using bupivacaine . Results Forty-seven percent of patients had a definite or greater response to the screening injection at one or more levels but only 15 % had a 50 % or greater response to a confirmatory block . Response to zygapophysial joint injection was not associated with any single clinical feature or set of clinical features . Conclusions The zygapophysial joint is an important source of pain but the existence of a “ facet syndrome ” must be question ed Abstract Disagreement still exists in the literature as to the significance of the high-intensity zone ( HIZ ) demonstrated on magnetic resonance imaging ( MRI ) as a potential pain ¶indicator in patients with low back pain . A prospect i ve blind study was therefore conducted to evaluate the lumbar disc high-intensity zone with the pain provocation response of lumbar discography . Consecutive patients with low back pain unresponsive to conservative treatment and being considered for spinal fusion were subjected to MRI followed by lumbar discography as a pre-operative assessment . The discographer was blinded to the results of the MRI scans . We used the chi-squared test to analyse our results . Ninety-two HIZs were identified in 73 patients , mainly occurring at L4/5 ( 48 % ) and L5/S1 ( 35 % ) . Significant correlation was found between abnormal disc morphology and the HIZ ( P < 0.001 ) . In morphologically abnormal discs ( grade s 3 , 4 and 5 ) , there was a significant correlation between the HIZ and exact or similar pain reproduction ( P < 0.001 ) . The sensitivity , specificity and positive predictive value for pain reproduction were high , at 81 % , 79 % and 87 % respectively . The nature of the HIZ remains unknown , but it may represent an area of secondary inflammation as a result of an annular tear . We conclude from our study that the lumbar disc HIZ observed on MRI in patients with low back pain is likely to represent painful internal disc disruption PURPOSE To investigate the predictive value of magnetic resonance ( MR ) imaging of abnormalities of the lumbar intervertebral disks , particularly with adjacent endplate changes , to predict symptomatic disk derangement , with discography as the st and ard . MATERIAL S AND METHODS Fifty patients aged 28 - 50 years with chronic low back pain and without radicular leg pain underwent prospect i ve clinical examination and sagittal T1- and T2-weighted and transverse T2-weighted MR imaging . Subsequently , patients underwent lumbar discography with a pain provocation test ( 116 disks ) . MR images were evaluated for disk degeneration , a high-signal-intensity zone , and endplate abnormalities . Results of pain provocation at discography were rated independently of the image findings as concordant or as nonconcordant or painless . Sensitivity , specificity , positive predictive value ( PPV ) , and negative predictive value ( NPV ) were calculated to assess the clinical relevance of MR abnormalities . RESULTS Normal disks on MR images were generally not painful at provocative discography ( NPV , 98 % ) . Disk degeneration ( sensitivity , 98 % ; specificity , 59 % ; PPV , 63 % ) and a high-signal-intensity zone ( sensitivity , 27 % ; specificity , 85 % ; PPV , 56 % ) were not helpful in the identification of symptomatic disk derangement . When only moderate and severe type I and type II endplate abnormalities were considered abnormal , all injected disks caused concordant pain with provocation ( sensitivity , 38 % ; specificity , 100 % ; PPV , 100 % ) . CONCLUSION Moderate and severe endplate abnormalities appear be useful in the prediction of painful disk derangement in patients with symptomatic low back pain Study Design . This is a prospect i ve study of the validity of a positive test result in provocative lumbar discography for the diagnosis of “ discogenic pain . ” Objective . To investigate the hypothesis that provocative discography by strict criteria accurately identifies a low back pain illness due to a primary disc lesion . Summary and Background Data . According to the Sackett and Haynes criteria for establishing diagnostic test validity , no test without a gold st and ard external st and ard can be meaningfully applied . Provocative discography as a test for determining “ discogenic pain ” has , to date , not been compared against a gold st and ard . Absent a gold st and ard reference , there can be no validity assessment or systematic improvement of test accuracy . This is the first study to apply an external gold st and ard evaluation of the diagnostic validity of discography in any manner . Methods . Over a 5-year period using a strict enrollment protocol , 32 patients with low back pain and a positive single-level low-pressure provocative discogram , underwent spinal fusion . Subjects with known patient selection comorbidities were excluded . Generic surgical limitations /morbidity were controlled by comparison to the clinical outcomes of a strictly-matched cohort of 34 patients having a well-accepted single-level lumbar pathology ( unstable spondylolisthesis ) . Treatment success was compared between groups . Results . In the control-spondylolisthesis group , 23 of 32 patients ( 72 % ) met the highly effective success criteria compared with 8 of 30 in the presumed discogenic pain cohort ( 27 % ) . The proportion of patients who met the “ minimal acceptable outcome ” was 29 of 32 ( 91 % ) in the spondylolisthesis group and 13 of 30 ( 43 % ) in the presumed discogenic pain group . Adjusting for surgical morbidity and dropout failure , by either criteria of success , the best-case positive predictive value of discography was calculated to be 50 % to 60 % . Conclusions . Positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness in this first study comparing discography results to a gold st and ard Study Design . A prospect i ve , consecutive , cohort study of patients with acute low back pain classified into subgroups based on examination data and treated with a specific treatment approach . Objective . To calculate the interrater reliability of a classification system , and to compare initial patient characteristics and outcomes of physical therapy treatment when a classification approach is used . Summary of Background Data . Classification of patients with low back pain into homogeneous subgroups has been identified as a research priority . Identifying relevant subgroups of patients could improve clinical outcomes and research efficiency . Methods . Consecutive patients referred to physical therapy for treatment of acute low back pain were evaluated and classified into one of four subgroups ( immobilization , mobilization , specific exercise , or traction ) before treatment . Physical therapy treatment was based on the patient ’s classification . The classifications were compared for initial patient characteristics , frequency and duration of physical therapy , and improvement in Oswestry scores . Results . In this study , 120 patients were evaluated and classified . Analysis of interrater reliability showed a kappa value of 0.56 . Differences were found among the classifications for age , initial Oswestry score , history of low back pain , symptom distribution , and average change in Oswestry score with treatment . Conclusions . Reaching a consensus regarding relevant patient subgroups requires data on the reliability and validity of existing classification systems . Further work is required to vali date improvement in treatment outcomes using a classification approach OBJECTIVE The purpose of this study was to determine if vibration pain provocation could be combined with magnetic resonance imaging ( MRI ) to increase its specificity in identifying symptomatic disc disruption identified by discography . DESIGN Prospect i ve single-blind study . SETTING Data were collected at a spine specialty clinic and at a diagnostic imaging center . PATIENTS A total of 206 discs in 78 patients ( 41 males , 37 females ; average age , 39.7 years ; range , 18 - 73 years ) were evaluated by MRI , spinous process vibration , and discography . INTERVENTIONS A h and -held prototype vibrator was applied to the spinous process of each intervertebral disc level to be evaluated . The type of pain provoked with vibration as well as with discography was recorded as painless , dissimilar to clinical pain , or similar/exact reproduction of clinical pain . The discograms and MRI scans were scored on a 0 - 4 scale . A system was defined for combining the vibration results with MRI . OUTCOME MEASURES The results of the vibration and MRI were compared with the results of computed tomography/discography to determine how well the results of the evaluations agreed . RESULTS Vibration pain provocation agreed with discographic pain provocation in 70.9 % of the discs . The specificity of MRI  compared with discographic findings was only 55.7 % . However , this figure improved significantly to 81.3 % when relying on the vibration pain provocation in discs with mild or moderate disruption . The sensitivity of the combined evaluation was 85.9 % and the accuracy 83.0 % . CONCLUSIONS A small h and -held vibrator could produce pain provocation results similar to those obtained by discography . Results of this noninvasive pain provocation method can improve the specificity and accuracy of MRI  in identifying symptomatic disc lesions Study Design A prospect i ve analysis of the clinical outcome of a consecutive series of patients treated with posterior lumbar arthrodesis .  Preoperative data were collected retrospectively by chart review . Objectives To measure by independent review the clinical outcome of posterolateral intertransverse fusion as a treatment for discogenic low back pain in a highly selected group of patients . Summary of Background Data Although numerous studies have reported on the surgical management of degenerative disc disease , they have been difficult to interpret because they lack patient‐oriented outcome assessment and objective pain measurement criteria , independent review , and include patients with diagnoses other than degenerative disc disease . Methods Between 1991 and February 1993 all patients seen by a single surgeon , evaluated with magnetic resonance imaging and discography , and treated with posterolateral lumbar fusion were review ed by independent investigation . Outcome was assessed in the areas of radiographic fusion , pain , function , and patient satisfaction . Results Twenty‐three patients ( 12 women , 11 men ; 100 % follow‐up an average of 47 months after surgery [ range , 24–84 months ] ) met the inclusion criteria . Overall , 39 % had a good or excellent result , 13 % fair , and 48 % poor . Nine of 10 patients receiving worker 's compensation had a poor result ; four of five patients with radiographic pseudarthrosis  had a poor result . Statistically significant improvement in the visual analogue scale was noted in the good and excellent group ( P = 0.0001 ) and the fair group ( P = 0.002 ) with no change in the poor group . Patients out of work more than 3 months before surgery tended to have poor results . Overall , 56 % of patients were extremely satisfied with the result of their surgery . Conclusion Posterolateral intertransverse fusion can be used to successfully manage chronic discogenic back pain . However , patient selection remains a challenge , and successful outcome appears to be limited in the subset of patients receiving worker 's compensation and those chronically disabled . Prospect i ve and r and omized study with objective pain criteria , independent review , and patient‐oriented outcome is recommended This prospect i ve study was design ed to determine the prevalence of lumbar facet joint pain in a consecutive series of patients with chronic low back pain treated at an interventional , multidisciplinary private pain management practice utilizing double diagnostic blocks , to determine the prevalence of false positive rate of uncontrolled facet joint blocks , and to determine the relationship of clinical features of responders and non-responders to double diagnostic blocks . One hundred and twenty patients with low back pain with or without lower extremity pain were selected . The procedure consisted of diagnostic blocks using lidocaine and bupivacaine on separate occasions , usually two weeks apart . Each facet joint nerve was infiltrated with either 0.4 to 0.6 ml of 1 % lidocaine ( Xylocaine(R ) ) or 1 % lidocaine ( Xylocaine(R ) ) and 0.25 % bupivacaine ( Marcaine(R ) ) . A definite response was defined as substantial with at least 75 % relief of pain in the symptomatic area following local anesthetic block . Confirmatory blocks using bupivacaine 0.25 % were performed at the same levels as the first injection if definite relief was obtained . The response to bupivacaine blocks which lasted longer than the lidocaine blocks was accepted as a positive response . All blocks were performed under fluoroscopic guidance . Eighty-one patients ( 67.5 % ) reported a definite response to lidocaine blocks . Confirmatory blocks with bupivacaine were performed in all 81 patients with 54 patients , i.e. 45 % of total sample or 66.6 % of lidocaine positive group reporting definite response with a false positive rate of 41 % . Prevalence and relationship of pain referral pattern in patients with and without facet joint pain confirmed by double blocks showed no significant correlation . We found no relationship between the history , physical findings , age , gender , trauma , duration of pain , and diagnostic blocks . However , history of previous surgery showed a negative correlation as only 29 % of the patients after previous surgery were positive in contrast to 51 % of the nonsurgical population . The results of this study echo previous concerns of reliability of uncontrolled single blocks , history , and clinical features . This study demonstrated that the facet joint is a source of pain in 45 % of the patients suffering with chronic low back pain in an interventional pain management setting in a private practice BACKGROUND CONTEXT Whether discographic injections would be positive in subjects with benign persistent " backache " who are not seeking treatment is unknown . This information is important , because benign backache undoubtedly co-exists in patients with chronic low back pain ( CLBP ) illness that is not discogenicin origin . If these subjects had a high rate of positive discography , the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness . Conversely , if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections , the basic tenet of discographic diagnosis would be strengthened . PURPOSE To compare , using a strict experimental design , the relative pain and concordancy response to provocative discography in subjects with clinical ly insignificant " backache " and clinical subjects with CLBP illness considering surgical treatment . STUDY DESIGN Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain ( CLBP ) illness . PATIENT SAMPLE Twenty-five subjects with mild persistent low back pain ( LBP ) were recruited for an experimental discography study . Subjects were recruited from a clinical study of patients having had cervical spine surgery . Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP , be taking no medications for backache , have no activity restrictions because of LBP , and have normal psychometric scores . To more closely approximate the pain behavior in CLBP illness , 50 % ( 12 ) of the " backache " group were recruited with a chronic painful condition ( neck/shoulder ) unrelated to the low back . CLBP subjects , patients coming to discography for consideration of surgical treatment , were used as control subjects . OUTCOME MEASURES Results of discography were determined using the criteria of Walsh et al. : pain response of 3 or greater , two or more pain behaviors , a negative " control " discographic injection , and a similar or exact concordancy rating . METHODS Discography was performed on experimental subjects and control patients . Experienced raters , who were blinded to control versus experimental status of the subjects , scored the magnetic resonance image , discogram , psychometric tests and discography videotapes of the subjects ' pain behavior . RESULTS Thirteen of 25 volunteer subjects had pain rated as " bad " or worse with disc injection . There were 12 painful and fully concordant disc injections in 9 of these 25 " backache " subjects ( 36 % ) . These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain . All positive discs had annular disruption to or through the outer annulus . Of the 9 subjects with positive discograms , 3 had no chronic pain states and 6 did . All subjects with positive injections had negative control discs . In comparison , in 52 subjects with CLBP illness 38 ( 73 % ) had at least one positive disc injection . CONCLUSIONS In a group of volunteer subjects with persistent " backache , " 36 % were found to have significant pain on disc injection , which is reported to be concordant with their usual pain . The presence of positive concordant pain responses and negative control discs in 33 % of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinical ly relevant spinal pathology Study Design A prospect i ve study was done to assess the diagnostic value of radionuclide imaging ( bone scan ) in the evaluation of sacroiliac joint syndrome . Objectives To determine the sensitivity and specificity of radionuclide imaging in establishing a diagnosis of sacroiliac joint syndrome in patients with low back pain . Summary of Background Data There is no pathognomonic symptom or sign to establish the diagnosis of sacroiliac joint syndrome . It has been accepted that confirmation of sacroiliac joint syndrome requires relief of pain , a positive response to a sacroiliac joint block . Bone scanning has been proposed as a useful imaging technique to evaluate for sacroiliac joint syndrome . The authors explored the use of nuclear imaging as a cost‐effective and noninvasive technique in the diagnostic algorithm of sacroiliac joint syndrome . Methods Patients presenting to the author 's Spine Center with complaints of low back pain including the region of the sacral sulcus were screened for inclusion into this study . Positive response to three provocative sacroiliac joint maneuvers was requisite , two of which had to be Patrick 's test and pain with palpation over the sacral sulcus . Patients who met these criteria were entered into a physical therapy program comprised of lumbar spine stabilization techniques and excluded any interventions considered specific for sacroiliac joint syndrome . Those whose symptoms failed to improve with this program underwent bone scan and fluoroscopically guided sacroiliac joint block . Response to sacroiliac joint block was assessed with pre‐ and post‐block visual analog scale scores completed by the patient . A reduction of the VAS rating by at least 80 % was considered a positive response to sacroiliac joint block . Results Fifty consecutive patients met the author 's criteria and underwent bone scan and sacroiliac joint block . Thirty‐one patients who had positive responses to sacroiliac joint block comprised the positive sacroiliac joint block group . Nineteen patients had less than 80 % pain reduction with sacroiliac joint block and were labeled the negative sacroiliac joint block group . Four patients had positive bone scans , all of whom were in the positive sacroiliac joint group . Conclusions The results demonstrated very low sensitivity and high specificity of nuclear imaging in the evaluation of sacroiliac joint syndrome . The authors do not recommend bone scan in the diagnostic algorithm for sacroiliac joint syndrome Study Design . The presence or absence of rapidly central izing , peripheralizing , or abolishing low  back and radiating pain , as identified during a McKenzie mechanical lumbar assessment of patients with chronic lumbar pain , was compared prospect ively with discographic pain provocation and anular competency . Objectives . To evaluate any relation between the responses of central ization and peripheralization with discographic findings . Summary of Background Data . Central ization of referred pain has been reported as a very common occurrence during McKenzie assessment and treatment . Patients whose pain central izes have been shown to achieve superior treatment outcomes . A dynamic internal disc model has been hypothesized as an underlying mechanism for central ization that has not been studied previously . Methods . Patients with chronically disabling low back pain who were referred for discography underwent preliminary blinded McKenzie clinical assessment and were categorized into three groups by their pain response . Patterns , or lack thereof , of pain response were then compared with blinded discographic pain provocation and anular findings . Results . During the McKenzie assessment , the referred pain of 50 % central ized with 74 % having positive discograms , of which 91 % had an intact anulus . The pain of 25 % peripheralized only ( would not central ize ) ; 69 % of these had positive discograms , but only 54 % had an intact anulus . The distal pain of 25 % did not respond at all , and only 12.5 % of these had positive discograms . Conclusion . The McKenzie assessment process reliably differentiated discogenic from nondiscogenic pain ( P < 0.001 ) as well as competent from an incompetent anulus ( P < 0.042 ) in symptomatic discs and was superior to magnetic resonance imaging in distinguishing painful from nonpainful discs Study Design . One hundred and three lumbar intervertebral discs ( L3/4-L5/S1 ) of 36 patients with low back pain were examined with computed tomography ( CT ) diskography and magnetic resonance imaging ( MRI ) . Objectives . To determine whether lumbar endplate degeneration correlates with the degree of disc degeneration or disc rupture and to determine if there is an association between pain provocation during diskography and lumbar endplate degeneration . Summary of Background Data . There have been numerous attempts to explain the pathogenesis of pain provocation during diskography , but the possibility of endplate degeneration as a source of pain has not been widely assessed . Methods . One hundred and three lumbar intervertebral discs ( 36 L3/4 , 36 L4/5 , and 31 L5/S1 intervertebral discs ) of 36 patients were examined . On the basis of MRI , the intervertebral discs were divided into four categories based on the degree of endplate degeneration . Based on pain provocation on diskography , the intervertebral discs were divided into three categories : no pain , indifferent/untypical pain , and familiar/typical pain . Based on disc degeneration and disc rupture , the intervertebral discs were divided into four categories in accordance with the Dallas Discogram Description : Grade s 0–3 of both degeneration and rupture . Results . There was a positive correlation between endplate degeneration and disc degeneration and a positive correlation between disc rupture and pain provocation , but there was no association between endplate degeneration and disc rupture and no correlation between endplate degeneration and pain provocation on diskography . Conclusions . This study showed a stronger association between endplate degeneration and disc degeneration than between endplate degeneration and disc rupture . The results indicate that the contrast injection during diskography reflects mainly pain of discogenic origin , whereas the possible pain associated with endplate damage can not be depicted by CT diskography BACKGROUND CONTEXT Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac ( SI ) joint sources of pain . No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated . PURPOSE To identify significant components of a clinical examination that are associated with symptomatic lumbar discs , zygapophysial joints and SI joints . STUDY DESIGN A prospect i ve , criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics . PATIENT SAMPLE The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections .  OUTCOME MEASURES Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections . Statistical analysis included chi-squared test for independence , phi and odds ratios with confidence intervals . METHOD Patients received blinded clinical examinations by physical therapists , and diagnostic injections were used as the criterion st and ard . RESULTS Significant relationships were found between discogenic pain and central ization of pain during repeated movement testing , and pain when rising from sitting . Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting . Sacroiliac joint pain was related to three or more positive pain provocation tests , pain when rising from sitting , unilateral pain and absence of lumbar pain . CONCLUSIONS Significant correlations exist between clinical examination findings and symptomatic lumbar discs , zygapophysial and SI joints . The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests , central ization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints BACKGROUND CONTEXT The " central ization phenomenon " ( CP ) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing ( a McKenzie evaluation ) . A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain . PURPOSE Estimation of the diagnostic predictive power of central ization and the influence of disability and patient distress on diagnostic performance , using provocation discography as a criterion st and ard for diagnosis , in chronic low back pain patients . STUDY DESIGN / SETTING This study was a prospect i ve , blinded , concurrent , reference st and ard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain . PATIENT SAMPLE Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures . Patients were typically disabled and displayed high levels of psychosocial distress . The sample included patients with previous lumbar surgery , and most had unsuccessful conservative therapies previously . OUTCOME MEASURES DIAGNOSIS results of provocation discography . INDEX TEST The CP . Psychometric evaluation : Rol and -Morris , Zung , Modified Somatic Perception question naires , Distress Risk Assessment Method , and 100-mm visual analog scales for pain intensity . METHODS Patients received a single physical therapy examination , followed by lumbar provocation discography .  Sensitivity , specificity , and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures . RESULTS A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography .  Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis . Disability and pain intensity ratings were high , and distress was common . Sensitivity , specificity , and positive likelihood ratios for central ization observed during repeated movement testing for pain distribution and intensity changes were 40 % , 94 % , and 6.9 respectively . In the presence of severe disability , sensitivity , specificity , and positive likelihood ratios were 46 % , 80 % , 3.2 and for distress , 45 % , 89 % , 4.1 . In the subgroups with moderate , minimal , or no disability , sensitivity and specificity were 37 % , 100 % and for no or minimal distress 35 % , 100 % . CONCLUSIONS Central ization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress
target: The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ ( but not the facet joint ) as the source of low back pain .
background: Clinical practice guidelines state that the tissue source of low back pain can not be specified in the majority of patients .
  However , there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain .
  The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc , facet joint or sacroiliac joint ( SIJ ) as the source of low back pain .