pain pattern explanation forms

Pain Pattern Explanation Forms

1. Cervical Facet Pain Pattern

2. Cervical Radicular/Dynatome Pain Pattern

3. Costotransverse Joint Pain Pattern

4. Fibromyalgia Points

5. Hip Joint Pain Pattern

6. Lumbar Dermatomes: Chemical Radiculitis

7. Lumbar Dermatomes: Disc Pathology

8. Lumbar Disc Pathology Healed

9. Lumbar Epidural Fibrosis

10. Lumbar Facet Pain Pattern

11. Lumbar Stenosis

12. Sacroiliac Joint Pain Pattern

13. Thoracic Facet Pain Pattern

14. Upper Cervical Joint Pain Pattern

The OEA pain pattern handouts are PDF files that can be used for patient

education and marketing. They help you explain your diagnosis with original

illustrations that the patients can take home with them. There is limited text so

you can tell your explanation of the treatment plan.

The pain patterns can be printed in color or black and white. Once purchased, our

business card will be replaced with yours to personalize each handout.

Each illustration is based on the pain patterns that have been established in books

or research articles when available. Normal anatomy and pathoanatomy

illustrations are shown for the clinician to explain the diagnosis to the patient and

how their treatment can influence the pain generator. These can also be utilized

as marketing tools.

The following pages are some guidelines that can be utilized to explain the

handouts to patients.

Esteban

Sticky Note

Click on each title to link you to the specific pain pattern. You can click on the (c) 2012 www.oeabrochures line to bring you back to this page.

Cervical Facet Pain Pattern

The cervical facet joints are the joints of the

neck.

Neurophysiologic studies have shown that

cervical facet‐joint capsules are sources of

neck pain.1

Dwyer et al.2 established pain patterns of the

cervical facet joints.

o Parasagittal cervical and cervicothoracic pain.

o Do not/rarely cause midline cervical pain or arm pain.

o Do not cross to the other side. Left facet joints do not cause

right sided pain and vice versa.

o Can be unilateral pain (from joints on one side of the spine) or

bilateral (pain from both joints on both sides of the spine.)

When pain is chronic or severe, the pain can extend beyond these

pain patterns.

Facet joints do not have to show degeneration on diagnostic imaging

to be painful. This is usually due to a joint capsule sprain (synovitis).

Facet joints that do show degeneration on diagnostic imaging can be

either a joint capsule sprain (synovitis) or degeneration (arthrosis) or

both.

Consider that the patient may have more than one pain generator.

Cervical facet joints limited cervical axial rotation and therefore

rotation is often the most painful motion for patients with facet joint

pain.3

1. Cavanaugh JM, Lu Y, Chen C, Kallakuri S. Pain generation in lumbar and cervical facet

jointsJournal of Bone and Joint Surgery, American Volume. 2006 Apr;88. Suppl 2:63‐7.

2. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal

volunteers. Spine. 1990;15(6):453‐457.

3. Sizer et al, Differential Diagnosis of Local Cervical Syndrome versus Cervical Brachial Syndrome.

Pain Practice, Volume 1, Number 1, 2001 21–35.

Cervical Radicular Dermatomes and Dynatome/

Pain Patterns

Dermatomes are regions of altered

sensation from irritated or damaged nerve

roots

Symptoms that follow a dermatome

(numbness, tingling or pain) may indicate

a pathology that involves the related

nerve root. These symptoms can follow

the entire dermatome or just part of it.

Dynatomes are the distribution of

referred pain (unlike dermatomes which only deal with sensation)

from cervical root irritation. Slipman et al.1, have establish the

cervical dynatomes. They are similar as dermatomes but not exactly

the same.

When symptoms cover more than one dermatome/dynatome it may

suggest more severe pathology and involvement of more than one

nerve root.

1. Slipman CW, Plastaras CT, Palmitier RA, Huson CW, Sterrenfeld EB. Symptom provocation of

fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to

dermatomal maps. Spine. 1998;23:2235‐2242.

2. Sizer et al, Differential Diagnosis of Local Cervical Syndrome versus Cervical Brachial Syndrome.

Pain Practice, Volume 1, Number 1, 2001 21–35.

Costotransverse Joint Pain Pattern

Costotransverse joints are the joints where

the ribs attach to the spine.

Young et al established pain patterns for the

costotransverse joints.1

Costotransverse joints

o Cause parasagittal thoracic pain.

o Do not/rarely cause midline thoracic pain or arm pain.

o Do not cause pain that crosses to the other side. The right

costotransverse joints do not cause left side thoracic pain and

vice versa.


bilateral (pain from both sides of the spine).


pain patterns.

Costotransverse joints do not have to show degeneration on

diagnostic imaging to be painful. This is usually due to a joint sprain

(synovitis).

Costotransverse joints that do show degeneration on diagnostic

imaging can be either a joint sprain (synovitis) or degeneration

(arthrosis) or both.


1. Young BA, Gill HE, Wainner RE, Flynn TW. Thoracic Costotransverse Joint. Pain Patterns: a study

in normal volunteers. BMC. Musculoskeletal Disorders 2008, 9:140.

2. Sizer PS, Phelps V, and Azevedo E. Disc Related and Non‐Disc Related Disorders of the Thoracic

Spine. Pain Practice, Volume 1, Number 2, 2001 136–149.

Fibromyalgia Points

Criteria for Fibromyalgia1

Widespread pain for at least three months,

defined as the presence of all of the following:

Pain on the right and left sides of the body

Pain above and below the waist (including

shoulder and buttock pain)

Pain in the axial skeleton (cervical, thoracic or lumbar spine, or anterior

chest)

Pain on palpation with a 4‐kg force in 11 of the following 18 sites (nine

bilateral sites, for a total of 18 sites):

1. Occiput: at the insertions of one or more of the following muscles:

trapezius, sternocleidomastoid, splenius capitus, semispinalis capitus

2. Lower cervical: at the anterior aspect of the interspaces between the

transverse processes of C5–C7

3. Trapezius: at the midpoint of the upper border

4. Supraspinatus: above the scapular spine near the medial border

5. Second rib: just lateral to the second costochondral junctions

6. Lateral epicondyle: 2 cm distal to the lateral epicondyle

7. Gluteal: at the upper outer quadrant of the buttocks at the anterior

edge of the gluteus maximus muscle

8. Greater trochanter: posterior to the greater trochanteric prominence

9. Knee: at the medial fat pad proximal to the joint line

1. Wolfe F, Smythe HA, Yunas MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis & Rheumatism. 1990;33:160–72.

Hip Joint Pain Pattern

The hip joints are the joints where the thigh

bone (femur) meets the pelvis.

Lesher et al.1 established pain patterns for

the hip joints.1

Hip joints

o Cause hip, buttock, groin, thigh and

even lower leg pain (10%).

o Do not/rarely cause back pain

o Can be unilateral pain (left or right hip) or bilateral (pain from

both hips).


pain patterns.

Hip joints do not have to show degeneration on diagnostic imaging to

be painful. This is usually due to a joint capsule sprain (synovitis).

Hip joints that do show degeneration on diagnostic imaging can be

either a joint sprain (synovitis) or degeneration (arthrosis) or both.


1. Based on: Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M. Hip Joint Pain Referral

Patterns: A Descriptive Study. Pain Medicine. 2008. 9(1):22‐25.

Lumbar Dermatomes: Chemical Radiculitis

Discs do not have to bulge to cause

pain from the nerve root. They can leak

chemicals and produce nerve root pain

following a dermatomal pattern.

Dermatomes are regions of altered

sensation from irritated or damaged nerve roots.

Symptoms that follow a dermatome (numbness, tingling or pain) may

indicate a pathology that involves the related nerve root. These

symptoms can follow the entire dermatome or just part of it.

When symptoms cover more than one dermatome it may suggest

more severe pathology and involvement of more than one nerve

root.

1. Sizer PS Jr, Phelps V, Matthijs O. Pain generators of the lumbar spine. Pain Pract. 2001;1(3):255‐

273.

2. Sizer PS Jr, Phelps V, Dedrick G, Matthijs O. Differential diagnosis and management of spinal

nerve root‐related pain. Pain Pract. 2002;2(2):98‐121.

3. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of

pain response to tissue stimulation during operations on the lumbar spine using local

anesthesia. Orthop. Clin. North Am. 1991;22(2):181‐187.

Lumbar Dermatomes: Disc Pathology

Lumbar Dermatomes

In this example, nerve root pain is due to disc

pathology.

Dermatomes are regions of altered sensation

from irritated or damaged nerve roots.

Symptoms that follow a dermatome (numbness, tingling or pain) may indicate a

pathology that involves the related nerve root. These symptoms can follow the

entire dermatome or just part of it.

When symptoms cover more than one dermatome it may suggest more severe

pathology and involvement of more than one nerve root.

Disc Pathology: Lumbar Disc Pathology has various presentations.

1. Normal Disc

2. Internal Disc Disorder: Small tear at the inner part of the outer third of the disc where the

annulus is innervated.

3. Outer Disc Disorder: Larger tear that extends to the outer part of the annulus. Discography

is a good way to diagnose the morphology of the disc and establish the disc as a pain

generator.

4. Protrusion: Small disc bulge and the outer layers of the annulus are intact

5. Prolapse: Large disc bulge that breaks through the layers of the annulus but not the

posterior longitudinal ligament (PLL).

6. Extrusion: Large disc bulge that breaks through the layers of the annulus and the PLL. This

often causes pain in a multitude of dermatomes.

7. Sequestration (not shown; rare): Disc fragment breaks away from the rest of the discs.


273.

2. Sizer PS Jr, Phelps V, Dedrick G, Matthijs O. Differential diagnosis and management of spinal

nerve root‐related pain. Pain Pract. 2002;2(2):98‐121.

3. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of

pain response to tissue stimulation during operations on the lumbar spine using local

anesthesia. Orthop. Clin. North Am. 1991;22(2):181‐187.

Lumbar Disc Pathology Healed

Lumbar Disc Pathology has various

presentations

1. Normal

2. Internal Disc Disorder

3. Outer Disc Disorder

4. Protrusion

5. Prolapse

6. Extrusion

7. Sequestration (not shown): rare

Discs do heal. However, they have poor blood

supply and therefore do not heal as well as

structures that have better blood supply. Therefore, it is

essential to create an optimal healing environment for the discs. This includes

proper nutrition and exercise.

This handout is designed to help the patient understand what is causing their pain

and know that they can heal. Patients that focus on the negative sides of their

condition may not heal as quickly. Therefore, this handout shows a list of

treatment options that can help improve healing.

Lumbar Epidural Fibrosis

Chronic disc pathology and radiculitis can create epidural fibrosis

(scar tissue in the epidural space). This scar tissue can cause severe

leg pain.

This condition is more commonly seen after a lumbar surgery.

Some people scar more than others. When this happens inside the

spine, it can lead to epidural fibrosis.

Sometimes regular epidural can help this condition, but other times

a special procedure is needed. This special procedure is called epidural lysis of

adhesions or the Racz catheter procedure.

Pain patterns have not been established for lumbar epidural fibrosis. The two

most common levels for lumbar surgery are L4‐5 and L5‐S1 and therefore the L5

and S1 dermatomes were used for the pain pattern in this handout.

Lumbar Facet Pain Pattern

Neurophysiologic studies have shown that lumbar

facet‐joint capsules are a source of pain.1

Fukui et al.2 established pain patterns for the lumbar

facet joints:

There is a large overlap where the lumbar facet joints

cause pain. However, it is also important to note where facet joints do not cause

pain.

The diaphragm shows where joints most commonly cause pain.

Lumbar facet pain typically cause:

o Parasagittal lumbar and buttock pain (40‐70%), lateral hip (10‐30%) and

occasionally posterior thigh (10‐30%) and groin pain (5‐10%).

o Do not/rarely cause midline lumbar pain or lower leg pain.

o Do not cross to the other side.

o Can be unilateral pain (from joints on one side of the spine) or bilateral

(pain from both sides of the spine).

When pain is chronic or severe, the pain can extend beyond these pain patterns.

Facet joints do not have to show degeneration on diagnostic imaging to be

painful. This is usually due to a joint sprain (synovitis).

Facet joints that do show degeneration on diagnostic imaging can be either a

joint sprain (synovitis) or degeneration (arthrosis) or both.


1. Cavanaugh JM, Lu Y, Chen C, Kallakuri S. Pain generation in lumbar and cervical facet

jointsJournal of Bone and Joint Surgery, American Volume. 2006 Apr;88. Suppl 2:63‐7.

2. Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y. Distribution of Referred Pain

From the Lumbar Zygopophyseal Joints and Dorsal Rami. The Clinical Journal of Pain.

1997; 13: 303‐307.


273.

Lumbar Stenosis

Stenosis is the medical term for narrowing.

The lumbar spine has five vertebral bodies in

the lower back. Nerve roots exit off the spinal

cord travel though the spinal canal and then

through small openings on the sides of the

vertebrae (foramen). When the foramen is narrowed or has osteophytes

(bone spurs) causing compression or irritation to the nerve roots, this is

called foraminal stenosis.

The entire spinal canal can be narrowed by a combination of building discs,

facet joint hypertrophy and/or ligamentum flavum hypertrophy. When this

occurs and the buttock and leg symptoms are bilateral, this is central

stenosis.

Lumbar stenosis can result is a variety of symptoms. Typically, symptoms

are felt in the buttock and legs but can be in the low back as well. Keep in

mind that if a spine is degenerated enough for stenosis, there may also be

facet joint arthrosis as well. The symptoms can be tingling (paresthesia),

pain, numbness, or weakness (in order of severity).

The lumbar dermatomes are listed for referral patterns of numbness or

tingling per nerve root as adapted from several anatomy books.

Sacroiliac Joint Pain Pattern

Sacroiliac joints are the joints of the pelvis where the

sacrum connects to the ilium.

The sacroiliac joint is a source of pain.

Fortin et al.1 established pain patterns for the

sacroiliac joint:

o Typically causes buttock pain but can radiate

diffusely down the posterior thigh

o Does not/rarely cause midline lumbar pain.

o Does not cross to the other side.

o Can be unilateral pain (from joints on one side of the pelvis) or

bilateral (pain from both sides of the pelvis).


pain patterns.

Sacroiliac joints do not have to show degeneration on diagnostic

imaging to be painful. This is usually due to a joint sprain (synovitis).

Sacroiliac joints that do show degeneration on diagnostic imaging

can be either a joint sprain (synovitis) or degeneration (arthrosis) or

both.


1. Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral maps upon applying a new

injection/arthrography technique. Part I: Asymptomatic volunteers. Spine. 1994;19(13):1475‐

1482.

2. Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain referral maps upon applying a new

injection/arthrography technique. Part II: Clinical evaluation. Spine. 1994;19(13):1483‐1489.

3. Sizer PS Jr, Phelps V, Thompsen K. Disorders of the sacroiliac joint. Pain Pract. 2002;2(1):17‐34.


273.

Thoracic Facet Pain Pattern

Dreyfuss et al.1 established pain patterns for

the thoracic facet joints:

Thoracic facet pain:

o Causes parasagittal cervicothoracic and

thoracic pain.

o Does not/rarely cause midline thoracic

pain or arm pain.

o Facet joint pain does not cross to the other side.


bilateral (pain from both sides of the spine).


pain patterns.

Facet joints do not have to show degeneration on diagnostic imaging

to be painful. This is usually due to a joint sprain (synovitis).


either a joint sprain (synovitis) or degeneration (arthrosis) or both.


1. Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophyseal joint pain patterns. A study in normal

volunteers. Spine. 1994;19(7):807‐811.

2. Dryfuss P, Tibiletti C, Dreyer S, Sobel J. Thoracic zygapophyseal pain: A review and description of

an intraarticular block technique. Pain Digest. 1994;4:44‐52.

3. Sizer PS, Phelps V, and Azevedo E. Disc Related and Non‐Disc Related Disorders of the Thoracic

Spine. Pain Practice, Volume 1, Number 2, 2001 136–149.

Upper Cervical Joint Pain Pattern

The upper cervical joints are the top

two joints of the neck. They are

called the altanto‐occipital (C0‐1)

joint and atlanto‐axial (C1‐2) joint.

These joint can cause upper cervical pain and even headaches. These

headaches are called cervicogenic headaches. They can feel as severe

as migraines but do not have an associated aura.

Dreyfus et al.1 established pain patterns of the cervical facet joints.

o Parasagittal cervical and cervicothoracic pain.

o The altanto‐occipital (C0‐1) joint is generally more diffuse in

the sub‐occipital region.

o The atlanto‐axial (C1‐2) joint is typically a smaller pain pattern

behind the ear.

o Do not/rarely cause midline cervical pain or arm pain.

o Do not cross to the other side. Left joints do not cause right

sided pain and vice versa.


bilateral (pain from both joints on both sides of the spine.)


pain patterns.

Joints do not have to show degeneration on diagnostic imaging to be

painful. This is usually due to a joint capsule sprain (synovitis).


either a joint capsule sprain (synovitis) or degeneration (arthrosis) or

both.


1. Dreyfuss P, Michaelsen M, Fletcher D. Atlanto‐occipital and lateral atlanto‐axial joint pain

patterns. Spine. 1994;19:1125‐1131.

2. Sizer PS, Phelps V, Azevedo E, Hay A, Vaught M. Diagnosis and Management of Cervicogenic

Headache. Pain Practice, Volume Pain Practice. 2005;5(3): 255–274.

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