Marc's Musings | November 2015


Signs and Symptoms of Myofascial Pain: An International Survey of Pain Management Providers and Proposed Preliminary Set of Diagnostic Criteria. Evan Rivers et al. Pain Medicine 2015 16(9) pp 1794-805

This study reviewed 214 responses to a survey of clinicians of the International Association for the Study of Pain (IASP) and the American Academy of Pain Medicine on criteria to diagnose myofascial pain. From this review, a proposed set of diagnostic criteria was developed that included essential items identified by the majority of clinicians. The aim of this study was to move away from a descriptive diagnosis, as found in Simons and Travell’s seminal work, to a more formal set of diagnostic criteria. The proposed set of diagnostic criteria for myofascial pain syndrome suggests that the following be met:

  1. A tender spot is found with palpation with or without referral of pain;
  2. Recognition of symptoms by the patient during palpation of the tender spot;
  3. At least three of the following:
  • Muscle stiffness or spasm;
  • Limited range of motion of an associated joint;
  • Pain worsens with stress;
  • Palpation of a taut band and/or nodule associated with a tender spot.


This is excellent progressive work that more appropriately narrows the criteria into a consensus document which, if supported by appropriate pain medicine communities, can be adopted as formal diagnostic criteria for myofascial pain, which has been lacking for many years. These criteria should allow much more vigorous and standardised research to occur in this area. I support the development of these proposed diagnostic criteria.

Lumbar Diskography and Failed Back Syndrome in Patients Receiving Worker’s Compensation. Anderson et al. Orthopedics 2015 38(11) pp 951-8

This study looked at patients from the Ohio Bureau of Workers' Compensation who underwent discogenic fusion between 1993 and 2013. 909 patients proceeded to spinal fusion without discography (control group) and 682 patients had provocative discography before spinal fusion. Somewhat surprisingly, provocative discography before subsequent spinal fusion was a positive predictor of persistent pain after surgery long term (FBSS) with an odds ratio of 1.4 and significant p-value (<0.05). The rate of persistent pain was 14% in the group exposed to discography and 9% in the group not exposed.


This raises concerns that, in some manner, directly or indirectly, provocative lumbar discography may worsen outcomes for patients proceeding to spinal fusion. This could be from elevated pain levels causing central sensitisation or from subsequent narcotic administration causing central sensitisation or some other form of producing pain in discs other than the operated level. In the absence of clear definitive guidelines that show that provocative lumbar discography helps appropriately triage patients to successful spinal fusion, one would now currently have to recommend it not be performed in a group positive for Worker’s Compensation. This is not to say that the same thing would apply to functional anaesthetic discography where 1ml of local anaesthetic is distilled to only one disc and relief of pain is the index criteria rather than the production of pain. No evidence to date has suggested that functional anaesthetic discography is a risk factor for persistent pain after spine surgery.

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