Classification of spinal pain

A useful classification of spinal pain has been put forward by J.P. O’Brien. I use it in a slightly modified form.
Type A pain is dull, deep and aching and is poorly localized. It may be felt in the back or may be referred to distant areas. The distribution of pain is fairly constant but it doesn’t correspond to the known areas of supply of nerves or nerve roots. This ‘sclerotome pain’ may radiate to the eye, chest wall, elbow, groin, lower abdomen or foot, and not surprisingly it can give rise to diagnostic problems. For example, much so-called chronic sinusitis arises from TPs in the neck. Type A pain is the kind most typically associated with TPs.

Type B pain arises from the superficial tissues (skin, fascia, superficial ligaments and muscles, tips of spinous processes). It is felt at the site of trouble and is accurately localized.

Type C pain is due to involvement of the spinal nerves or sympathetic trunk. Stimulation of a spinal nerve causes sharp ‘electric’ superficial pain in a dermatome distribution. There may be paralysis or weakness, loss of reflexes, paraesthesiae or anaesthesia, or autonomic effects. Although Type C pain is described as having a dermatome distribution, remember that the accuracy of dermatome charts is uncertain and indeed the dermatomes themselves are not fixed entities even in the same individual.

Acupuncture can be useful in Type A and Type B pain but has little effect in Type C pain. From the acupuncture point of view the presence or absence of TPs is very important. In general, acupuncture is more likely to be successful in patients who have TPs but there may be success even if they are absent.

Treatment is best carried out with the patient sitting. If there is any fear that the patient will faint, he should be placed sitting on the couch with his back towards you; then, if he starts to faint, he can be brought to lie down without difficulty.

There are numerous sites for needling in the head and neck. The main subdvisions of this area are as follows.

Trapezius and Occiput (G20, G20.5, G21)

Radiation:
– usually forwards and above the mouth

Indications:
– headache, migraine, “sinusitis”, watering eyes
– mild to moderate depression and anxiety

Tips of spinous processes

Indications:
– localized central pain

Cervical articular pillar

Radiation:
– almost anywhere in upper half of body

Indications:
– painful neck, arm
– interscapular pain
– carpal tunnel syndrome
– numbness of hands
– vertigo

Periorbital region

Indication:
– eye disorders

Frontomaxillary sinus area (B1, B2, S2)

Indications:
– recurrent sneezing, allergic rhinitis, hay fever

Deep infratemporal fossa (“sphenopalatine ganglion” –
spg)

Indication:
– painful disorders of trigeminal nerve

The periosteal technique may be used in the neck by needling the cervical vertebrae. The area to aim at is the column of articular process between C3 and C5. The patient is asked to look slightly downwards and slightly to the opposite side; then a 30 mm needle (preferably a fine one) is inserted gently at about 45 degrees. In a thin patient it is generally quite easy to reach the spine (at a depth of about 1 cm), but if the patient is heavily muscled or fat it may be difficult. In such cases it may be safer to restrict oneself to soft- tissue needling.

Part 2