Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review

Key Points

1. Centralization may indicate a discogenic source of pain.
2. Absence of midline low back pain and a combination of sacroiliac joint pain provocation tests may indicate sacroiliac joint pain.
3. These tests may give people suffering from low back pain a biomedical diagnosis that could better direct their care.

BACKGROUND & OBJECTIVE

Low back pain is a very common diagnosis and is the leading cause of years lived with disability (1).Despite the large burden, very often, low back pain is categorized as “nonspecific,” and interventions tend not to address a particular pathology or structure.

This review was an update on a review from 2007 (2) to determine the accuracy of diagnostic tests used to determine if the disc, sacroiliac joint, or facet joints is the source of low back pain.

Low back pain is a very common diagnosis and is the leading cause of years lived with disability

While addressing the biological, psychological, and social aspects of a person's presentation is very important, patients are often dissatisfied with the diagnosis of nonspecific low back pain.

METHODS

MEDLINE, CINAHL, and EMBASE databases were searched for articles from March 2006 and January 25, 2023 utilizing the same search strategies used in the previous review by Hancock et al. (2007) (2). Studies in all languages were included if they met inclusion criteria.

Studies eligible for inclusion must include participants without serious pathology, use a reference standard test advocated by the International Association for the Study of Pain (IASP), assess at least one index test available to primary care clinicians, and present data allowing the development of contingency tables.

Two authors reviewed articles to rate the risk of bias, and publication bias was assessed post hoc; for the index tests, sensitivity, specificity, and likelihood ratios were calculated.

RESULTS

• MRI findings of disc degeneration, high-intensity zone (HIZ), annular fissure, Modic type 1, Modic type 2, and uptake of the facet joint on SPECT increased the likelihood that the disc was a nociceptive contributor in persistent low back pain.

• The only clinical examination test that indicated discogenic pain was the positive centralization phenomenon.

• The only clinical examination tests that were informative toidentify sacroiliac joint pain were the absence of midline low back pain, and a combination of sacroiliac joint provocation tests.

• There were no clinical tests found to be informative in identifying the facet joint as the source of pain.

LIMITATIONS

One limitation is that all of the studies were done in tertiary settings for patients referred for additional testing. These findings may not be generalizable to the primary care setting, and the impact this may have on the diagnostic accuracy of the tests is unknown.

Another limitation is that there were only 21 new articles since the original review in 2007, and some index tests need stronger evidence to increase confidence in the diagnostic accuracy of the test.

CLINICAL IMPLICATIONS

Low back pain continues to challenge individuals and clinicians worldwide. Acute low back pain tends to improve quickly with little intervention, but 4% to 25% of patients may transition to having chronic low back pain (3). Once a person transitions from acute low back pain to chronic low back pain, typically pain lasting over three months (4), they may be best addressed with a multidisciplinary biopsychosocial rehabilitation approach (5).

The biopsychosocial approach has been much discussed over the past 40 years (6), and its application to treating pain is challenging. Even when the biopsychosocial lens is being applied to care, studies have found that the biomedical model is conflated with the biopsychosocial approach (7).

This study focuses purely on potential biological contributors to chronic low pain, and finding tests that will accurately identify the biological contributor to the pain. While addressing the biological, psychological, and social aspects of a person's presentation is very important, patients are often dissatisfied with the diagnosis of nonspecific low back pain (8). This study offers more certainty around tests that may identify a biological contributor to a person’s pain. While that may satisfy a person’s need for a diagnosis, the larger question is how that information may direct the care to address that person’s pain.

+STUDY REFERENCE

Han C, Hancock M, Sharma S, Sharma S, Harris I, Cohen S, Magnussen J, Maher C, Traeger A (2023) Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review.eClinicalMedicine, 59,101960.

SUPPORTING REFERENCE

1. Dieleman, JL, Cao, J, Chapin, A, Chen, C, Li, Z, Liu, A, Horst, C, Kaldjian, A, Matyasz, T, Scott, KW, Bui, AL, Campbell, M, Duber, HC, Dunn, AC, Flaxman, AD, Fitzmaurice, C, Naghavi, M, Sadat, N, Shieh, P & Squires, E 2020, ‘US Health Care Spending by Payer and Health Condition, 1996-2016’, JAMA, vol. 323, no. 9, pp. 863–884.
2. Hancock, MJ, Maher, CG, Latimer, J, Spindler, MF, McAuley, JH, Laslett, M &Bogduk, N 2007, ‘Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain’, European Spine Journal, vol. 16, no. 10, pp. 1539–1550.
3. Nieminen, LK, Pyysalo, LM &Kankaanpää, MJ 2021, ‘Prognostic factors for pain chronicity in low back pain: a systematic review’, PAIN Reports, vol. 6, no. 1, p. e919.
4. International Association for the Study of Pain n.d., Definitions of Chronic Pain Syndromes, International Association for the Study of Pain (IASP).
5. Kamper, SJ, Apeldoorn, AT, Chiarotto, A, Smeets, RJEM, Ostelo, RW, Guzman, J & van Tulder, MW 2014, ‘Multidisciplinary biopsychosocial rehabilitation for chronic low back pain’, Cochrane Database of Systematic Reviews, no. 9.
6. Jull, G 2017, ‘Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging?’, British Journal of Sports Medicine, vol. 51, no. 16, pp. 1187–1188.
7. Mescouto, K, Olson, RE, Hodges, PW &Setchell, J 2020, ‘A critical review of the biopsychosocial model of low back pain care: time for a new approach?’, Disability and Rehabilitation, vol. 44, no. 13, pp. 1–15.
8. Lim, YZ, Chou, L, Au, RT, Seneviwickrama, KMD, Cicuttini, FM, Briggs, AM, Sullivan, K, Urquhart, DM &Wluka, AE 2019, ‘People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review’, Journal of Physiotherapy, vol. 65, no. 3, pp. 124–135.