Wall Street Gazette Misnomer, Part 2

By | July 7, 2011


Continuing our analysis of the article “Diagnosing a Patient as a Faker” from Tuesday’s Wall Street Journal, David Kloth, past president of the American Society of Interventional Pain Physicians, makes an interesting comment about the subjective nature of pain. He talks about the different responses of patients with nerve root compression.

If you are considering the diagnosis of a pancreatic tumor an anatomical test such as an abdominal MRI is or primary importance.

The problem with his statement is that our evaluation of the degree of nerve root compression is also subjective. We know that the appearance of a nerve root on MRI is poorly correlated with pressure on the nerve and nerve activity. We are making the epistemological mistake of using an anatomical test to make a neurophysiologic evaluation. I cannot tell you how many times I have seen the same patient return with a complaint of increased radicular low back pain and then find that the repeat MRI is either unchanged or improved from the previous study. It is crucial to understand that an MRI is a better marker for pain than a measure of it.


On the other hand if you are trying to manage diabetes, this simple physiological test to determine the blood glucose level is much more helpful than a CAT Scan of the pancreas.

Even when indirect measures of nerve function, such as Nerve Conduction Velocity tests and EMG (electromyograms) are available the role of the brain in integrating the incoming signals from the injured nerves is highly complex. I always tell my patients that disc disease resulting in nerve root compression is partly a disease of the disc, partly a disease of the nerve and partly a disease of the brain, because only at the level limbic system in the brain do the abnormal nerve signals resulting from the compressing disc actually be come pain. Before that point they are just abnormal nerve signals.


Tomorrow we will look at the multifaceted problem of prescription drug abuse and what can be done about it. We will also look at the secondary problems this abuse creates even in patients who use these medicines appropriately.


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