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Mystery Back Pain

Back pain is not always easy to diagnose.

Under standard medical care, 85% of cases fall under the nonspecific category, defined as a physical spine injury of unknown cause. The gold standard tool, the MRI, is sensitive for picking up many forms of damage. But it may be unclear which abnormalities are relevant. Other types of injury are altogether invisible to the MRI.

This may become a problem for you if your clinician is over-reliant on spinal imaging for your diagnosis. You may feel as if you are on a wild goose chase, pursuing a range of treatment that is not working. Or therapy is making you worse. The solution to uncertainty is to discover the root-cause of your pain.

This process depends on clinical diagnosis.

What is clinical diagnosis?

Clinical diagnosis is finding the cause of your condition from a medical interview and a physical examination.

It is an age-old skill set undermined by deficient training, brief visits, and undue deference to technology. The symptoms and signs determined by a clinical diagnosis is often the only method to arrive at the root-cause of your problem. In fact, skilled clinicians can diagnose over 90% of back pain—rarely is the pain actually unknowable and nonspecific.

Your symptoms, which are communicated during a medical interview, and your signs of injury, which are explored in the physical examination, form patterns. These patterns capture key characteristics of your pain which include:

  • Location of symptoms — in the back or legs?
  • Provocation from posture, movements, and activities
  • Quality of the pain — throbbing, dull, burning, or stabbing?
  • Severity

A clinical diagnosis will provide you a roadmap out of pain.

How does a clinical diagnosis help find the cause?

The information from a clinical diagnosis fits into patterns. For example, a disc bulge causing sciatica may present with shooting pain down the leg, worsened by a long commute, and producing a throbbing sensation.

The clinical diagnosis gives the MRI context. Let’s say an MRI shows two problems—an endplate fracture at L1-L2 and central disc bulge at L5-S1 compressing a right-sided nerve root. An ache in the upper back would be the expected symptom from the endplate fracture. Sciatica would be the probable pain from the disc bulge.

As you can see, without this additional clinical information, it would not be clear which of the two problems is responsible for the pain. It might be both. It might be a separate injury out of the field of view of the MRI. Or it might be a subtle injury that is radiographically invisible.

But how does a clinical diagnosis help with fixing the problem?

The best treatment for your spine depends on the cause. Just as an ankle sprain and bone fracture of the foot are not treated the same, so too is spine rehabilitation guided by the clinical diagnosis.

Knowing the diagnosis allows your clinician to give you an individualized treatment approach— one with a higher chance to wind down your pain and increase your function.

A clinical diagnosis will help you understand:

  • Pain-triggers to avoid
  • Safe postures, movements, and activities to navigate the world
  • Rehabilitation exercises to correct movement and structural deficits that are holding your back

A program great for one injury mechanism will be ruinous for another. This is why the online debates about what works for fixing back pain never ends. McKenzie press-ups. Yoga. Inversion tables. This exercise. That exercise.

The right tool depends on the problem.

What are examples of how understanding the cause change the treatment and ultimate outcome?

Case 1: Degenerative spondylolisthesis or facet injury?

A 60-year-old man was told he needed fusion surgery. He had a slippage injury called degenerative spondylolisthesis. Arising from an old disc injury, this problem caused his L4 vertebra to slip forward relative to the L5 vertebra below. A surgeon told him a fusion would fix his back pain.

But his examination showed that his facet joints were the main source of his pain. Learning how to improve his posture, along with a facet steroid injection, resolved his issue within three months. In this case, the right diagnosis helped the patient avoid surgery altogether.

Case 2: Sciatica or something else?

A 40-year-old woman with burning leg pain reports that it is hard for her to stand or sit. Just five minutes of either and she is in excruciating pain. She has to lie down throughout her work day. On the physical exam, spine bending does not affect her symptoms. But a broad range of nerve stretches reproduce her pain. Her MRI shows disc bulges at L4-L5 and L5-S1, along with cysts over her nerves.

This pattern indicated that the cysts of the sacrum, known as Tarlov cysts, were the true source of her pain. Though two surgeons had advised her to undergo disc surgery, I recommended a surgery focused on the cysts instead. Within six months of her surgery, most of her pain was gone and she could function again.

Select References

Freedman, Kevin B., et al. “Educational deficiencies in musculoskeletal medicine.” Journal of Bone and Joint Surgery, 2002.

McGill, Stuart. Low back disorders: evidence-based prevention and rehabilitation. Human Kinetics, 2015.

Jim, Lysander. Specific Spine: A Doctor’s Guide to a Healthy Back. M.D. Muse Media, 2023.

Chou, Roger. “Low back pain (chronic).” American family physician, 2011.