As a medical student, I was bemused and puzzled by the diagnostic conundrums facing Internal Medicine when dealing with ‘Pyrexia or Fever of Unknown Origin”, (PUO or FUO). My bemusement of the splitting of hairs turned to frustration which led me to embrace Surgery in general and Orthopedics in particular, where the diagnosis of a fracture is usually obvious to everyone and the treatment is straight forward – reduction and stabilization.
It is somewhat ironic that after embracing Orthopedics, I choose to specialize in Spinal Disorders where idiopathic spinal pain or spinal pain of unknown origin remains our diagnostic dilemma.
The diagnostic problem would be so much easier if there was series of blood tests available to help us determine exactly what the causative pathology was and where it was located.
We can demonstrate and localize spinal pathology very precisely, but as the Radiology report often concludes – “Clinical correlation advised.” (as the radiology cannot tell what levels the pain generator is located). We have some success with pain and symptom stimulation tests such as stress discography and selective nerve root blocks but there are false positives and negatives, and thoughts of ‘water boarding’ come to mind.
In a spine with multiple levels of significant pathology, the dilemma is to ascertain which levels are producing the presenting symptoms and to determine which levels require surgery — minimal surgery is not just ‘minimally invasive’ but also just operating on the symptomatic levels — just the minimal number of pathologic levels.
Of course, the sinister causes of spinal pain (e.g. fracture, tumor, infection) do not have these diagnostic problems as imaging biopsy and blood tests can accurately locate and diagnose the symptomatic pathology.
So, my time managing spinal trauma was much more accurate, successful and rewarding than my time managing spinal pain.
There have been amazing major advances in the surgical management of spinal disorders but not as much in advances in the management of the difficult problem of non-specific or idiopathic spinal pain.
We have all heard of the comments on an idiopathic diagnosis: “The patient is pathetic and the doctor is an idiot.”
-Anthony Dwyer, M.D.
(The opinions stated in this blog are those of the author Dr. Anthony Dwyer and not necessarily those of the American College of Spine Surgery).