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KMID : 1148120170070010018
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Journal of Advanced Spine Surgery
2017 Volume.7 No. 1 p.18 ~ p.33
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Comparisons of Motion Provocation Predictors and Confounders Between Discogenic and Facetogenic Back Pain
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Jin Yong-Jun
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Abstract
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Objective: The aim of this study was to analyze significant motion predictors in patients with discogenic and facetogenic back pain confirmed by diagnostic injections and to see confounders which influence motion predictors.
Methods: Medial branch block and epidural steroid injection were used for facetogenic and discogenic midline pain. Transforaminal epidural steroid injection was selected for discogenic lateralized back pain. Positive response was defined as over 75% pain relief. Sixty-four patients (facetogenic pain, 45 bilateral or 9 unilateral, 82% pain relief ), Sixty-three patients (discogenic midline pain, 83%), and twenty-three patients (discogenic lateralized pain, 85%) had been enrolled prospectively in one institution between June 2010 and October 2013. Motion provocation tests were conducted during standing, sitting, flexion, extension, lateral bending, rotation, and extension with rotation for the detection of motion predictors. A self-weighted grade system was applied for pain provocation. Confounders such as age, sex, facet joint degeneration, flexion pain, grade of protrusion, circumferential annular tear, transverse annular tear, and spino-pelvic parameters were assessed to find the influence on motion predictors.
Results: In patients with facetogenic pain, pain provocation was prominent during standing (p=0.006), extension (p=0.052), rotation (p=0.000), and extension with rotation (p=0.000). In those with discogenic midline pain, more pain generated during flexion (p=0.000) and sitting (p=0.044). The difference in spino-pelvic parameters between two pain groups was not observed. The difference between discogenic midline and lateralized pain occurred during flexion (midline, p=0.046) and lateral bending (lateralized, p=0.057). Similarly, flexion (p=0.068) and lateral bending (p=0.067) might be also insignificant but helpful predictors to differentiate discogenic lateralized pain from facetogenic lateralized pain. For facetogenic pain, there were significant confounders as follows; standing (facet capsule enhancement, pelvic incidence), sitting (sex), extension (spino-pelvic parameters), lateral bending (pelvic tilt), rotation (age, sex, arthritis, facet capsule enhancement, pelvic tilt). Extension with rotation showed relatively less changes. For discogenic pain, a lake type circumferential tear generated less flexion pain and more extension pain. A superior transverse tear influenced sitting, extension, and lateral bending. A protrusion without a transverse tear increase flexion pain. Higher pelvic incidence and pelvic tilt generated more extension and extension with rotation pain. Among motions, sitting was not influenced by most probable confounders.
Conclusion: Predictors of facetogenic pain were extension with rotation, rotation, standing, extension, and lateral bending in order of probability. Flexion and sitting may be predictors of discogenic midline pain. Flexion and lateral bending may be predictors favoring discogenic lateralized pain compared with facetogenic pain. However, these motions may be vulnerable to parameters such as age, sex, facet arthritis, facet enhancement, circumferential or transverse tear, and spino-pelvic parameters. Considering the confounders’ effect, predictors were likely to be extension with rotation for facetogenic pain, sitting for discogenic midline pain, flexion and lateral bending for discogenic lateralized pain compared with facetogenic pain. These points should be considered in making a diagnosis during the physical examination in the outpatient clinic.
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KEYWORD
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Motion provocation, Midline back pain, Discogenic, Facetogenic, Predictor, Confounder
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