The posterior elements of the vertebral column are innervated by branches of the dorsal rami of t... more The posterior elements of the vertebral column are innervated by branches of the dorsal rami of the spinal nerves, while the intervertebral discs and related ligaments are innervated by various branches of the ventral rami and sympathetic nervous system. A knowledge of this nerve supply forms the basis for a systematic classification of the possible sources of primary spinal pain, and the basis for several diagnostic techniques that use needles to provoke and anaesthetize putative sources of pain. In particular, the demonstration of a nerve supply to intervertebral discs vindicates the concept fhat these structures intrinsically may be sources of pain.
This paper offers a mechanistic account of back pain which attempts to incorporate all of the mos... more This paper offers a mechanistic account of back pain which attempts to incorporate all of the most important recent advances in spinal research. Anatomical and pain-provocation studies show that severe and chronic back pain most often originates in the lumbar intervertebral discs, the apophyseal joints, and the sacroiliac joints. Psychosocial factors influence many aspects of back pain behaviour but they are not important determinants of who will experience back pain in the first place. Back pain is closely (but not invariably) associated with structural pathology such as intervertebral disc prolapse and endplate fractures, although age-related biochemical changes such as those revealed by a ‘dark disc’ on MRI have little clinical relevance. All features of structural pathology (including disc prolapse) can be re-created in cadaveric specimens by severe or repetitive mechanical loading, with a combination of bending and compression being particularly harmful to the spine. Structural...
Objectives To determine prevalence rates of hemorrhagic complications in patients who either ceas... more Objectives To determine prevalence rates of hemorrhagic complications in patients who either ceased or continued anticoagulants during interventional pain procedures. Methods A total of 1,936 consecutive patients were prospectively monitored during a total of 12,723 injection procedures. The prevalence of hemorrhagic complications was tallied for a variety of procedures performed on patients who ceased or continued various anticoagulants. Results No hemorrhagic complications occurred in any patient who continued anticoagulants. Sufficiently large sample sizes were obtained to conclude that, in patients who continued warfarin or clopidrogel during lumbar transforaminal injections and for lumbar facet procedures, the zero prevalence of complications had 95% confidence intervals of 0% to 0.3%. This prevalence was significantly lower than the risk of medical complications in patients who ceased warfarin. Conclusions Lumbar transforaminal injections and lumbar facet injections have a ver...
Aim of Investigation: The plant lectin soybean-agglutinin (SBA) has been shown to bind to small d... more Aim of Investigation: The plant lectin soybean-agglutinin (SBA) has been shown to bind to small dorsal root aanalion (DRGI cells and to the sunerficial laminae of the dorsal horn in the rat; which suggests that it is binding to unmyelinated primary afferent fibres (C-fibres). The aim of this study was to quantify SBA labelling of DRG cells in the cat and rat, to examine SBA labelling in the dorsal horn and to determine the ultrastructural localization of SBA binding in the dorsal roots. Methods: Deeply anaesthetized cats and rats were perfused with 4% paraformaldehyde in phosphate buffer. Wax sections of dorsal root ganglia, cryostat sections of dorsal horn and vibratome sections of dorsal roots were reacted with 40-lOOug/ml of SBA-Horseradish peroxidase conjugate (SBA-HRP). Following incubation of the sections with diaminobenzidine, sections were examined under a light microscope and morphometric analysis of the DRG performed. Dorsal root sections were embedded in Epon and transverse ultrathin sections examined on the electron microscope. Results: SBA labelling was found in 50% of cat DRG cells and 34% of rat DRG cells. The labelled cells were small and ranged in size from 14um to 40um in the rat and from 16um to 60vm in the cat. In the dorsal horn of both species labelling was found in laminae I and II, and at the ultrastructural level, labelling was seen only in unmyelinated fibres in the dorsal roots. Conclusion: The lectin SBA binds to a subpopulation of C-fibre afferents in the rat and cat and therefore might serve as a useful marker in immunocytochemical studies of the neurotransmitters involved in the transmission of information from C-fibre terminals.
Journal of Manipulative and Physiological Therapeutics, 2007
This editorial focuses on the topic of outcome research and offers alternate views of what may be... more This editorial focuses on the topic of outcome research and offers alternate views of what may be important to the practitioner. (J Manipulative Physiol Ther 2007;30:333Q334) I t works. This is what every craft group would like to be said of its interventions. As a referring practitioner, I would like to know if a treatment works so that I can use it for my patients. However, the assertion that it works begs 3 subordinate questions: in what respects, by how much, and for how long? Any number of instruments is available by which to measure outcomes in various domains, such as pain, disability, function, and psychologic distress. Most are known by some sort of acronym, for example, Short Form 36 (SF-36), Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), illness behavior questionnaire (IBQ), Symptom Checklist 90 Revised (SCL-90R), visual analog scale (VAS), and numerical pain rating scale (NPRS). Research experts would have us use several, if not many, of these to verify outcomes. Yet, that advice applies only if we are interested in the particular domains that the specialized instruments measure. For practical purposes, I would be satisfied if an investigator told me about pain, function, use of other health care, and return to work. Pain can be measured by a numerical pain rating scale. 1 Function can be assessed using patient-specified functional outcomes. 2-4 For this instrument, the patient nominates 4 activities of daily living that are impaired by their pain and that most dearly they would want restored by a successful treatment. If those activities are not restored, the treatment cannot be held to have been a success. Use of other health care is pivotal to assessing outcomes. A successful treatment
Best Practice & Research Clinical Rheumatology, 1999
Tumours, infections, aneurysms and metabolic and inflammatory diseases are rare causes of neck pa... more Tumours, infections, aneurysms and metabolic and inflammatory diseases are rare causes of neck pain. Most cases involve neck pain of unknown origin or a whiplash-associated disorder. Neck pain is common in the general community and more common in certain occupations. The natural history is relatively benign, but some 10% of patients will suffer chronic, severe symptoms. Psychosocial factors have been refuted as risk factors; the cardinal risk factors relate to occupation. In whiplash, the severity of initial symptoms is the cardinal determinant of chronicity. History is the major factor when considering diagnosis, physical examination adding little to the diagnosis. Imaging is not indicated in the vast majority of cases. The available evidence does not support most of the physical, medical and surgical therapies currently practised. Confident reassurance is paramount and justified for acute cases. Proven options for chronic neck pain are few.
Objectives. To determine the extent and strength of evidence that supports the belief that cervic... more Objectives. To determine the extent and strength of evidence that supports the belief that cervical intervertebral discs are a source of neck pain. Design. The evidence from anatomical, laboratory, experimental, diagnostic, and treatment studies was summarized and analyzed for concept validity, face validity, content validity, and construct validity. Results. Evidence from basic sciences shows that cervical discs have a nociceptive innervation, and experimental studies show that they are capable of producing neck pain. Disc stimulation has been developed as a diagnostic test but has rarely been used in a disciplined fashion. The prevalence of cervical disc pain has not been properly established but appears to be low. No treatment has been established that reliably achieves complete relief of neck pain in substantial proportions of patients. Conclusions. Basic science evidence supports the concept of cervical disc pain, but epidemiologic and clinical evidence to vindicate the clinical application of the concept is poor or lacking.
Fundamental to any assessment of an appropriate use criterion (AUC) for sacroiliac pain is the re... more Fundamental to any assessment of an appropriate use criterion (AUC) for sacroiliac pain is the recognition that there are at least two entities in question. The two are distinctly different conceptually; each requires a different paradigm of diagnosis and treatment, and the evidence base for each differs both in quality and quantity.
The posterior elements of the vertebral column are innervated by branches of the dorsal rami of t... more The posterior elements of the vertebral column are innervated by branches of the dorsal rami of the spinal nerves, while the intervertebral discs and related ligaments are innervated by various branches of the ventral rami and sympathetic nervous system. A knowledge of this nerve supply forms the basis for a systematic classification of the possible sources of primary spinal pain, and the basis for several diagnostic techniques that use needles to provoke and anaesthetize putative sources of pain. In particular, the demonstration of a nerve supply to intervertebral discs vindicates the concept fhat these structures intrinsically may be sources of pain.
This paper offers a mechanistic account of back pain which attempts to incorporate all of the mos... more This paper offers a mechanistic account of back pain which attempts to incorporate all of the most important recent advances in spinal research. Anatomical and pain-provocation studies show that severe and chronic back pain most often originates in the lumbar intervertebral discs, the apophyseal joints, and the sacroiliac joints. Psychosocial factors influence many aspects of back pain behaviour but they are not important determinants of who will experience back pain in the first place. Back pain is closely (but not invariably) associated with structural pathology such as intervertebral disc prolapse and endplate fractures, although age-related biochemical changes such as those revealed by a ‘dark disc’ on MRI have little clinical relevance. All features of structural pathology (including disc prolapse) can be re-created in cadaveric specimens by severe or repetitive mechanical loading, with a combination of bending and compression being particularly harmful to the spine. Structural...
Objectives To determine prevalence rates of hemorrhagic complications in patients who either ceas... more Objectives To determine prevalence rates of hemorrhagic complications in patients who either ceased or continued anticoagulants during interventional pain procedures. Methods A total of 1,936 consecutive patients were prospectively monitored during a total of 12,723 injection procedures. The prevalence of hemorrhagic complications was tallied for a variety of procedures performed on patients who ceased or continued various anticoagulants. Results No hemorrhagic complications occurred in any patient who continued anticoagulants. Sufficiently large sample sizes were obtained to conclude that, in patients who continued warfarin or clopidrogel during lumbar transforaminal injections and for lumbar facet procedures, the zero prevalence of complications had 95% confidence intervals of 0% to 0.3%. This prevalence was significantly lower than the risk of medical complications in patients who ceased warfarin. Conclusions Lumbar transforaminal injections and lumbar facet injections have a ver...
Aim of Investigation: The plant lectin soybean-agglutinin (SBA) has been shown to bind to small d... more Aim of Investigation: The plant lectin soybean-agglutinin (SBA) has been shown to bind to small dorsal root aanalion (DRGI cells and to the sunerficial laminae of the dorsal horn in the rat; which suggests that it is binding to unmyelinated primary afferent fibres (C-fibres). The aim of this study was to quantify SBA labelling of DRG cells in the cat and rat, to examine SBA labelling in the dorsal horn and to determine the ultrastructural localization of SBA binding in the dorsal roots. Methods: Deeply anaesthetized cats and rats were perfused with 4% paraformaldehyde in phosphate buffer. Wax sections of dorsal root ganglia, cryostat sections of dorsal horn and vibratome sections of dorsal roots were reacted with 40-lOOug/ml of SBA-Horseradish peroxidase conjugate (SBA-HRP). Following incubation of the sections with diaminobenzidine, sections were examined under a light microscope and morphometric analysis of the DRG performed. Dorsal root sections were embedded in Epon and transverse ultrathin sections examined on the electron microscope. Results: SBA labelling was found in 50% of cat DRG cells and 34% of rat DRG cells. The labelled cells were small and ranged in size from 14um to 40um in the rat and from 16um to 60vm in the cat. In the dorsal horn of both species labelling was found in laminae I and II, and at the ultrastructural level, labelling was seen only in unmyelinated fibres in the dorsal roots. Conclusion: The lectin SBA binds to a subpopulation of C-fibre afferents in the rat and cat and therefore might serve as a useful marker in immunocytochemical studies of the neurotransmitters involved in the transmission of information from C-fibre terminals.
Journal of Manipulative and Physiological Therapeutics, 2007
This editorial focuses on the topic of outcome research and offers alternate views of what may be... more This editorial focuses on the topic of outcome research and offers alternate views of what may be important to the practitioner. (J Manipulative Physiol Ther 2007;30:333Q334) I t works. This is what every craft group would like to be said of its interventions. As a referring practitioner, I would like to know if a treatment works so that I can use it for my patients. However, the assertion that it works begs 3 subordinate questions: in what respects, by how much, and for how long? Any number of instruments is available by which to measure outcomes in various domains, such as pain, disability, function, and psychologic distress. Most are known by some sort of acronym, for example, Short Form 36 (SF-36), Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), illness behavior questionnaire (IBQ), Symptom Checklist 90 Revised (SCL-90R), visual analog scale (VAS), and numerical pain rating scale (NPRS). Research experts would have us use several, if not many, of these to verify outcomes. Yet, that advice applies only if we are interested in the particular domains that the specialized instruments measure. For practical purposes, I would be satisfied if an investigator told me about pain, function, use of other health care, and return to work. Pain can be measured by a numerical pain rating scale. 1 Function can be assessed using patient-specified functional outcomes. 2-4 For this instrument, the patient nominates 4 activities of daily living that are impaired by their pain and that most dearly they would want restored by a successful treatment. If those activities are not restored, the treatment cannot be held to have been a success. Use of other health care is pivotal to assessing outcomes. A successful treatment
Best Practice & Research Clinical Rheumatology, 1999
Tumours, infections, aneurysms and metabolic and inflammatory diseases are rare causes of neck pa... more Tumours, infections, aneurysms and metabolic and inflammatory diseases are rare causes of neck pain. Most cases involve neck pain of unknown origin or a whiplash-associated disorder. Neck pain is common in the general community and more common in certain occupations. The natural history is relatively benign, but some 10% of patients will suffer chronic, severe symptoms. Psychosocial factors have been refuted as risk factors; the cardinal risk factors relate to occupation. In whiplash, the severity of initial symptoms is the cardinal determinant of chronicity. History is the major factor when considering diagnosis, physical examination adding little to the diagnosis. Imaging is not indicated in the vast majority of cases. The available evidence does not support most of the physical, medical and surgical therapies currently practised. Confident reassurance is paramount and justified for acute cases. Proven options for chronic neck pain are few.
Objectives. To determine the extent and strength of evidence that supports the belief that cervic... more Objectives. To determine the extent and strength of evidence that supports the belief that cervical intervertebral discs are a source of neck pain. Design. The evidence from anatomical, laboratory, experimental, diagnostic, and treatment studies was summarized and analyzed for concept validity, face validity, content validity, and construct validity. Results. Evidence from basic sciences shows that cervical discs have a nociceptive innervation, and experimental studies show that they are capable of producing neck pain. Disc stimulation has been developed as a diagnostic test but has rarely been used in a disciplined fashion. The prevalence of cervical disc pain has not been properly established but appears to be low. No treatment has been established that reliably achieves complete relief of neck pain in substantial proportions of patients. Conclusions. Basic science evidence supports the concept of cervical disc pain, but epidemiologic and clinical evidence to vindicate the clinical application of the concept is poor or lacking.
Fundamental to any assessment of an appropriate use criterion (AUC) for sacroiliac pain is the re... more Fundamental to any assessment of an appropriate use criterion (AUC) for sacroiliac pain is the recognition that there are at least two entities in question. The two are distinctly different conceptually; each requires a different paradigm of diagnosis and treatment, and the evidence base for each differs both in quality and quantity.
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Papers by Nikolai Bogduk