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.

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. • 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
www.MarylandClinicalDiagnostics.com
(1) Business Week, pages 104-105, Jan. 27, 1992

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-

6. 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.

7. 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 the
radiation emitted by the injected material. The tracer accumulates at areas of
inflammation, bone growth, cancer and infection. The test is sensitive but not specific.

8. 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

9. 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.
•

11. 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.

12. 3D-CT of the
Wrist, with black
arrow showing
the linear
fracture which
had been
missed by
regular X-ray
and plain CT
scan. 3D-CT is
essentially a
computer
program which
subtracts soft
tissue from a CT.

14. EMG-Nerve conduction studies

15. 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.
•

16. 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 visually
obvious. If the vessel is unobstructed, or not compressed, then the pulse is clearly
seen on the recording device. Blockage produces the flat line.

17. 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.

18. SPECT SCAN IMAGE

19. 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

20. 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

21. 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.

22. Gallium Scan Images
Gallium scan of the feet,
showing gout in the big
toe, and old stress
fractures in the
metatarsals. Gallium is
better for older lesions
than Indium, but Indium is
more specific for acute
infection. A bone scan is
less specific, and would
have also identified these
lesions, but couldn’t
differentiate between
infection and inflamation.

23. 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

24. PET Scan Images
PET scan images can be used to determine the function of
an organ, such brain function, or kidney function

25. 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 39:5 270-276
When 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

26. Cine MRI images

27. 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

29. Sympathetic block-Stellate Ganglion
This is used to determine if a patient has complex regional pain syndrome in
the arm. If effective, the arm will get warm, and the pain will disappear. The
block will last about an hour.

30. Lumbar sympathetic block
A block of the lumbar sympathetic ganglion, which reside outside of the spinal
canal. Used for the diagnosis of complex regional pain syndrome.

31. Peripheral Nerve Blocks-a test
A peripheral nerve block of a mixed motor sensory nerve clarifies the source of
pain. 0.5% Marcaine should be used, to provide a sensory block, without
creating a motor block. If the pain goes away, the source of the pain has been
diagnosed. The effect will last about an hour

32. 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

33. 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

34. 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 www.MarylandClinicalDiagnostics.com

35. Body Jacket with Thigh Spika-a test
This back brace is If the patient
the only back has a fusion,
brace which the brace
stabilizes the L5- can be used
S1 spinal segment post-
as well as the rest operatively.
of the lumbar
segments. This
body jacket is a
test. If the patient
gets relief with this
jacket, then this is
indicative of an
unstable lumbar
segment, and the
patient should
have facet blocks,
root blocks and
provocative
discograms.

36. 2 poster brace-a test
This brace stabilizes the
cervical spine. The patient
wears it for at least a week If it
takes away the pain, then the
patient should have cerivical
facet blocks, cervical root
blocks, and provocative
discograms. If the patient has
an fusion, the brace can be
used post-operatively.

37. 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

38. Epidurals of no diagnostic value
The 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.