Course 8 medical tests used to diagnose painful


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Medical Tests Used to Diagnose Painful Conditions is a power point which outlines the correct medical tests to use to diagnose chronic pain problems. These are the tests used by the top academic medical institutions in the country, and the efficacy of these tests is documented by clinical outcome studies. The presentation is heavily illustrated, so the reader can really understand what a test measures.

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Course 8 medical tests used to diagnose painful

  1. 1. Course 8 Medical Tests Used to Diagnose Painful Conditions Nelson Hendler, MD, MS Former Assistant Professor of Neurosurgery Former Clinical Director of Mensana Clinic Former Associate Professor of Physiology University of Maryland School of Dental Surgery Past president-American Academy of Pain Management
  2. 2. • Business Week listed the 8 best pain clinics in the United States including Mayo Clinic, Mensana Clinic, Johns Hopkins Hospital and Cleveland Clinic (1)• The medical team from two of these clinics used 55 medical tests to help clarify the origin of pain• Most of these were physiological tests• What follows is a list of the tests, and what they actually tell a physician about the cause of the pain, based on outcome studies• These tests are part of the Treatment Algorithm of the Diagnostic Paradigm found at Business Week, pages 104-105, Jan. 27, 1992
  3. 3. Selecting the Correct Test• While this sounds self-evident, very often physicians don’t apply logic when selecting tests• If a patient tells a doctor that his neck pain is worse when bending his head forward or backwards, but feels fine when upright, it would be logical to order X-rays when the patient is leaning forward or backward. This is not often done• Infection is a metabolic process, creating cellular activity, at a microscopic level. So a physiological test, such as a bone scan, would reveal more about the process than an anatomical test, such as an X-
  4. 4. X-rays versus Flexion Extension X-rays• Most patients complain of worse pain when they lean forward or backwards.• Static (upright) X-rays do not demonstrate movement between the vertebral bodies.• Flexion-Extension X-rays show what happens to the vertebral bodies when there is motion forward and backwards.• Like a partially broken twig- the defect is not evident until the twig is put under tension.
  5. 5. The BONE SCAN consists of injecting a radioactive tracer, such as technetium-99m-MDP, into the vein, and then scanned with a gamma camera, a device sensitive to theradiation emitted by the injected material. The tracer accumulates at areas ofinflammation, bone growth, cancer and infection. The test is sensitive but not specific.
  6. 6. When to use an MRI• MRIs can be used to detect space occupying lesions, where a tumor or bone is compressing a soft tissue, such as a blood vessel or muscle• MRIs are not good for detecting damaged discs:• Jensen et. al. N. Eng J. Med, ’94, reported 98 patients with no back pain, but 27 had protruding disc. The MRI had a 28% false positive rate.• In 90 patients, all of whom has a positve provocative discogram (a physiological test) 77% of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)• Therefore, there is a 77% false negative rate for MRI Braithwaite, et al, Eur. Spine J. ’98
  7. 7. Thermography• This technique measures temperature differences in the body• The technique can detect temperature changes only to a depth of 5 centimeters, or about 2 inches.• It cannot be used as a substitute for mammography, or for detecting disc disease(1)• It can be used for detecting gross temperature differences in a limb, such as Complex Regional Pain Syndrome (type I) –see next slide (2) Uematsu, S., Hendler, N., Hungerford, D., Long, D., Ono, N.: "Thermography and Electromyography in the Differential Diagnosis of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy." Electromyography and Clinical Neurophysiology. Vol. 21, pp.165-182, 1981. Hendler, N., Uematsu, S., Long, D.: "Thermographic Validation of Physical Complaints in Psychogenic Pain Patients." Psychosomatics. Vol. 23, No. 3, March, 1982.•
  8. 8. 3D-CT• This is a computer manipulation of a CT scan, which can detect bony lesions which may be missed by a regular CT (1)• In one article from Johns Hopkins, 100 patients with no prior surgery had bony lesions on 3D- CT which were missed by a regular CT 56% of the time• 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76% of the time (2)• (1)Hendler, N., Zinreich, J., Kozikowski, J.: "Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients." Psychosomatics. Vol. 34, No. 1:90-96, January/February, 1993.• (2) Zinreich SJ, Long DM, Davis R, Quinn CB, McAfee PC, Wang H.• Three-dimensional CT imaging in postsurgical "failed back" syndrome. J Comput Assist Tomogr. 1990 Jul-Aug;14(4):574-80.
  9. 9. 3D-CT of theWrist, with blackarrow showingthe linearfracture whichhad beenmissed byregular X-rayand plain CTscan. 3D-CT isessentially acomputerprogram whichsubtracts softtissue from a CT.
  10. 10. EMG-Nerve conduction studies
  11. 11. Neurometers• Neurometers measure the three types of sensory nerves, at the frequencies specific for each nerve.. A beta, A delta and C fibers• Electrical current is applied at one of three frequencies, and the patients reports when he just begins to felt the electrical current• This current perception threshold determine if the nerve response is in the normal range, or damaged• This test is specific for sensory nerves• Raj, P., Chado, H., Angst, M., Heavner, J., Dotson, R.,Brandstater, M., Johnson, B., Parris, W., Finch, P.,Shahani, B.,Dhand, U., Mekhail, N., Daoud, E., Hendler,N., Somerville, J., Wallace, M., Panchal, S., Glusman, S., Jay, G., Palliyath, S., Longton, W., Irving,G.“Painless Electrodiagnostic Current Perception Threshold and Pain Tolerance Threshold Values in CRPS Subjects and Healthy Controls: A Multicenter Study.” Pain Practice. Vol. 1, No. 1: 53, 60, March, 2001.• Masson EA, Boulton AJ. The Neurometer: validation and comparison with conventional tests for diabetic neuropathy.,. Diabet Med. 1991;8 Spec No:S63-6.•
  12. 12. Vascular flow studies (Doppler)This test will determine if there is a blockage or compression of a blood vessel.Print outs of actual studies are shown below. The results of the tests are visuallyobvious. If the vessel is unobstructed, or not compressed, then the pulse is clearlyseen on the recording device. Blockage produces the flat line.
  13. 13. SPECT Scan• A single-photon emission computerized tomography (SPECT) scan helps analyze the function of internal organs.• A SPECT scan is a type of nuclear imaging test, which means it uses a radioactive substance and a special camera to create 3- D pictures.• A SPECT scan can show how blood flows in the heart or what areas of the brain are more active or less active• SPECT can be helpful in determining which parts of the brain are being affected by dementia, clogged blood vessels, seizures, encephalitis, and head injuries• Areas of bone healing or cancer progression usually light up on SPECT scans, to help diagnose hidden bone fractures, and the progression of cancer that has spread to the bones.
  15. 15. Indium 111 Scan• The indium white blood cell scan, also called "indium leukocyte imaging," "indium-111 scan” is a nuclear medicine procedure in which white blood cells are removed from the patient, tagged with the radioisotope Indium-111, and then injected intravenously into the patient. The tagged white blood cells subsequently localize to areas of relatively new infection. The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy
  16. 16. Indium 111 Scan Image• 56 year old female presents• with nausea, flushing,• and low back pain.• No history of hypertension.• Blood work revealed elevated• levels of white blood cells,• and sed rate.• The right kidney showed• markedly increased uptake,• Compatible with a severe• acute kidney infection
  17. 17. Gallium Scan• A gallium scan is a type of nuclear medicine study that uses a radioactive tracer to obtain images of a specific type of tissue, or disease state of tissue. Gallium salts like gallium citrate and gallium nitrate are used. The form of salt is not important, since it is the freely dissolved gallium ion Ga+3 which is active. For these applications, the radioactive isotope gallium- 67 (67Ga), which has a decay half-life of 3.26 days, is used.• Gallium-67 is immaged with a gamma camera, with a SPECT camera, or with SPECT/CT hybrid machines.• Gallium is taken up by tumors, inflammation, and both acute and chronic infection, allowing these pathological processes to be imaged by nuclear scan techniques.• Gallium is particularly useful in imaging osteomyelitis that does not involve the spine.
  18. 18. Gallium Scan ImagesGallium scan of the feet,showing gout in the bigtoe, and old stressfractures in themetatarsals. Gallium isbetter for older lesionsthan Indium, but Indium ismore specific for acuteinfection. A bone scan isless specific, and wouldhave also identified theselesions, but couldn’tdifferentiate betweeninfection and inflamation.
  19. 19. PET Scan• PET stands for positron emission tomography• Radioactive medicine is produced in a cyclotron• The radioactive medicine is then tagged to a natural chemical, like glucose, water, or ammonia.• The tagged chemical is a radiotracer.• The radiotracer is injected into the patient• Tomography shows how the trace is taken up by the body• This measures activity and function of an organ
  20. 20. PET Scan ImagesPET scan images can be used to determine the function ofan organ, such brain function, or kidney function
  21. 21. Cine MRI for TMJ• Xavier Tomas, MD, Jaume Pomes, MD, Juan Berenguer, MD, Llorenç Quinto, MD, Carlos Nicolau, MD, Josep Maria Mercader, MD and Vicente Castro, MD: MR Imaging of Temporomandibular Joint Dysfunction: A Pictorial ReviewDentomaxillofac Radiol July 1, 2010 39:5 270-276When the mandible is in the closed-mouth position, the thick posterior band of the meniscus lies immediately above the condyle near the twelve o’clock position.Disk injuries are the most common cause of TMJ dysfunction. MR imaging is currently the standard imaging technique for diagnosing disk injuries. In the early stages of internal derangement, the disk retains its normal shape. Over time, however, the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area, leading to a biconvex or rounded disk (23). Irregular and rounded morphologic features are universally considered to indicate disease
  22. 22. Cine MRI images
  23. 23. Root blocks-Compare to facet block• L3-L4 root Normal Size Neural Foramin Normal Disc Height Root Vertebral slippage due Block to reduced disc space height and lax ligament Normal Vertebral Body Alignment Ligament holding vertebral bodies together
  24. 24. Sympathetic block-Stellate GanglionThis is used to determine if a patient has complex regional pain syndrome inthe arm. If effective, the arm will get warm, and the pain will disappear. Theblock will last about an hour.
  25. 25. Lumbar sympathetic blockA block of the lumbar sympathetic ganglion, which reside outside of the spinalcanal. Used for the diagnosis of complex regional pain syndrome.
  26. 26. Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source ofpain. 0.5% Marcaine should be used, to provide a sensory block, withoutcreating a motor block. If the pain goes away, the source of the pain has beendiagnosed. The effect will last about an hour
  27. 27. Neuropsychological Testing• This is the most reliable way to determine brain damage after a head injury, or severe whiplash• There are a variety of questionnaires involved in this testing, which should take 6-8 hours• These tests will determine memory loss, trouble with executive function-decision making, calculation capabilities, logical thinking, and other function• Preliminary research shows no consistent overlap of abnormalities with PET scans, SPECT scans and EEG. The tests measure different
  28. 28. SCL-90• This test was developed by Len Derogatis, PhD at Johns Hopkins Hospital.• The 90 questions measure the psychological state of a patient, which changes every 5 to 7 days.• This test can be used to measure improvement in depression, anxiety, and other conditions, in response to treatment• The test is self administered
  29. 29. Pain Validity Test• Developed by a team of physicians from Johns Hopkins Hospital, with 7 publications about it• The test can predict which patient will have a moderate or severe abnormality on objective medical tests, with 95% accuracy• The test can predict who will not have any abnormalities with 85% accuracy• The test is self administered over the Internet in English or Spanish, and results returned within 5 minutes after completion• See
  30. 30. Body Jacket with Thigh Spika-a testThis back brace is If the patientthe only back has a fusion,brace which the bracestabilizes the L5- can be usedS1 spinal segment post-as well as the rest operatively.of the lumbarsegments. Thisbody jacket is atest. If the patientgets relief with thisjacket, then this isindicative of anunstable lumbarsegment, and thepatient shouldhave facet blocks,root blocks andprovocativediscograms.
  31. 31. 2 poster brace-a testThis brace stabilizes thecervical spine. The patientwears it for at least a week If ittakes away the pain, then thepatient should have cerivicalfacet blocks, cervical rootblocks, and provocativediscograms. If the patient hasan fusion, the brace can beused post-operatively.
  32. 32. Blood Studies• Routinely, a patient with muscle and joint disease should have a Lyme titer, sed rate, C3, C4, rheumatoid factor, uric acid levels, ANA, SSA, and SSB• Patients with nerve entrapments should have TSH, T4, and thyroid antibody testing• Patients with peripheral neuropathy should have studies for blood sugar, A1C glycohemoglobin, RPR, STS, Lyme titer, B12
  33. 33. Epidurals of no diagnostic valueThe available literature included only blind epidural injections without fluoroscopy.The indicated evidence is positive (Level II-2) for short- term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis.The evidence is lacking with Level III for short and long- term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections.Parr AT, Diwan S, Abdi S.Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician. 2009 Jan-Feb;12(1):163-88.