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Identifying the specific pathology responsible for spinal pain is often difficult. This is particularly true given the high incidence of anatomic abnormalities in asymptomatic individuals, and the presence of normal anatomy in some painful individuals, at least as demonstrated on conventional imaging studies.1,2 The primary purpose of diagnostic injections for chronic spinal pain is to identify which anatomic structure of the spine is causing pain and what is the pathologic disorder affecting it. Before performing these injections, the clinical utility of making an anatomic diagnosis should be well established.

Whether or not it is important to make an anatomic diagnosis in patients with spinal pain is a matter of some debate.3,4 While some would argue that in the majority of patients, attempts at making an anatomic diagnosis are contraindicated, others feel that at a minimum, making a diagnosis will help patients to heal by providing them with a clear understanding of their problem.5 The most important reason to make an anatomic diagnosis, however, is if there are treatments that can be directed toward specific pathology, leading to good outcomes. Many patients with spinal pain can be treated with interventional pain management procedures. The success of these procedures may depend on an accurate anatomic diagnosis; however, typically little harm will come to the patient if the procedure fails. Traditionally, the indications for surgery have been felt to be neurologic loss. Increasingly, however, surgery is being performed for pain without neurologic loss, essentially becoming a pain management procedure. Although surgery may help some patients with chronic pain, the tissue injury that necessarily accompanies surgery may potentially lead to devastating consequences. If surgery is being considered for patients with chronic pain, an accurate diagnosis is essential. In this chapter, we focus on the role of diagnostic injections in presurgical decision making.

There are two types of spinal pain: radicular pain and axial pain.6 Radicular pain results from mechanical compression or chemical irritation of a nerve root, or both. Establishing an anatomic diagnosis for patients with radicular pain is important, as surgical treatments have excellent outcomes in well-selected patients. The source of radicular pain, typically either a herniated nucleus pulposus or spinal stenosis, can be definitively diagnosed at surgery; therefore, there is a gold standard that can be used to assess the validity of diagnostic studies. Consequently, the ability of both clinical findings and imaging studies to diagnose the site of pathology is well defined. A diagnostic injection may be indicated when imaging studies suggest that more than one nerve root may be responsible for a patient’s symptoms. In that circumstance, a selective epidural injection may be useful.

In contrast to radicular pain, the relationship between spinal pathology and axial pain is uncertain. There are a number of anatomic structures that are potential sources of pain, including myofascial tissues, synovial joints, and the intervertebral discs. Although discogenic pain is felt by many to be ...

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