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The diagnosis of lumbar back pain is difficult and uncertain due to the various conditions which can present with this problem. Effective back pain management depends on identifying what kind of back pain problem is present, and many people have suggested that there are many back pain subtypes which need to be identified before treatment can be well targeted. The variations in diagnoses for low back pain and related symptoms include: postural pain; trigger point pains; nerve root compression; neuropathic pain; facet joint pain; disc related pain and lumbar stenosis.

The spinal facet joints, intervertebral discs, muscles and ligaments are all potential sources of mechanical back pain, a pain derived from the damaged or injured tissues and transmitted by the nervous system. When the nervous system is damaged or injured it can start generating pain itself, leading to the production of what is termed neuropathic pain. Typical diagnoses of this kind of pain are post-shingles pain, phantom pain, nerve root damage pain and diabetic neuropathy pain. Patients suffer badly with this kind of unpleasant pain and it is difficult to treat.

A recent study performed by researchers from Massachusetts General Hospital in Boston and Addenbrooke’s Hospital in Cambridge, UK, has investigated this difficulty. They recognised that the assessment by taking a score of pain intensity does not reflect the reality of the complex nature of pain processes by which pain is generated. They set out to design an assessment which would take these complexities into account, allowing the clearer identification of the diagnosis and thereby a potentially more accurate treatment. They developed a standardised tool to use in the assessment of chronic pain with the aim of delineating differing pain subtypes.

130 people with peripheral neuropathic pain and 57 people with mechanical low back pain were surveyed and given a standardised assessment. An interview with 16 questions was then applied followed by a specific series of twenty-three physical tests. A list of words applicable to pain descriptions was provided and patients were asked to indicate which ones most accurately described their pain. In chronic pain patients often have an alteration in the ability to feel touch, vibratory and pin prick stimuli so the ability to discriminate these sensibilities is tested.

In neuropathic pain patients it was possible to identify six sub-groups and in non neuropathic patients two further subgroups were noted. Researchers were also able to distinguish the 6 questions and 10 physical tests which were best suited to making the most accurate discrimination between the pain subtypes. Testing this tool on one hundred and thirty seven further patients allowed the researchers to see it worked effectively and that patient acceptability was good. A particular group of neuropathic pain subtypes could be elucidated by a relatively low number of signs and symptoms which were not related to the presenting causative conditions.

The recording of the symptoms was less sensitive in distinguishing the neuropathic nature of the pains than the physical examination. The pain quality was less important than often noted and the pinprick testing more helpful. The researchers tried to link the pain subtypes with specific underlying biological mechanisms, with spontaneous pain of a burning nature linked to spontaneous discharges in heat sensitive pain nerves and pain from brushing related to increased sensitivity of cells in the dorsal horn of the spinal cord.

The physical examination was more sensitive in delineating neuropathic diagnoses of pains than the recording of the types and nature of symptoms.  The qualities of the pain were less helpful and the testing of pinprick more helpful. The researchers attempted to connect the underlying neural mechanisms with the pain subtypes. The heat sensitive pain nerves were linked to burning pains of a spontaneous type and heightened sensitivity of the spinal cord dorsal horn cells was linked to increased pain from brushing over the skin.