Pain in Spine: Which Diagnostic Test Do I Need?

Though most spinal problems cause symptoms of pain in the neck, back, arm or leg, the underlying cause of that pain can differ for different patients. It is important to understand the exact source of the pain in order to apply the right treatment. While some spinal ailments (infection, fracture, tumour) are fairly straightforward, other conditions require specific diagnostic testing. Further, sooner an accurate diagnosis is made, the sooner a patient can be given appropriate treatment for the pain and return to everyday activities.

Medical history

A medical history in form of questions is important for a doctor in determining the source of pain in spine. These range from the onset of the pain (sudden or gradual), situations that worsen or improve pain, any prior history of similar pain, along with recent illnesses and associated symptoms.

Physical examination

During a physical examination, a doctor looks for the following:

1. Signs of nerve damage as patient walks on heels, toes, and sole of feet.
2. Reflexes, using a reflex hammer at the knee and behind the ankle.
3. Testing of nerve, muscle strength and any tension on sciatic nerve by asking patient to lift leg while lying flat on the back.
4. Testing for sensation using pin, paper clip or sharp object.

Depending on the patient's response, the doctor may also carry out a pelvic, abdominal or rectal examination to look for signs of any disease that could be causing the pain in spine. 

Imaging tests

1. X-rays - An x-ray uses radioactive materials to generate pictures of bone, and in case of spinal testing, it can look for any signs of decrease in height between spinal discs, bone spurs, hardening of nerve bundles, facet hypertrophy, and instability due to extension of limbs. Patient is asked to lie still on a table and hold specific positions while x-ray images are taken of the spine.
2. Magnetic Resonance Imaging (MRI) scan - An MRI scan creates computer-generated images using magnetic and radio waves. While an x-ray can only take images of the bone, MRI can cut through the spine and detect any abnormality in soft tissues like nerves and ligaments. It can also show dehydration of spinal discs, facet joint hypertrophy, stenosis or herniated disc. The patient is asked to lie on a table that slides into machine with large, round tunnel. Images taken by the machine's scanner are relayed to a computer. Read more here. 
3. Computer Assisted Tomography (CAT) scan - A CAT scan can show images of both bone and soft tissue. It generates cross-sectional images of spine, allowing each section of spine to be viewed separately. It can detect degeneration of bones and spine disc issues. However, the CAT scan images are not as clear as x-ray or MRI. CAT scan is often used along with myelogram to make soft tissues more easily visible. Patient is asked to lie on a table that slides into a large scanner.
4. Myelogram - It is an older test that examines spinal cord and spinal canal. Using a spinal tap (inserting a needle in the lower back and into the spinal canal), a doctor injects a special x-ray dye into the spinal sac. The dye mixes with spinal fluid and shows up in x-ray images. The images outline the spinal cord and nerve roots, which allow the doctor to identify any issue with the discs. The patient lies on a tilting table; flow of the dye in the spinal region as the table tilts shows any indentation or abnormal shape. Myelogram is often combined with x-rays or CAT scan to give better images.
5. Bone scan - A bone scan is used to locate the spinal area causing a problem. A radioactive material called a 'tracer' is injected into the bloodstream through an IV injection. The chemical travels to and attaches itself to any area in a bone undergoing rapid changes. The radioactivity sent out by the tracer is captured in form of images by a special camera. A bone scan helps to identify a problem area such as bone tumours or compression fractures, and can also determine bone density and osteoporosis.

Electrodiagnostic tests

Electromyogram (EMG) - Using tiny electrodes that are inserted into muscles of the lower spine, EMG helps to determine the function of nerve roots leaving the spine. It detects abnormal electric signals in the muscles, and can show if a nerve (that is supplied by the muscle) is being irritated as it leaves the spine.

Facet joint block

Facet joint block is a procedure that determines if a facet joint is irritated or inflamed. A local anaesthetic medication is injected into the joint - if all pain being experienced by a patient goes away after a while, the facet joint is identified as the problem.

Bone density screening

Bone densitometry measures the bone density and mineral content using a small amount of x-ray or ultrasound to create images of finer or heel. It is useful in screening patients for a more advanced test, the DXA scan.

The DXA scan or bone density test uses a special X-Ray machine called a DXA (dual energy X-ray absorptiometry) to scan spine, hip or entire body for early loss of bone. (Chronic bone loss can lead to spinal fractures)

Spinal tap

This is used to obtain a sample of the cerebrospinal fluid, which surrounds the spinal cord. Spinal tap checks the content of the fluid and its pressure to look for bleeding, infection, inflammation or rise in protein level that could indicate infection, tumour or haemorrhage around the brain or spinal cord. A needle is inserted into the spinal canal in the lumbar area to obtain the sample.

Discogram

This involves an x-ray exam of the intervertebral discs to determine any damage to them and for assessing surgery. A dye is injected into the centre of the injured spinal disc, which becomes visible on x-ray film and a fluoroscope screen. This test is more advanced than an x-ray or myelogram in identifying disc problems.

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