Diagnostic problems in the lumbar spine.

In summary then, the diagnostic problems of the lumbar spine are myriad. They can include conditions which are congenital, tumorous, traumatic, toxic, metabolic, inflammatory, degenerative, infectious, circulatory, mechanical, or psychoneurotic. In addition many of these combinations can be found in the problem now alluded to as "spinal stenosis". Even under this condition, spinal stenosis is classified as congenital and acquired. Under the acquired forms of stenosis there are degenerative, combined stenosis, spondylotic, postoperative, posttraumatic, and miscellaneous types such as that due to Paget's disease or fluorosis. A diagnosis of these conditions can best be made by an experienced historian and examiner since they are never clear-cut and sometimes it is a "sixth sense" of the physician which helps him make the diagnosis. The diagnosis, once suspected, can best be confirmed with proper laboratory tests including myelography and tomography. The treatment, of course, depends specifically on the pathology which is diagnosed. The surgical approach to lumbar spinal stenosis and nerve root entrapment is discussed in Chapter 15. Due to the work of Verbiest and others, much has been done to elucidate this confusing diagnostic area (1, 9). However, much more needs to be learned. We do not completely understand the pain receptors for discogenic pain as well as reasons why various forms of treatment seem to have a 60% success rate no matter what is done. One of the reasons that long-term results are so difficult to come by in this type of work is the fact that these patients cannot be easily categorized by a simple method such as the study of a long bone fracture and the acquisition of a large series with one type of treatment. There are so many psychogenic factors as well as multifaceted treatment regimes used by experts throughout the world that a perfect follow-up with controls is practically impossible. Hopefully, better standardization of diagnostic procedures, nonoperative and operative treatment forms, and analysis of long-term end results may be forthcoming in the future as we elucidate this confusing problem called "low back pain".