My first clue to discogenic pain begins with my first view of the patient as I walk into the room. Patients with discogenic pain may prefer to stand or pace around the room. If seated, they may recline back to one side to relieve the pressure. First, I take note of height/weight/obesity. Inspection of the lumbar region may reveal surgical scars or a kyphotic or scoliotic deformity. Palpation of the spine may reveal midline tenderness at one of the vertebral levels. The muscles on either side of the spine may reveal spasm and trigger points. If there is a spondylolisthesis (slip of one verterbral bone on another), there may be a “step deformity” on exam where the bony projections appear to step down at one level. The so called “straight leg raise” may put pressure on the disc and cause back pain, but more commonly can put increased pressure on the nerve root and reproduce pain down the buttock or leg. Full lumbar range of motion at the waist is usually limited and painful. Discogenic pain can be reproduced with both flexion and extension and rotation.
As far as picking up a facet mediated presentation on exam; well, that is a bit more difficult. Extending the lumbar spine and “loading” the facets can be a clue. However, that motion can routinely increase discogenic pain as well. It’s been said that the “gold standard” diagnostic test for facet mediated pain is a facet injection, where the facet nerve is blocked and then the patient is put through various motions and asked about their pain.
by Nathan S. Walters, MD
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