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Diagnosing Pain Generators

outofcontrolooutofcontrol Posts: 264
What is the most accurate method of diagnosing pain generators? Is there a test that can pinpoint what is causing the pain? Does everyone here have the exact cause of your pain pin-pointed, or is it more of "it could be caused by your X or your O"? If they can't pin-point the pain generator, how can they decide whether or not it can be fixed??


  • No, this is the most challenging issue in spine medicine! In many cases, the pain generators can't be pinpointed, or there are many pain generators.

    Some of the tests they use, such as discograms, are not even supported by a consensus of all doctors. Some doctors think discograms' risks outweigh their benefits.

    And they are finding that people aren't as alike as they once thought in terms of which area on the spine contains nerves that serve a particular area.

    This is why no single test result, a discogram, an MRI, an X-ray, etc can diagnose a person. Doctors have to use the results of all of those tests along with the physical exam to try to deduce what is causing the pain.

    Sometimes, there just isn't enough information to justify surgery- you can't open someone up because you think it *might* help them. Sometimes the information adds up, and the doctor decides there is adequate evidence that a particular issue is causing pain, and surgery is warranted.

    And more often than you'd like to think, multiple doctors would look at the same information and reach different conclusions!

    Imagine opening your eyes after surgery, with your recovery still ahead of you, and finding that the original pain hasn't changed a bit? This is why it pays to learn as much as you can and be your own advocate. Many people go into back surgery assuming that diagnosis of back problems and surgical repairs are just like (to steal someone else's analogy) breaking and setting a leg- you look on the x-ray, diagnose the break, and fix it. It actually is much more than that, and the difference in outcomes between the best surgeons (who of course choose their patients carefully) and the poorest can be extreme.

    And for those of us who are in that position, a back injury requiring a major surgery is likely to be a lifelong issue rather than an issue the surgeon "fixes" forever.
  • HB is right in that finding pain generators can be like putting together a puzzle for spine doctors, and there are many members here that fight that battle.

    But, on the flip side, for me it was all very clear cut with x-rays and an MRI (both cervical and lumbar) and most recently with a cervical MRI and CT scan due to continued pain in my cervical area.

    I think that finding a great spine specialist is important, but that doesn't mean that it will be easy to find the problem. It just means that the chances are a bit higher because of their specialty.

    Another issue can be that they'll find the problem (as it was with my lumbar issues) and then once they got in there it was worse than they expected. My surgeon said that my lumbar was more unstable than he had originally thought from the imaging and was glad he did the surgery when he did.

    So it can go either way, depending on several factors. I think that those of us that have proper clear-cut diagnoses are very lucky because there are many who go through test after test and still can't find the problem. It's been said here before that spineys are probably the only people who are happy when they're told they need surgery - that's because the problem has been found and there's a course of action to try and make it better.

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  • Yes, surgery is at least a light at the end of the tunnel :) I totally get that.

    That always has to be balanced, though, by the understanding that if you search long enough, you might find a doctor who tells you "I know what's wrong, and how to fix it." But unless he truly is the one surgeon who "got" it and figured it out, it could be a road to more pain instead of less.

    Sometimes the best surgeons are the ones who say "surgery isn't the best option." And sometimes the best surgeon WILL find an answer. Only an educated, savvy patient is going to be able to make that distinction.
  • I think my pain is from stenosis at L4/L5. The PM doc thinks it is from the hardware at L5/S1.
    None of the ESI injections in either area have ever relieved the pain.
    Being a RN, I just want everything cut and dried--IT IS THIS, WE CAN/CANNOT FIX IT.
    If it can't be permanently fixed, then I will consider SCS or other long term treatment.
    I don't want to stay where I am right now.
  • So are ESI done as a treatment or a diagnostic tool?
    Are discograms only done if it is likely you will require surgery?
    If a MRI shows several non-serious/non specific issues, but a person has had severe chronic pain, what would the patient request to hopefully discover the problem.
    Thanks all! I am going to take control of my treatment--no longer outofcontrol
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  • That's the problem- you can try to pinpoint it, but it's not always possible. If ESI at both locations do not help, then is there not a possibility also that it's mechanical in nature? Sometimes they are all contributing.

    One of the tools they use is the dermatome map, which gives the approximate sensory area for each nerve group.

    Trying to take control of your medical care can be frustrating, because many decisions are still in the hands of physicians. Better to make it a partnership :)
  • I know, I know.
    But it is so frustrating!!!!
  • I hear ya! Keep trying. Have you tried a neurosurgeon?
  • You say that you think your problem is stenosis at L4/5. Why?

    As for diagnostic treatments, a discogram may help diagnose a disc problem, but it won't do any good for stenosis or facet joint problems. ESI's can work for a disc problem, but a FJI would be needed for facet joints. As for stenosis, I think they do a diagnostic nerve block to see if a rhizotomy, or nerve burn, will help (not sure on that one, though).

    I had a bulging disk, stenosis and facet joint problems at L4/5. My symptoms were severe back and hip pain and shooting pain down the back of my legs to my calves. Bending backwards hurt like the dickens and bending forward (or sitting) gave me some relief.

    I had an ESI and medrol pack and voila, the shooting pains were gone, apparently it helped the bulging disc. Sadly, the leg pains were replaced with a wider, steady pain down the back of both legs to my knees. They tried FJIs, no help, and a diagnostic nerve burn, no help either. So I ended up with a fusion at L4/5 to open up space for the stenosis and to fuse together the facet joints.

    What are your symptoms?
  • Anyway....I have stenosis at L4/L5.
    Before I had the L5/S1 fusion, the second opinion neurosurgeon said I needed decompression at L4/L5 along with the fusion. My neurosurgeon did not agree, and (I trusted my neurosurgeon) we proceeded with the fusion alone. He said if I continued to have problems post op, then we would do the decompression at L4/L5.
    Immediately following the L5/S1 fusion, I had complete left foot drop. The back and left leg pain is worse than it was before the fusion surgery.
    My neurosurgeon told me that he did not know what caused the foot drop or continued pain. He said that the did not think that any additional surgery would help. After 6 months of PT, he sent me to pain management.
    The post op MRI still showed stenosis at L4/L5. I am not sure how the fusion should appear on exray, but, to me, they look "crooked" or at odd angles.
    My PM doc has done several series of ESI at L4/L5 and L5/S1. They really have not helped. Several months ago he did two caudal ESI.
    I have not had a FJI or rhizotomy. I don't know why he continues to do ESI at the same level, when there is no relief. I feel that this is a waste of time and money. I am not sure if these were done as a treatment or for diagnostic purposes, but I think we need to move to the next step.
    I have asked my WC case manager for a second opinion on whether or not surgery would help. I do want to return to the doc that did the surgery. I still have not had a reply from WC.
    I hate to verbalize my concerns to my PM doc. I don't want to make him think I don't trust his plan of care, but quite honestly, I have a hard time trusting any doc now.
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