PAINÒ 147 (2009) 17–19

www.elsevier.com/locate/pain

Topical review

On the definitions and physiology of back pain, referred pain, and radicular pain
Nikolai Bogduk *
University of Newcastle, Newcastle Bone and Joint Institute, Royal Newcastle Centre, PO Box 664J, Newcastle, NSW 2300, Australia

1. Introduction spine it has been named somatic referred pain [3,5], in order to dis-
tinguish it both from visceral referred pain and radicular pain. So-
Despite the efforts of the International Association for the Study matic referred pain does not involve stimulation of nerve roots. It is
of Pain [6,21], confusion still persists amongst clinicians about the produced by noxious stimulation of nerve endings within spinal
definitions of back pain, referred pain, radicular pain, and radicu- structures such as discs, zygapophysial joints, or sacroiliac joints.
lopathy. Basic scientists now stand to inherit this confusion as they The proposed mechanism of referral is convergence of nociceptive
develop animal models of back pain [7]. afferents on second-order neurons in the spinal cord that happen
Pivotal to the definition of these entities are seminal studies also to subtend regions of the lower limb [21]. As a general rule, so-
undertaken 50, 60, and 70 years ago. The legacy of this pioneering matic referred pain is perceived in regions that share the same seg-
work has not properly permeated medical education, publications mental innervation as the source. Since somatic referred pain is not
or clinical practice. caused by compression of nerve roots, there are no neurological
signs.
2. Nociceptive back pain Somatic referred pain is dull, aching and gnawing, and is some-
times described as an expanding pressure. It expands into wide
By definition, nociceptive back pain must be pain that is evoked areas that can be difficult to localize [2,13,18]. Once established,
by noxious stimulation of structures in the lumbar spine. The qual- it tends to be fixed in location. Subjects often find it difficult to de-
ity of pain so evoked has been determined in studies of normal vol- fine the boundaries of the affected area, but can confidently iden-
unteers, in whom discrete noxious stimuli were delivered to tify its centre or core. The earliest studies depicted segmental
selected lumbar structures. In the original studies, muscles of the maps of the referred pain patterns [13,18] (Fig. 1). However,
back [17] or the interspinous ligaments [18] were stimulated, although pain from different segments in the lumbar spine refers
using injections of hypertonic saline. Others replicated these stud- to different regions in the lower limb, patterns are not consistent
ies [2,13]. Later, the lumbar zygapophysial joints [22,23] and the amongst subjects or between studies. Most significantly, however,
sacroiliac joints [14] were stimulated with injections of contrast the pattern is not dermatomal. If anything, the pattern corresponds
medium that evoked pain by distending these joints. The dura ma- to the segmental innervation of deep tissues in the lower limb,
ter has been stimulated mechanically [27] and chemically [10]. such as muscles and joints. Moreover, although somatic referred
Surgeons who have operated on patients under local anaesthesia pain tends most often to centre over the gluteal region and proxi-
have probed various structures mechanically, and showed that mal thigh, it can also extend as far as the foot (Fig. 1). Such distri-
the posterior surface of the lumbar intervertebral discs are the butions have been evoked in normal volunteers and patients by
most potent source of experimentally-induced back pain stimulating the lumbar zygapophysial joints [22,23] or interverte-
[12,20,29]. Uniformly, these experimental studies showed that bral discs [25], and relieved in patients by anaesthetizing their
noxious stimulation causes dull, aching pain in the back. Conse- zygapophysial joints [11,23,26]. To be consistent with these exper-
quently, when it occurs clinically, this type of pain that should imental data, when dull aching pain that spreads into the lower
be inferred to be nociceptive back pain. limb and settles into a relatively fixed location occurs in patients,
it should be recognized as somatic referred pain, when it occurs
3. Somatic referred pain in patients.

Noxious stimulation of structures in the lumbar spine can pro- 4. Radicular pain
duce referred pain in addition to back pain. The pain spreads into
the lower limbs, and is perceived in regions innervated by nerves Radicular pain differs from somatic referred pain both in mech-
other than those that innervate the site of noxious stimulation – anism and clinical features. Physiologically, it is pain evoked by ec-
the core of the definition of referred pain [21]. Since the source topic discharges emanating from a dorsal root or its ganglion [21].
of spinal referred pain lies in the somatic tissues of the lumbar Disc herniation is the most common cause, and inflammation of
the affected nerve seems to be the critical pathophysiological pro-
cess [3]. The clinical features of radicular pain were established in
* Tel.: +61 2 49223505; fax: +61 2 49 223559.
studies of patients who underwent surgery for disc herniation. In
E-mail address: [email protected].

0304-3959/$36.00 Ó 2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2009.08.020
18 N. Bogduk / PAINÒ 147 (2009) 17–19

The term – sciatica, is arcane. It stems from an era when the

mechanisms of referred pain were not understood, and any re-
ferred pain was attributed to irritation of the peripheral nerve that
passed through the region of pain. The taxonomy of the IASP rec-
ommends replacement by the term – radicular pain [21].

5. Radiculopathy

Radiculopathy is yet another, distinct entity [21]. It is a neuro-

logical state in which conduction is blocked along a spinal nerve
or its roots. When sensory fibers are blocked, numbness is the
symptom and sign. When motor fibers are blocked weakness en-
sues. Diminished reflexes occur as a result of either sensory or mo-
tor block. The numbness is dermatomal in distribution and the
weakness is myotomal. However, radiculopathy is not defined by
Fig. 1. Patterns of somatic referred pain evoked by noxious stimulation of the pain. It is defined by objective neurological signs. Although radicu-
interspinous ligaments at the segments indicated. Based on Kellgren [18].
lopathy and radicular commonly occur together, radiculopathy can
occur in the absence of pain, and radicular pain can occur in the ab-
one study, the affected nerves and adjacent nerves were challenged sence of radiculopathy.
by squeezing them with forceps in awake patients [24]. In another Careful clinical examination remains the best tool for diagnos-
study, sutures were placed around the nerves, during surgery, and ing a radiculopathy. Electrophysiological testing should rarely be
led out through the wound, so that they could be pulled on the fol- necessary. The indications and validity of electrophysiological test-
lowing day [27]. The pain evoked was distinctive. It had a lancinat- ing are beyond the scope if this review, but they have been ad-
ing quality, and traveled along the length of the lower limb, in a dressed elsewhere [1,4,9].
band no more than 2–3 inches wide (see Fig. 2). This is the only A common maxim is that the segmental origin of radicular
type of pain that has been produced by stimulating nerve roots. pain can be determined from its distribution. This is not true.
So, reciprocally, it is only this type of pain that should be inter- The patterns of L4, L5, and S1 radicular pain cannot be distin-
preted as radicular pain. guished from one another [24,28]. Segments can be estimated
Significantly, squeezing or pulling normal nerve roots does not only when radiculopathy occurs in combination with radicular
produce radicular pain. Only if nerve roots have previously been pain. In that event, it is the dermatomal distribution of numbness
inflamed does mechanical stimulation evoke radicular pain [27]. – not the distribution of pain – that allows the segment of origin
For compression alone to be painful, it seems that it must involve to be determined.
the dorsal root ganglion. Although this has not been verified in
experiments on human volunteers, it is borne out in animal 6. Discussion
studies.
Studies in laboratory animals have provided a neurophysiologic Failure to distinguish radicular pain from somatic referred pain
correlate of radicular pain. Squeezing normal nerve roots evokes may lead to misdiagnosis and thereby mismanagement. Back pain
only a momentary discharge, but squeezing a dorsal root ganglion, and somatic referred pain are common, but radicular pain is not.
or squeezing an inflamed dorsal root, evokes discharges in Ab as When radicular pain has been strictly defined, its prevalence is
well as Ad and C fibers [15,16]. Radicular pain, therefore, is not only about 12% or less [8]. Mistaking somatic referred pain for
due to a discharge exclusively in nociceptive afferents; it is due radicular pain creates the erroneous impression that radicular pain
to a heterospecific discharge in the affected nerve. The evoked sen- is more common. Because of the strong possibility that somatic re-
sation is very unpleasant but is not exactly pain, in a classical, noci- ferred pain has been mistaken for radicular pain in the past, studies
ceptive sense. The qualities of lancinating, shocking, or electric are of the prevalence of radicular pain are not reliable [19].
consonant with more than nociceptive afferents discharging. Since With respect to clinical management, imaging is justified for
the English language lacks a more precise word, this sensation is, the investigation of radicular pain and radiculopathy because
nevertheless, by default, called pain. imaging can often establish the causative lesion. The same does
not apply for somatic referred pain. Plain radiographs, MRI scan,
or CT scan are unable to reveal the cause of somatic pain, in
the majority of cases. Moreover, they carry the risk of false-posi-
tive interpretations. Finding degenerative changes, disc bulges
and possible nerve root compression is immaterial to the diagno-
sis if the patient has somatic referred pain, but can lead to unnec-
essary surgery if somatic referred pain is mistaken for radicular
pain.
Since nociceptive back pain and somatic referred pain do not
involve nerve injury, there are no grounds for expecting neurolog-
ical symptoms or signs. In particular, allodynia should not be a
feature; and, indeed, allodynia has never been recorded in cases
of nociceptive back pain. In contrast, since radicular pain and
radiculopathy do involve pathology of a nerve trunk, allodynia
is a theoretical possibility, provided that the nerve suffers an
appropriate injury. However, allodynia is not a typical feature of
Fig. 2. An illustration of the lancinating quality of radicular pain traveling into the radicular pain or radiculopathy, unless there is true nerve damage
lower limb along a narrow band. and neuropathy rather than simply compression or inflammation.
Allodynia (Ancient Greek άλλος állos "other" and οδύνη odúnē "pain") is a pain due to a
stimulus which does not normally provoke pain
 N. Bogduk / PAINÒ 147 (2009) 17–19 19

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