One of the major difficulties with dealing with the problem of spinal pain is that there is little definitive evidence for what causes pain in the majority of patients [12]. Low back pain is ubiquitous and virtually the normal human condition. Over a lifetime, three fourths of adults have at least one episode of low back pain. The overall incidence of consistent complaints of low back pain is above 30 %, and at least 10 % of adults are complaining at any one time. Low back pain is one of the most common reasons why anyone sees a physician and one of the most common reasons for referral from one physician to another [13].

Many different groups of therapists treat patients. Generalists usually tell patients the problem is musculoskeletal in origin. This is repeated by all those involved with the utilization of passive physical measures and manipulation of the spine. These therapists usually believe in the musculoskeletal therapy and add correctable malalignment as a cause. Neurosurgeons have focused upon the intervertebral disk as the cause of pain and only in the recent past have begun to emphasize the biomechanical causes of spinal pain. Orthopedic surgeons have emphasized instability and disrupted biomechanics which they try to correct. Spinal surgeons today are more likely to have both skills and therefore treat both the disk and biomechanical issues together [14].

Since the majority of the acute spinal pain syndromes relent spontaneously without treatment, it is virtually impossible to ever determine the cause. Once we go beyond a point that spontaneous improvement is likely to occur, then it becomes much more feasible to actually determine a cause of pain and thus develop the most rational solution for that pain. Unfortunately, many physicians still maintain a stereotyped approach based upon a simplistic assessment of symptoms and without any of the diagnostic adjuncts which are currently available. My goal in this presentation is outline my own highly personal approach to spinal problems causing pain in hopes that this will lead others to develop similar protocols which can be expanded as new information becomes available. The emphasis will be upon pain. This is because the majority of spinal surgery is done for pain, not neurological deficit. When neurological deficits are important, they can be emphasized, but my fundamental premise is that most surgery is carried out for pain and in the absence of pain would not be required no matter what the imaging abnormalities. The few exceptions can be emphasized [3, 13, 15].

The first issue is always history. The importance of an accurate history cannot be overemphasized. In the National Low Back Pain Study, the 16 experts who were the investigators in the eight nationally recognized centers of the study made a correct diagnosis and predicted therapy in virtually every patient after the history was complete and before a physical examination was done or imaging studies were reviewed. The correct diagnosis and eventual treatment were chosen in over 90 % of patients, and the changes made after physical examination and imaging studies usually were related to levels rather than fundamental diagnosis. Key issues are the severity of pain, the presence of neurological complaints, the spatial and temporal characteristics of the pain as related to known anatomical radicular patterns, a history of intercurrent disease, and an assessment of the impact of the problem on the patient’s life.

The physical examination is textbook and needs no reiteration here. The only important point is the lack of specificity in the physical examination for the majority of patients. We have all learned in training the triads of reflex, sensory, and motor change which specify the root involved or spinal level. In the National Low Back Study, the textbook triads occurred in less than 1 % of patients subsequently shown to have one or more lumbar roots compressed requiring surgery. The nonspecific findings of back tenderness, lack of range of motion, and focal pain to palpation had no value in diagnosis or decision making. Thus, the physical examination is rarely an important issue unless it demonstrates a significant neurological deficient which requires urgent care [7].

A history of bladder or bowel difficulty or findings of significant perineal sensory loss, sphincter disturbance, or a lower extremity neurological loss one would not want to be permanent may all be indications for urgent care.

Remember the history of intercurrent disease should focus upon the possibility of infection, trauma, or cancer as particular causes of pain and deficits.

Some years ago, the Health Policy Institute formulated back pain guidelines through the consensus process with a large number of experts in the management of spinal pain contributing. The conclusions were that in the presence of acute low back pain with or without sciatica, and the absence of a history of trauma or a significant neurological deficit, no imaging of the back pain problem was required. Expectant management with symptomatic relief could be instituted for at least 1 month and if symptoms persisted, then imaging was recommended. With a history of trauma plane spine films immediately could be obtained but were not required. This is more a legal issue in the United States than a medical consideration. Early mobilization was recommended [3, 15].

Intractable pain not easily relieved, a history of trauma, a concern for intercurrent disease, or a significant neurological deficit may all be reasons for proceeding with immediate evaluation depending upon severity.

From the National Back Pain Study, we learned that even patients with classic herniated disk syndromes virtually all improved spontaneously without any therapy [3]. Thus, my approach to the patient with the herniated disk is to treat the pain and mobilize the patient quickly, and the majority will recover without intervention. If the patient has severe radicular pain which is limiting function, a local steroid injection around the root will nearly always give relief. If the patient has severe pain without such a specific radicular component, then oral steroids for 4 or 5 days will usually provide relief. From the National Low Back Pain data, it appears that nearly all patients will be improving at 1 month and most will be fully functional at that time. Nearly all will recover over 3 months. Indications for surgery become intractable pain that cannot be relieved, a significant or progressive neurological deficient, or a social situation that does not tolerate 1–3 months of incapacitation. Some patients are simply unwilling to wait and want a solution.

Another important issue is mobilization following an acute back syndrome. There is excellent data indicating that patients are benefited by early mobilization. When true disk herniation has occurred, I limit vigorous activity such as strenuous sports and heavy lifting for a minimum of 3 months and typically for 6 months until I have MRI evidence of disk resolution.

Over the years, I have operated upon 7–10 % of those patients referred to me with known acute disk herniations. The remainder recovered spontaneously [7].

It is common for patients with acute and chronic low back pain to be offered physical therapy, analgesics, manipulation therapy, or employ a wide variety of nonoperative treatments which they choose for themselves. In the National Low Back Pain Study, we were able to examine the outcome of these therapies for over 2000 patients. We could not determine that any therapy including physical therapy and exercise, manipulation therapy, and acupuncture had any statistically verifiable influence upon the rate of recovery or the eventual outcome for the patient. Therefore, I use none of them in the management of patients [3, 16].

A major issue for American neurosurgeons is the virtual requirement by the majority of insurance carriers that surgery be preceded by a prolonged course of physical therapy. All the evidence we have suggest that this is a waste of time and money. On the other hand, simply waiting or providing the best symptomatic control possible will allow a substantial number of patients to recover spontaneously. Lack of understanding of this natural history has led many practitioners in the field of spinal pain to believe their specific therapies were responsible for recovery when they are simply observing the natural history of the disease [13].

Even though the majority of patients with acute spinal pain recover, there are a significant number who do not. Because of the enormous numbers of patients with spinal pain worldwide, the small percentage who do not recover remain a very large public health problem. These are the patients typically referred to spinal surgeons for evaluation. When confronted with a patient who has not made the expected spontaneous recovery, it is important to have a rational understanding of spinal pain as a problem and an equally rational evaluation system to try to determine the specific pain generators in an individual patient. It is equally important to identify present or impending neurological issues as well and to understand psychosocial factors.

It is not my purpose in this chapter to try to define every spinal syndrome [12]. Rather it is to emphasize that the history is key in determining whether the patient requires treatment or not and usually will lead to diagnosis and guide that treatment. However, diagnoses made are frequently not specific and need to be verified and supplemented from other sources.

There are some generalities that are helpful. Local spinal pain without radiation suggests an axial problem. This may be muscle/ligament disease, it may be degenerative disk disease, and it may be from vertebrogenic sources. Radicular pain obviously implies root compression. Pseudoradicular pain cannot be differentiated clinically, and referred radicular pain is slowly being recognized as a real clinical phenomenon. It is poorly understood and cannot be completely defined at present. Nevertheless, there is good evidence that irritation of joint capsules, annulus, and posterior longitudinal ligament may produce an apparent radicular pain syndrome without obvious nerve root compression.

The history will usually localize the region of the spine where the pain originates. The severity is a key issue because treatment typically is dependent upon the influence of the pain upon the life of the patient. There is no reason to contemplate a major interventional procedure for a patient whose pain is relatively minor and easily tolerated. The history suggests the possibility of an underlying serious disease. Significant neurological loss emphasizes the need for prompt action. Once the problem is severe enough for referral to a spinal surgeon, then imaging is appropriate if it has not already been accomplished.

The standard examinations are well known. Plane spinal films with oblique and dynamic views are still important. They help appreciate motion and anomalies of the spine which may be important in surgery.

The CT scan is now available with two- and three-dimensional reconstructions. These studies are important for assessment of bony anatomy.

The MRI with and without contrast is important because it gives the best views of soft tissues. The nerve roots and spinal cord with all surrounding structures can be well evaluated [8].

It is important to remember that a rare patient has low lumbar and sacral pain associated with sciatica on the basis of sacral and/or pelvic pathology. So when imaging studies are not definitive for a typical clinical syndrome, then examinations of these areas may be required with the same modalities.

The problem with imaging studies is that nonspecific degenerative changes are present in the majority of the adult population. They do not correlate well with clinical complaints. Simply finding severe degenerative changes in the lumbar spine does not suggest the patient with those changes will even have any symptoms. Minor changes can rarely be associated with specific clinical syndromes.

There are a few obvious diagnoses which correlate very well with the clinical syndrome. Such things as spinal tumor, infection, and spinal stenosis are adequately defined by imaging. The truly herniated disk and/or spinal stenosis is typically well defined also. Severe scoliosis and spondylolisthesis are satisfactorily diagnosed as well. Corrective procedures can be planned for all of such specific syndromes. However, the patient with nonspecific back pain with or without leg pain and degenerative disease without obvious canal or foraminal stenosis may need more definitive evaluation. There has been a great tendency in the past to dismiss these patients without complete exploration of the possible causes of spinal pain and the things which might be done to alleviate it.

Myelography with associated postinjection CT is still occasionally required for specialized situations. For the usual patient with back pain, the myelogram is rarely needed.

The majority of patients who present with spinal pain will not have a definitive diagnosis made on the basis of history, physical examination, and imaging [17]. These measures will be adequate to diagnose almost all patients needing urgent care since progressive neurological deficit is typically related to a specific imaging finding. The large number of patients without these specific abnormalities are usually dismissed by the surgeon and relegated to ineffective modalities of treatment. I personally think that it is important they be investigated for potential interventions by going further to try to identify the causes of spinal pain. These additional steps require the use of diagnostic blockade [10, 11, 13].

The theory and utility of these blocks require some explanation. They are poorly understood by the majority of physicians even those expert in spinal problems. The theoretical basis for their application is straightforward. The first concept indicates that irritating the painful part may reproduce the pain which the patient experiences. Thus, placing a needle onto a painful joint may cause the same pain the patient suggests. Placing the needle close to an irritated nerve root will have the same effect. Thus the first phase of the procedure is to determine if placing the needle may reproduce the patient’s pain. The second concept is that the anesthetization of the structure or its innervation with a local anesthetic will provide temporary respite from the pain. The relief of pain should be related to the duration of action of the anesthetic used or controlled by placebo.

It has been demonstrated that placebo blocks interposed with real blocks will provide the best selectivity and specificity. An alternative proposed by Bogduk is single blinding of the block so the patient does not know the actual structure being blocked and utilization of anesthetic agents of differing durations to assess the veracity of patient responses [13].

Thus, in a typical block situation, the patient does not know what structure is being blocked and does not know the duration of relief expected from the anesthetic. The individual performing the block should be skilled in questioning patients concerning outcome. The patient is queried concerning the production of concordant pain. That is, does the procedure reproduce the patient’s usual pain? Then ideally, a third individual not directly related to the procedure or the patient’s care should query the patient concerning the outcome for pain relief over the relevant time period. Bogduk and several collaborators have studied selectivity and specificity of these blocks and have demonstrated acceptable values which make them useful adjuncts for the determination of the origins of spinal pain. Placebo control blocks approach 90 % accuracy. Those without placebo control fall more in the 70 % range. A positive block (one following which pain is relieved) has greater value than a negative block (one in which pain is not relieved). Accepting the limitations, these blocks can be helpful in determining origins of pain in patients with indeterminate imaging studies and form an important part of the diagnostic capabilities of the spinal surgeon. There is another important point, however. The decision for surgery is not based upon the outcome of these blocks. The purpose of the block is to determine origins of pain to guide a reparative surgical procedure to be the most specific possible. The decision for surgery is based upon the full patient evaluation and the totality of the examinations.