Clinical diagnosis scale for pain lumbar of facet origin: Systematic review of literature and pilot study

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"Tamanyo" => 47111 ] ] "descripcion" => array:1 [ "en" => "Visual analogue scale for post-surgical pain." ] ] ] "textoCompleto" => "IntroductionLumbar pain is a very common symptom that affects 60–90% of adults at some time in their life, with a prevalence of 20–30%, and is the most common cause of limitation of activities in individuals under 45 years of age.<a class="elsevierStyleCrossRefs" href="#bib0335">1–12</a> It can be caused by damage to multiple anatomical structures as a consequence of the extensive sensory innervation that can itself generate pain, for example pain of radicular, discogenic or sacroiliac origin, musculoligamentous pain or facet pain (FP).<a class="elsevierStyleCrossRefs" href="#bib0365">7,8,11,13–20</a>The facet or zygapophyseal joint is a diarthrodial joint, which is formed by a subcentral bone that is covered by articular cartilage and a synovial membrane, the capsule, and the articular space, which can hold approximately 1–1.5cc of fluid.<a class="elsevierStyleCrossRef" href="#bib0435">21</a> This is a crucial element in the biomechanics of the spinal column, fulfilling two basic functions: control of the direction and range of movement and load distribution. Under normal conditions, the three biomechanical columns described in the lumbar region perform a balanced and modular action, such that the facet joint receives between 0% and 33% of the load depending on posture, but in the case of hyperlordosis, prolonged high loads and disc degeneration, this percentage can rise to as much as 70%. With regard to innervation, the facet joint has dual innervation (except L5–S1) from the medial branch of the primary dorsal ramus of the same level and one level above,<a class="elsevierStyleCrossRef" href="#bib0365">7</a> making the interpretation and treatment of the pain more complex.FP accounts for 15–40% of lumbar pain.<a class="elsevierStyleCrossRefs" href="#bib0440">22–24</a> The first description in the literature of the facet joint as a pain generator was published by Goldwaith in 1911,<a class="elsevierStyleCrossRef" href="#bib0455">25</a> and the term “facet syndrome” was coined in 1933 by Gorme.<a class="elsevierStyleCrossRef" href="#bib0460">26</a> Facet syndrome includes a broad spectrum of disorders originating in the facet joints (osteoarthritis, capsular ligament tears, synovial cysts and articular cartilage lesions/degeneration).<a class="elsevierStyleCrossRefs" href="#bib0430">20,22,26,27</a> Nevertheless, distinguishing pain originating in the facet joints from pain originating in other nearby structures can be challenging.<a class="elsevierStyleCrossRef" href="#bib0470">28</a> For this reason, over time clinical criteria, imaging criteria and criteria based on response to percutaneous procedures have been proposed to achieve this distinction.<a class="elsevierStyleCrossRefs" href="#bib0475">29–37</a> The results suggest that the tests currently available have little to no validity and the evidence is controversial with regard to the diagnosis of FP.<a class="elsevierStyleCrossRefs" href="#bib0440">22,28,38–44</a> This article therefore seeks to develop a diagnostic scale that integrates the presence of signs and symptoms to diagnose lumbar pain of facet origin without the need for a percutaneous surgical procedure.Materials and methodsPhase 1. Systematic review of the literatureA systematic review of the clinical diagnosis of lumbar pain of facet origin was conducted in the main databases (PubMed, Science Direct, Ovid, SciELO, LILACS) based on Mesh terms for PubMed and specific search terms in the other databases: Low Back Pain, Zygapophyseal Joint, Zygapophyseal Joint/diagnosis, Zygapophyseal Joint/diagnostic imaging, Low Back Pain/diagnosis, Low Back Pain/diagnostic imaging, facet joint pains, facet joint syndrome, facet joint/Diagnosis. The search was performed for all articles published up to 31 December 2016, and the eligibility criteria for the studies were based on the PICO framework and the study objectives. All articles featuring lumbar FP in the title, abstract and primary endpoint, out of the diagnostic study, were included. The selected articles were reviewed in full by two assessors, and, in the event of disagreement, the help of a third assessor was used to exclude the article, taking the selected articles as a reference. Articles with bias of any type, methodologies not endorsed by reviewers, articles sponsored by the pharmaceutical industry or the presence of conflicts of interest that could interfere in the analysis of the results were excluded. The studies approved after the two filters described above were those included to perform the systematic review based on the PRISMA checklist.Phase 2. List of signs and symptomsThe clinical characteristics (signs and symptoms) for the diagnosis of lumbar pain of facet origin were obtained from the selected articles. All of the signs and symptoms were submitted to a group of experts made up of 7 neurosurgeons (including experts in spinal pathology and pain) and 4 neurosurgery residents, who critically assessed each sign and symptom, giving a score from 1 to 10, where 1 was the lowest and 10 was the highest.Phase 3. Development of the assessment questionnaireA two-part questionnaire was designed. The first part covered the patient's general identifying characteristics and medical history. The second part incorporated the signs and symptoms obtained in Phase 2 with a score greater than or equal to 50%, assessing the existence of symptoms using dichotomous questions and answers, while for clinical signs the treating physician assigned a score where a positive clinical sign was present.Phase 4. Application of the scale and pilot study in patients with facet painInclusion criteriaThis study included patients referred for neurosurgery consultations with lumbar pain of facet origin, in whom a percutaneous block was planned during June 2017 at the Hospital Universitario San Ignacio.Exclusion criteriaPatients were excluded if structural alterations in a location other than the joint facet that could cause axial (discs, vertebrae and sacroiliac joint) or radicular pain were found on imaging, if they suffered from a chronic or terminal disease, or if they did not agree to participate in the study.Phase 5. Percutaneous treatment and postoperative follow-upThe facet joint block was performed by the same neurosurgeon (JCA). The description of the technique used includes: patient in the prone decubitus position, identification of puncture points with fluoroscopy, injection of the skin at the points selected with local anaesthetic, puncture at each of the levels selected with a 22-gauge spinocath needle and location under fluoroscopy of the needle point at the base of the transverse apophysis on the upper edge at the selected levels, injection of the deposit corticosteroid mix (dexamethasone) with bupivacaine to complete the block of the posterior medial rami of each spinal root selected. For level L5–S1, the L5–S1 facet joint and ala of sacrum are located and the injection performed with the same needle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Follow-up was performed an average of 15 days after the procedure, assessing the response to treatment using the visual analogue scale (VAS) for pain, with an improvement equal to or greater than 70% considered to indicate a positive block.Phase 6. Clinical diagnostic scale proposalAfter performing the block and postoperative follow-up, the pre- and post-surgery pain VAS scores were compared with those signs that were positive in patients with positive bocks. Based on this, a proposal was designed for a clinical diagnostic scale for lumbar pain of facet origin.Data processing and statistical analysisAn exploratory analysis of the information was performed to verify and correct outlying or missing data. The behaviour of the numerical variables was assessed by a univariate analysis, with normality determined using the Shapiro–Wilk test, kurtosis and skewness. Those that met the assumption of normality will be shown as mean and standard deviation as measures of central tendency and dispersion, while the non-normal variables will be shown as median and interquartile range. The categorical variables will be presented as proportions or percentages.Ethical considerations and implementationThe project is institutional in nature, with regional coverage (Bogotá, Colombia), and does not include vulnerable populations. It was conducted under the direction of the Neurosurgery Unit in the Neuroscience Department of the Hospital Universitario San Ignacio and the Pontificia Universidad Javeriana, and the project was authorised and approved by the research office and by the ethics committee. The authors declare that this work did not offer any type of incentive or payment for participation in the study and the participants did not bear any expense for their participation. The active participation of the subjects was not required as the data were extracted from medical records and images taken within the institution. There are no conflicts of interest.ResultsPhase 1. Systematic review of the literatureOf the articles found in the initial search, 73 were initially selected based on their title. Of these, 11 were excluded due to being duplicated and 12 were unavailable. Of the 50 remaining articles, 29 were excluded as they did not meet the inclusion criteria. A total of 21 articles that met the inclusion criteria and 5 found in their associated bibliographies were included for the selection of the clinical diagnostic criteria (signs and symptoms) of lumbar pain of facet origin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Phase 2. List of signs and symptomsBased on the bibliographic search, a total of 36 signs and symptoms for diagnosis of lumbar facet syndrome were divided into 26 symptoms and 10 clinical signs (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Phase 3. Development of the assessment questionnaireOf the 36 signs and symptoms that were submitted to the group of experts, a total of 12 signs and symptoms (8 symptoms and 4 clinical signs) were included in the assessment questionnaire (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). <a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a> give an overview of the new lumbar facet sign and Kemp's test.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Phase 4. Application of the scale and pilot study in patients with FPThirty-one patients were included, the majority of them women (80.6%) with a mean age of 60±11.5 years and a mean pre-surgical pain VAS score of 8±1.7. 45.2% of patients had no history of percutaneous procedures. The L4, L5 and S1 facet block was the most common level operated on. Prior to this, 90.3% of patients underwent a SPECT bone scintigraphy study showing increased radiotracer uptake in the affected joint (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Phase 5. Percutaneous treatment and postoperative follow-upOf the blocks performed (n=31), a total of 28 patients were assessed in postoperative follow-up. The remaining 3 patients did not attend the follow-up and were not included in the final analysis due to a lack of postoperative outcome data. A total of 28 patients were included in the final analysis. 78.6% of them had a positive block (n=22), with an average improvement of 90% and a pain VAS score of 1.75±2.5 (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>, <a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia>Phase 6. Clinical diagnostic scale proposalOf the 28 patients assessed in the pilot study, the most common signs and symptoms were: axial pain (100%), unilateral or bilateral lumbar or paraspinal pain (96.4%), Kemp's sign (82.1%), absence of a radicular pattern (71.4%) and more pain in the lower back than in the leg (64.3%) (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> and <a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). Of the patients with positive blocks (n=22), the most common signs and symptoms found were: axial pain (100%), unilateral or bilateral lumbar or paraspinal pain (95.5%), Kemp's sign (81.8%) alleviation or improvement of pain when resting (77.3%), absence of a radicular pattern and pain induced by pressure at the facet or transverse level (68.2%) and, finally, the new lumbar facet sign (46.4%, SD=3) (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Our proposal of a diagnostic scale based on this pilot study incorporates 6 clinical criteria (3 symptoms and 3 signs); the symptoms included are: (1) unilateral or bilateral axial lumbar pain, (2) improvement or alleviation when resting and (3) absence of a radicular pattern, although a pseudoradicular pattern may be present, but with more lumbar pain than irradiated pain. The clinical signs included are: (1) Kemp's sign, (2) induced pain in the articular or transverse apophysis and (3) sign of facet stress or new lumbar facet sign (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>).<elsevierMultimedia ident="tbl0035"></elsevierMultimedia>DiscussionThe lumbar facet joint has been recognised as a pain generator for more than a century.<a class="elsevierStyleCrossRefs" href="#bib0335">1,25,26,45</a> In spite of this, its diagnosis is still the subject of much debate,<a class="elsevierStyleCrossRefs" href="#bib0345">3–5,8,10,39,42–44,46–50</a>, meaning that there are still no definitive clinical criteria. Everything depends on clinical response after performing a facet joint block.The most recent proposal for a diagnostic scale was made in 1972 by Dr Michel Revel, who proposed the general criteria that bear his name. They comprise 7 clinical signs, with the presence of 5 out of 7 during the assessment of the patient predicting an adequate response to lumbar facet block with a sensitivity of 92% and specificity of 80%.<a class="elsevierStyleCrossRef" href="#bib0585">51</a> More recently, Laslett et al. published an article in 2006 that developed rules for clinical prediction in facet joint blocks, finding that the presence of ≥3 of the criteria (age >50, symptoms that improve when walking, symptoms that improve when seated, pain starts as paraspinal and the extension/rotation test) has a sensitivity of 85% and a specificity of 91% for facet joint pain.<a class="elsevierStyleCrossRef" href="#bib0590">52</a> Following this proposal, many authors have conducted studies of individual signs and symptoms for the diagnosis of facet syndromes, such as the new clinical sign, Kemp's sign, spinal percussion test, springing test and segmental rotation test, among others,<a class="elsevierStyleCrossRefs" href="#bib0395">13,53,54</a> without proposing a clear diagnostic scale. In the latest systematic review performed by Maas,<a class="elsevierStyleCrossRef" href="#bib0525">39</a> the diagnosis of lumbar pain of facet origin had not undergone significant changes in the last 17 years, there was no diagnostic scale available with adequate performance, and, finally, the patient's history and physical examination could only give a cautious direction for diagnosis. However, even this is not conclusive and leads to the use of invasive diagnostic blocks.Our proposal of a diagnostic scale based on this pilot study incorporates 6 clinical criteria (3 symptoms and 3 signs); the symptoms included are: (1) unilateral or bilateral axial lumbar pain, (2) improvement or alleviation when resting and (3) absence of a radicular pattern, although a pseudoradicular pattern may be present, but with more lumbar pain than leg pain. The clinical signs included are: (1) Kemp's sign, (2) induced pain in the articular or transverse apophysis and (3) sign of facet stress or new lumbar facet sign<a class="elsevierStyleCrossRefs" href="#bib0335">1,4–6,8,10,11,24,40,43,47,55</a> (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>).This work offers several advantages. Firstly, it brings together all of the symptoms and clinical signs that have been proposed to date for the diagnosis of lumbar pain of facet origin, providing clinical tools for a pre-surgical confirmatory diagnostic approach, without the need to resort to an invasive diagnostic method. It is also the latest published paper on the clinical diagnosis of lumbar pain of facet origin, correlating the pre-surgical pain VAS score and the post-surgical pain VAS score that translates to a post-operative improvement with confirmatory blocks, as well as a rigorous and detailed methodological process. This pilot study is comparable to those previously reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0375">9,10,14,37,39,46,53,56–60</a> Among the most recently published papers, that of Mars et al., conducted in the United Kingdom in 2015, was similar to this study in terms of methodology. This article was the product of a multi-institutional consensus on the clinical assessment of joint facet pain and therapeutic intra-articular facet joint injection techniques, among other topics. Based on clinical and physical examination, the proposed scale covers the classic signs and symptoms of FP, although few tests/assessments were included based on the evidence described in the literature. The scale was found to have a sensitivity of 80% and a positive predictive value of 74% in the combined movement pattern to identify patients with FP.<a class="elsevierStyleCrossRef" href="#bib0610">56</a>Currently, percutaneous block is still the gold standard for definitive diagnosis of lumbar pain of facet origin. However, the rate of false positive vary according to the published literature: 17–63%,<a class="elsevierStyleCrossRef" href="#bib0635">61</a> 33%,<a class="elsevierStyleCrossRef" href="#bib0640">62</a> 38% false positives and a positive predictive value of 31%,<a class="elsevierStyleCrossRef" href="#bib0645">63</a> between 25% and 41%,<a class="elsevierStyleCrossRef" href="#bib0650">64</a> and between 25% and 44%.<a class="elsevierStyleCrossRef" href="#bib0655">65</a> The rate of false positives may be due to the presence of underlying lumbar pathologies. In the study published by Cohen et al., a possible explanation in patients with negative discography and false positives in facet blocks was myofascial pain, which accounted for a larger proportion of symptoms in these patients. It is well known that myofascial pain is a common cause of lumbar pain, especially in patients in whom other causes have been ruled out (i.e. negative facet blocks and discography).<a class="elsevierStyleCrossRef" href="#bib0640">62</a> On the other hand, Dreyfuss et al. demonstrate that with only 0.5ml of contrast there is an aberrant propagation of contrast medium to adjacent neural structures such as the epidural space and intervertebral foramina, occurring in 16% of cases, which may be denser in patients with discogenic or radicular pain (the symptoms of which are likely to be alleviated once local anaesthetic leaks into these areas), who may have increased false positives in facet blocks compared to those without discopathy or radiculopathy.<a class="elsevierStyleCrossRef" href="#bib0660">66</a> Finally, factors have been studied that might influence response to facet blocks. These are: age, psychological factors, body mass index, previous spinal surgery, gender, smoking, influence of previous sedation and exposure to opiates and anaesthetic volume injected.<a class="elsevierStyleCrossRef" href="#bib0655">65</a>This study is limited by the restriction of the search to a single language, as this precludes signs and symptoms described in other languages. As an additional consideration, based on the explanation and individual criteria provided by the experts in the consensus of signs and symptoms, the decisions could be biased, as is the case of the new lumbar facet sign, devised by a member of the evaluating committee and belonging to our hospital's neurosurgery group. Thirdly, as it is a prospective work, it was found that between the surgical procedure and the postoperative control, patients tended to overlook the complex notion of absolute improvement, which could limit real assessments of pain.We aim to continue this work in a second phase, and are considering carrying out prospective cohort studies with a larger, inter-institutional population, calculating sensitivity, specificity and p-values, among others, for each sign and symptom, thereby validating the scale proposed above internally and externally. We also aim to perform comparisons of cost-effectiveness of clinical diagnostic criteria vs. imaging vs. percutaneous surgical management. We aim to compare our criteria with those proposed by Revel and make other proposals for diagnostic scales that might follow this work.ConclusionAlthough the joint facet has been known as a pain generator for a century, diagnosis based on medical history and physical examination remains inconclusive. The literature is heterogeneous with regard to diagnostic proposals, so we must therefore rely on non-invasive methods such as X-rays, MRI and SPECT bone scans to arrive at an approximate diagnosis. The only currently validated diagnostic gold standard is the lumbar facet block. However, this article proposes a diagnostic scale based on 3 symptoms and 3 clinical signs, which can be correlated with imaging studies and postoperative confirmatory percutaneous blocks.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1184292" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1104632" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1184293" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1104633" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Phase 1. Systematic review of the literature" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Phase 2. List of signs and symptoms" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Phase 3. Development of the assessment questionnaire" ] 3 => array:3 [ "identificador" => "sec0030" "titulo" => "Phase 4. Application of the scale and pilot study in patients with facet pain" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Exclusion criteria" ] ] ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Phase 5. Percutaneous treatment and postoperative follow-up" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Phase 6. Clinical diagnostic scale proposal" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Data processing and statistical analysis" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Ethical considerations and implementation" ] ] ] 6 => array:3 [ "identificador" => "sec0065" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Phase 1. Systematic review of the literature" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Phase 2. List of signs and symptoms" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Phase 3. Development of the assessment questionnaire" ] 3 => array:2 [ "identificador" => "sec0085" "titulo" => "Phase 4. Application of the scale and pilot study in patients with FP" ] 4 => array:2 [ "identificador" => "sec0090" "titulo" => "Phase 5. Percutaneous treatment and postoperative follow-up" ] 5 => array:2 [ "identificador" => "sec0095" "titulo" => "Phase 6. Clinical diagnostic scale proposal" ] ] ] 7 => array:2 [ "identificador" => "sec0100" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-30" "fechaAceptado" => "2018-05-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1104632" "palabras" => array:4 [ 0 => "Low back pain" 1 => "Facet/zygapophyseal joints" 2 => "Zygapophyseal joint block" 3 => "Dorsal branch of the spinal nerve" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1104633" "palabras" => array:4 [ 0 => "Dolor lumbar" 1 => "Articulación facetaria" 2 => "Bloqueo facetario lumbar" 3 => "Rama dorsal del nervio raquídeo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionLumbar pain affects between 60 and 90% of people. It is a frequent cause of disability in adults. Pain may be generated by different anatomical structures such as the facet joint. However, nowadays pain produced by the facet joint has no clinical diagnosis. Therefore, the purpose of this article is to propose a clinical diagnostic scale for lumbar facet syndrome. Materials and methodsThe study was conducted by means of 6 phases as follows, Phase 1, a systematic review of the literature was performed regarding the clinical diagnosis of facet-based lumbar pain based on the PRISMA checklist; Phase 2, a list of signs and symptoms proposed for diagnosis lumbar pain of facet origin was made. Phase 3, the list of signs and symptoms found was submitted to a committee of experts to discriminate the most significant signs and symptoms, these were linked to general sociodemographic variables to develop an evaluation questionnaire; Phase 4, the evaluation questionnaire was applied, including those selected signs and symptoms to a group of patients with clinical diagnosis of facet disease lumbar pain and who underwent a selective facet block. Phase 5, under standard technique selective facet block and subsequent postoperative clinical control at 1 month. Phase 6, given pre and postsurgical results associated with signs present in the patients we propose a clinical scale of diagnosis scale. Descriptive statistics and Stata 12.0 were used as statistical software. ResultsA total of 36 signs and symptoms were found for the diagnosis of lumbar facet syndrome that were submitted to the group of experts, where a total of 12 (8 symptoms and 4 signs) were included for the final survey. 31 patients underwent selective lumbar facet blockade, mostly women, with an average of 60±11.5 years, analogous visual scale of preoperative pain of 8/10, postoperative of 1.7/10, the signs and symptoms most frequently found included in a diagnostic scale were: 3 symptoms (1) axial or bilateral axial lumbar pain, (2) improvement with rest, (3) absence of root pattern, may have pseudoradicular pattern, however, the pain is greater lumbar than pain in the leg and 3 clinical signs (1) Kemp sign, (2) pain induced in joint or transverse process, (3) facet stress sign or Acevedo sign. ConclusionThe clinical diagnosis of lumbar facet pain is still debated. Few diagnostic scales have been postulated, with little or no external validity, so the present study proposes a diagnostic scale consisting of 3 symptoms and 3 clinical signs." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl dolor lumbar afecta entre el 60 y 90% de la población y es una causa frecuente de incapacidad en adultos. Puede ser generado por diferentes estructuras anatómicas, entre las cuales se encuentra la faceta articular. Actualmente, el diagnóstico de dolor lumbar de origen facetario depende de la realización de un procedimiento invasivo (bloqueo selectivo) y no puede hacerse exclusivamente con los hallazgos clínicos. Por lo cual, nuestro objetivo es desarrollar una escala de diagnóstico clínico para el dolor lumbar de origen facetario. Materiales y métodosEl estudio fue realizado por medio de 6 fases de la siguiente manera: Fase 1, se realizó una revisión sistemática de la literatura respecto al diagnóstico clínico del dolor lumbar de origen facetario basado en la lista de chequeo PRISMA. Fase 2, se realizó una lista de los signos y síntomas propuestos para diagnóstico de dolor lumbar de origen facetario. Fase 3, se sometió la lista de signos y síntomas encontrados a un comité de expertos para discriminar aquellos que son más significativos para los mismos, estos fueron unidos a variables generales sociodemográficas para desarrollar un cuestionario de evaluación. Fase 4, se aplicó el cuestionario de evaluación que incluía aquellos signos y síntomas seleccionados a un grupo de pacientes con diagnóstico clínico de dolor lumbar secundario a enfermedad facetaria y que fueron sometidos a un bloqueo facetario selectivo. Fase 5, bajo técnica estándar se realizó bloqueo facetario selectivo y posterior control clínico postoperatorio a un mes. Fase 6, se relacionaron los resultados pre- y posquirúrgicos con los signos positivos y se propone una escala clínica de evaluación diagnóstica. ResultadosSe encontraron un total de 36 signos y síntomas para el diagnóstico de síndrome facetario lumbar que fueron sometidos al grupo de expertos, donde fueron incluidos para la encuesta final un total de 12 (8 síntomas y 4 signos). Treinta y un pacientes fueron sometidos a bloqueo facetario lumbar selectivo, en su mayoría mujeres, con un promedio de 60±11,5 años, escala visual análoga del dolor prequirúrgica (EVAD) de 8/10, posquirúrgica de 1,7/10, los signos y síntomas más frecuentemente encontrados incluidos en una escala diagnóstica fueron: 3 síntomas, 1) dolor lumbar axial unilateral o bilateral, 2) mejoría con el reposo, 3) ausencia de patrón radicular, puede tener patrón pseudorradicular, sin embargo, el dolor es mayor el lumbar que dolor en la pierna. Y 3 signos clínicos, 1) signo Kemp, 2) dolor inducido en apófisis articular o transversa, 3) signo de estrés facetario o signo de Acevedo. ConclusiónEl diagnóstico clínico del dolor facetario lumbar no es aún claro. Pocas escalas diagnosticas han sido postuladas, con poca o baja validez externa, por lo cual, el presente estudio propone una escala diagnóstica conformada por 3 síntomas y 3 signos clínicos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez Vega JC, Acevedo-González JC. Escala de diagnóstico clínico para dolor lumbar de origen facetario: revisión sistemática de la literatura y estudio piloto. Neurocirugia. 2019;30:133–143." ] ] "multimedia" => array:14 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 948 "Ancho" => 950 "Tamanyo" => 65541 ] ] "descripcion" => array:1 [ "en" => "Lumbar facet block at levels L3–4–5–S1." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1066 "Ancho" => 1510 "Tamanyo" => 82680 ] ] "descripcion" => array:1 [ "en" => "Flow diagram of the systematic review." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1113 "Ancho" => 950 "Tamanyo" => 84896 ] ] "descripcion" => array:1 [ "en" => "Lumbar quadrant test or Kemp's test. Patient performs extension combined with rotation of the spinal region of interest, a positive test is considered with reproduction of the patients’ pain that is reduced by walking, standing up or resting." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 458 "Ancho" => 1200 "Tamanyo" => 44990 ] ] "descripcion" => array:1 [ "en" => "New lumbar facet sign. Phase 1: patient lies in the supine decubitus position with lower limbs in a resting position. Phase 2: forced flexion of the hip joint is performed with the leg extended, supporting the lower leg. Phase 3: the patient is asked to apply force downwards, and with the hand on the lower leg, the examiner applies an opposing force in the anterior direction. Phase 4: the examiner suddenly discontinues the opposing force on the lower leg, causing the limb to fall suddenly. Phase 5: before the leg falls onto the surface of the examination table, the examiner stops it from touching the table and lifts it again, holding the lower leg." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1151 "Ancho" => 1583 "Tamanyo" => 48528 ] ] "descripcion" => array:1 [ "en" => "Visual analogue scale for pre-surgical pain." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1151 "Ancho" => 1583 "Tamanyo" => 47111 ] ] "descripcion" => array:1 [ "en" => "Visual analogue scale for post-surgical pain." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1385 "Ancho" => 1998 "Tamanyo" => 163864 ] ] "descripcion" => array:1 [ "en" => "Positive signs and symptoms in the overall population." ] ] 7 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptom \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1–10 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Presence of pain</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral/bilateral lumbar/paraspinal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axial pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Pseudoradicular irradiation patterns</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain irradiating to above the knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper joints irradiate to the sides, groin, hip, lateral thigh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower joints irradiate to posterior thigh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More lumbar pain than leg pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Irradiation may be unilateral or bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with axial rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with torsion movements (lateral flexion) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain in transition from sitting to standing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increases when walking uphill \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increases with prolonged standing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increases with prolonged sitting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Time-based pattern</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Greater stiffness in the morning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Settles down somewhat during the day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stiffness may return later in the day or at night \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dull, deep pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increases with stress factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Revel's criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Improvement or absence of pain</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of radicular pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No pain or improvement with flexion, forward flexion or when seated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Improves when walking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal gait \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of pain in legs or muscle spasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain improves or is alleviated at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Sign</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No signs of neurological impairment (sensory or motor) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New lumbar facet sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain induced by pressure on the ipsilateral facet or transverse process \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evidence of unilateral paravertebral muscle spasm in the affected joint \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Localised paraspinal sensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Range of motion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinal percussion test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Springing test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Segmental rotation test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kemp Sign/lumbar Quadrant test and Extension-Rotation test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018879.png" ] ] ] ] "descripcion" => array:1 [ "en" => "List of the 36 signs and symptoms." ] ] 8 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Date: _______________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient: ____________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ID card no.: _____________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age: ______ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender: M___ F___ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contact telephone no.: __________________________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prior procedures: facet ____ sacroiliac ____ epidural ____ other __________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current procedure: _________________________________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bone scan: ________________________________________________________________________________________________________________________________________________________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre-surg. VAS: ________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-surg. VAS: ________ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018877.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sign/symptom \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral/bilateral lumbar/paraspinal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axial pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain irradiating to above the knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">More lumbar pain than leg pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain worsens with extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain worsens with axial rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absence of radicular pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alleviated or improves at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">New lumbar facet sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain induced by pressure on the facet joint or transverse process \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Range of motion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kemp's Sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018880.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Assessment questionnaire." ] ] 9 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sociodemographic characteristics n=31</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60±11.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Gender % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.6 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Prior procedures % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.2 (14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.7 (12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.7 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.45 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Bone scan % (n):</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.3 (28) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.7 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Procedure (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L1-2-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L2-3-4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L3-4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L3-4-5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L4-5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L4-5-S1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L5-S1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018881.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sociodemographic characteristics." ] ] 10 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Visual analogue scale for pain n=31</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Pre-surgical</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8±1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4–7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Post-surgical</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.75±2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4–7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018884.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pre-surgical and post-surgical pain assessments." ] ] 11 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">General population signs and symptoms (n=28) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pos. % (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Neg. % (n) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral/bilateral lumbar/paraspinal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.4 (27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.6 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axial pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain irradiating to above the knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.4 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.6 (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More lumbar pain than leg pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.3 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.7 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.4 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.6 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with axial rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.4 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.6 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of radicular pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.4 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.6 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alleviated or improves at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.4 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.6 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New lumbar facet sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.4 (13) SD=3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.9 (12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain induced by pressure on the facet joint or transverse process \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.1 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.9 (12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Range of motion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.9 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.1 (23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kemp's sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.1 (23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.9 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018882.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Positive signs and symptoms in the overall population." ] ] 12 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Positive blocks (n=22) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pos. % (n) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral/bilateral lumbar/paraspinal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.5 (21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axial pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain irradiating to above the knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.4 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More lumbar pain than leg pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.1 (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with axial rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.5 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of radicular pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.2 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alleviated or improves at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.3 (17) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New lumbar facet sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.9 (9) SD=2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain induced by pressure on the facet joint or transverse process \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.2 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Range of motion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63.6 (14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kemp's sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.8 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018883.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Positive signs and symptoms in patients with positive blocks." ] ] 13 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at7" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(1) Unilateral/bilateral axial lumbar pain \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(2) Improves or is alleviated with rest \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(3) Absence of a radicular pattern, although a pseudoradicular pattern may be present, but with more lumbar pain than leg pain \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Signs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(1) Kemp's sign \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(2) Induced pain in the articular or transverse apophysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(3) Sign of facet stress or new lumbar facet sign \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018878.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Proposed diagnostic scale for lumbar pain of facet origin." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 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Clinical diagnosis scale for pain lumbar of facet origin: Systematic review of literature and pilot study

Escala de diagnóstico clínico para dolor lumbar de origen facetario: revisión sistemática de la literatura y estudio piloto

Juan Carlos Gómez Vega

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juancarlosgomezvega18@gmail.com

Corresponding author.

, Juan Carlos Acevedo-González

Departamento de Neurociencias, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lumbar pain is a very common symptom that affects 60&#8211;90&#37; of adults at some time in their life&#44; with a prevalence of 20&#8211;30&#37;&#44; and is the most common cause of limitation of activities in individuals under 45 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">1&#8211;12</span></a> It can be caused by damage to multiple anatomical structures as a consequence of the extensive sensory innervation that can itself generate pain&#44; for example pain of radicular&#44; discogenic or sacroiliac origin&#44; musculoligamentous pain or facet pain &#40;FP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">7&#44;8&#44;11&#44;13&#8211;20</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The facet or zygapophyseal joint is a diarthrodial joint&#44; which is formed by a subcentral bone that is covered by articular cartilage and a synovial membrane&#44; the capsule&#44; and the articular space&#44; which can hold approximately 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>cc of fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">21</span></a> This is a crucial element in the biomechanics of the spinal column&#44; fulfilling two basic functions&#58; control of the direction and range of movement and load distribution&#46; Under normal conditions&#44; the three biomechanical columns described in the lumbar region perform a balanced and modular action&#44; such that the facet joint receives between 0&#37; and 33&#37; of the load depending on posture&#44; but in the case of hyperlordosis&#44; prolonged high loads and disc degeneration&#44; this percentage can rise to as much as 70&#37;&#46; With regard to innervation&#44; the facet joint has dual innervation &#40;except L5&#8211;S1&#41; from the medial branch of the primary dorsal ramus of the same level and one level above&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">7</span></a> making the interpretation and treatment of the pain more complex&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">FP accounts for 15&#8211;40&#37; of lumbar pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">22&#8211;24</span></a> The first description in the literature of the facet joint as a pain generator was published by Goldwaith in 1911&#44;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">25</span></a> and the term &#8220;facet syndrome&#8221; was coined in 1933 by Gorme&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">26</span></a> Facet syndrome includes a broad spectrum of disorders originating in the facet joints &#40;osteoarthritis&#44; capsular ligament tears&#44; synovial cysts and articular cartilage lesions&#47;degeneration&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">20&#44;22&#44;26&#44;27</span></a> Nevertheless&#44; distinguishing pain originating in the facet joints from pain originating in other nearby structures can be challenging&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">28</span></a> For this reason&#44; over time clinical criteria&#44; imaging criteria and criteria based on response to percutaneous procedures have been proposed to achieve this distinction&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">29&#8211;37</span></a> The results suggest that the tests currently available have little to no validity and the evidence is controversial with regard to the diagnosis of FP&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">22&#44;28&#44;38&#8211;44</span></a> This article therefore seeks to develop a diagnostic scale that integrates the presence of signs and symptoms to diagnose lumbar pain of facet origin without the need for a percutaneous surgical procedure&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Phase 1&#46; Systematic review of the literature</span><p id="par0020" class="elsevierStylePara elsevierViewall">A systematic review of the clinical diagnosis of lumbar pain of facet origin was conducted in the main databases &#40;PubMed&#44; Science Direct&#44; Ovid&#44; SciELO&#44; LILACS&#41; based on Mesh terms for PubMed and specific search terms in the other databases&#58; Low Back Pain&#44; Zygapophyseal Joint&#44; Zygapophyseal Joint&#47;diagnosis&#44; Zygapophyseal Joint&#47;diagnostic imaging&#44; Low Back Pain&#47;diagnosis&#44; Low Back Pain&#47;diagnostic imaging&#44; facet joint pains&#44; facet joint syndrome&#44; facet joint&#47;Diagnosis&#46; The search was performed for all articles published up to 31 December 2016&#44; and the eligibility criteria for the studies were based on the PICO framework and the study objectives&#46; All articles featuring lumbar FP in the title&#44; abstract and primary endpoint&#44; out of the diagnostic study&#44; were included&#46; The selected articles were reviewed in full by two assessors&#44; and&#44; in the event of disagreement&#44; the help of a third assessor was used to exclude the article&#44; taking the selected articles as a reference&#46; Articles with bias of any type&#44; methodologies not endorsed by reviewers&#44; articles sponsored by the pharmaceutical industry or the presence of conflicts of interest that could interfere in the analysis of the results were excluded&#46; The studies approved after the two filters described above were those included to perform the systematic review based on the PRISMA checklist&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Phase 2&#46; List of signs and symptoms</span><p id="par0025" class="elsevierStylePara elsevierViewall">The clinical characteristics &#40;signs and symptoms&#41; for the diagnosis of lumbar pain of facet origin were obtained from the selected articles&#46; All of the signs and symptoms were submitted to a group of experts made up of 7 neurosurgeons &#40;including experts in spinal pathology and pain&#41; and 4 neurosurgery residents&#44; who critically assessed each sign and symptom&#44; giving a score from 1 to 10&#44; where 1 was the lowest and 10 was the highest&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Phase 3&#46; Development of the assessment questionnaire</span><p id="par0030" class="elsevierStylePara elsevierViewall">A two-part questionnaire was designed&#46; The first part covered the patient&#39;s general identifying characteristics and medical history&#46; The second part incorporated the signs and symptoms obtained in Phase 2 with a score greater than or equal to 50&#37;&#44; assessing the existence of symptoms using dichotomous questions and answers&#44; while for clinical signs the treating physician assigned a score where a positive clinical sign was present&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Phase 4&#46; Application of the scale and pilot study in patients with facet pain</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Inclusion criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall">This study included patients referred for neurosurgery consultations with lumbar pain of facet origin&#44; in whom a percutaneous block was planned during June 2017 at the Hospital Universitario San Ignacio&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Exclusion criteria</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were excluded if structural alterations in a location other than the joint facet that could cause axial &#40;discs&#44; vertebrae and sacroiliac joint&#41; or radicular pain were found on imaging&#44; if they suffered from a chronic or terminal disease&#44; or if they did not agree to participate in the study&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Phase 5&#46; Percutaneous treatment and postoperative follow-up</span><p id="par0045" class="elsevierStylePara elsevierViewall">The facet joint block was performed by the same neurosurgeon &#40;JCA&#41;&#46; The description of the technique used includes&#58; patient in the prone decubitus position&#44; identification of puncture points with fluoroscopy&#44; injection of the skin at the points selected with local anaesthetic&#44; puncture at each of the levels selected with a 22-gauge spinocath needle and location under fluoroscopy of the needle point at the base of the transverse apophysis on the upper edge at the selected levels&#44; injection of the deposit corticosteroid mix &#40;dexamethasone&#41; with bupivacaine to complete the block of the posterior medial rami of each spinal root selected&#46; For level L5&#8211;S1&#44; the L5&#8211;S1 facet joint and ala of sacrum are located and the injection performed with the same needle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Follow-up was performed an average of 15 days after the procedure&#44; assessing the response to treatment using the visual analogue scale &#40;VAS&#41; for pain&#44; with an improvement equal to or greater than 70&#37; considered to indicate a positive block&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Phase 6&#46; Clinical diagnostic scale proposal</span><p id="par0055" class="elsevierStylePara elsevierViewall">After performing the block and postoperative follow-up&#44; the pre- and post-surgery pain VAS scores were compared with those signs that were positive in patients with positive bocks&#46; Based on this&#44; a proposal was designed for a clinical diagnostic scale for lumbar pain of facet origin&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Data processing and statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">An exploratory analysis of the information was performed to verify and correct outlying or missing data&#46; The behaviour of the numerical variables was assessed by a univariate analysis&#44; with normality determined using the Shapiro&#8211;Wilk test&#44; kurtosis and skewness&#46; Those that met the assumption of normality will be shown as mean and standard deviation as measures of central tendency and dispersion&#44; while the non-normal variables will be shown as median and interquartile range&#46; The categorical variables will be presented as proportions or percentages&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical considerations and implementation</span><p id="par0065" class="elsevierStylePara elsevierViewall">The project is institutional in nature&#44; with regional coverage &#40;Bogot&#225;&#44; Colombia&#41;&#44; and does not include vulnerable populations&#46; It was conducted under the direction of the Neurosurgery Unit in the Neuroscience Department of the Hospital Universitario San Ignacio and the Pontificia Universidad Javeriana&#44; and the project was authorised and approved by the research office and by the ethics committee&#46; The authors declare that this work did not offer any type of incentive or payment for participation in the study and the participants did not bear any expense for their participation&#46; The active participation of the subjects was not required as the data were extracted from medical records and images taken within the institution&#46; There are no conflicts of interest&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Phase 1&#46; Systematic review of the literature</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the articles found in the initial search&#44; 73 were initially selected based on their title&#46; Of these&#44; 11 were excluded due to being duplicated and 12 were unavailable&#46; Of the 50 remaining articles&#44; 29 were excluded as they did not meet the inclusion criteria&#46; A total of 21 articles that met the inclusion criteria and 5 found in their associated bibliographies were included for the selection of the clinical diagnostic criteria &#40;signs and symptoms&#41; of lumbar pain of facet origin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Phase 2&#46; List of signs and symptoms</span><p id="par0075" class="elsevierStylePara elsevierViewall">Based on the bibliographic search&#44; a total of 36 signs and symptoms for diagnosis of lumbar facet syndrome were divided into 26 symptoms and 10 clinical signs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Phase 3&#46; Development of the assessment questionnaire</span><p id="par0080" class="elsevierStylePara elsevierViewall">Of the 36 signs and symptoms that were submitted to the group of experts&#44; a total of 12 signs and symptoms &#40;8 symptoms and 4 clinical signs&#41; were included in the assessment questionnaire &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; <a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a> give an overview of the new lumbar facet sign and Kemp&#39;s test&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Phase 4&#46; Application of the scale and pilot study in patients with FP</span><p id="par0085" class="elsevierStylePara elsevierViewall">Thirty-one patients were included&#44; the majority of them women &#40;80&#46;6&#37;&#41; with a mean age of 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;5 years and a mean pre-surgical pain VAS score of 8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&#46; 45&#46;2&#37; of patients had no history of percutaneous procedures&#46; The L4&#44; L5 and S1 facet block was the most common level operated on&#46; Prior to this&#44; 90&#46;3&#37; of patients underwent a SPECT bone scintigraphy study showing increased radiotracer uptake in the affected joint &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Phase 5&#46; Percutaneous treatment and postoperative follow-up</span><p id="par0090" class="elsevierStylePara elsevierViewall">Of the blocks performed &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31&#41;&#44; a total of 28 patients were assessed in postoperative follow-up&#46; The remaining 3 patients did not attend the follow-up and were not included in the final analysis due to a lack of postoperative outcome data&#46; A total of 28 patients were included in the final analysis&#46; 78&#46;6&#37; of them had a positive block &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#44; with an average improvement of 90&#37; and a pain VAS score of 1&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;5 &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#44; <a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Phase 6&#46; Clinical diagnostic scale proposal</span><p id="par0095" class="elsevierStylePara elsevierViewall">Of the 28 patients assessed in the pilot study&#44; the most common signs and symptoms were&#58; axial pain &#40;100&#37;&#41;&#44; unilateral or bilateral lumbar or paraspinal pain &#40;96&#46;4&#37;&#41;&#44; Kemp&#39;s sign &#40;82&#46;1&#37;&#41;&#44; absence of a radicular pattern &#40;71&#46;4&#37;&#41; and more pain in the lower back than in the leg &#40;64&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> and <a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Of the patients with positive blocks &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#44; the most common signs and symptoms found were&#58; axial pain &#40;100&#37;&#41;&#44; unilateral or bilateral lumbar or paraspinal pain &#40;95&#46;5&#37;&#41;&#44; Kemp&#39;s sign &#40;81&#46;8&#37;&#41; alleviation or improvement of pain when resting &#40;77&#46;3&#37;&#41;&#44; absence of a radicular pattern and pain induced by pressure at the facet or transverse level &#40;68&#46;2&#37;&#41; and&#44; finally&#44; the new lumbar facet sign &#40;46&#46;4&#37;&#44; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Our proposal of a diagnostic scale based on this pilot study incorporates 6 clinical criteria &#40;3 symptoms and 3 signs&#41;&#59; the symptoms included are&#58; &#40;1&#41; unilateral or bilateral axial lumbar pain&#44; &#40;2&#41; improvement or alleviation when resting and &#40;3&#41; absence of a radicular pattern&#44; although a pseudoradicular pattern may be present&#44; but with more lumbar pain than irradiated pain&#46; The clinical signs included are&#58; &#40;1&#41; Kemp&#39;s sign&#44; &#40;2&#41; induced pain in the articular or transverse apophysis and &#40;3&#41; sign of facet stress or new lumbar facet sign &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The lumbar facet joint has been recognised as a pain generator for more than a century&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">1&#44;25&#44;26&#44;45</span></a> In spite of this&#44; its diagnosis is still the subject of much debate&#44;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">3&#8211;5&#44;8&#44;10&#44;39&#44;42&#8211;44&#44;46&#8211;50</span></a>&#44; meaning that there are still no definitive clinical criteria&#46; Everything depends on clinical response after performing a facet joint block&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The most recent proposal for a diagnostic scale was made in 1972 by Dr Michel Revel&#44; who proposed the general criteria that bear his name&#46; They comprise 7 clinical signs&#44; with the presence of 5 out of 7 during the assessment of the patient predicting an adequate response to lumbar facet block with a sensitivity of 92&#37; and specificity of 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">51</span></a> More recently&#44; Laslett et al&#46; published an article in 2006 that developed rules for clinical prediction in facet joint blocks&#44; finding that the presence of &#8805;3 of the criteria &#40;age &#62;50&#44; symptoms that improve when walking&#44; symptoms that improve when seated&#44; pain starts as paraspinal and the extension&#47;rotation test&#41; has a sensitivity of 85&#37; and a specificity of 91&#37; for facet joint pain&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">52</span></a> Following this proposal&#44; many authors have conducted studies of individual signs and symptoms for the diagnosis of facet syndromes&#44; such as the new clinical sign&#44; Kemp&#39;s sign&#44; spinal percussion test&#44; springing test and segmental rotation test&#44; among others&#44;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">13&#44;53&#44;54</span></a> without proposing a clear diagnostic scale&#46; In the latest systematic review performed by Maas&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">39</span></a> the diagnosis of lumbar pain of facet origin had not undergone significant changes in the last 17 years&#44; there was no diagnostic scale available with adequate performance&#44; and&#44; finally&#44; the patient&#39;s history and physical examination could only give a cautious direction for diagnosis&#46; However&#44; even this is not conclusive and leads to the use of invasive diagnostic blocks&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our proposal of a diagnostic scale based on this pilot study incorporates 6 clinical criteria &#40;3 symptoms and 3 signs&#41;&#59; the symptoms included are&#58; &#40;1&#41; unilateral or bilateral axial lumbar pain&#44; &#40;2&#41; improvement or alleviation when resting and &#40;3&#41; absence of a radicular pattern&#44; although a pseudoradicular pattern may be present&#44; but with more lumbar pain than leg pain&#46; The clinical signs included are&#58; &#40;1&#41; Kemp&#39;s sign&#44; &#40;2&#41; induced pain in the articular or transverse apophysis and &#40;3&#41; sign of facet stress or new lumbar facet sign<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">1&#44;4&#8211;6&#44;8&#44;10&#44;11&#44;24&#44;40&#44;43&#44;47&#44;55</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">This work offers several advantages&#46; Firstly&#44; it brings together all of the symptoms and clinical signs that have been proposed to date for the diagnosis of lumbar pain of facet origin&#44; providing clinical tools for a pre-surgical confirmatory diagnostic approach&#44; without the need to resort to an invasive diagnostic method&#46; It is also the latest published paper on the clinical diagnosis of lumbar pain of facet origin&#44; correlating the pre-surgical pain VAS score and the post-surgical pain VAS score that translates to a post-operative improvement with confirmatory blocks&#44; as well as a rigorous and detailed methodological process&#46; This pilot study is comparable to those previously reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">9&#44;10&#44;14&#44;37&#44;39&#44;46&#44;53&#44;56&#8211;60</span></a> Among the most recently published papers&#44; that of Mars et al&#46;&#44; conducted in the United Kingdom in 2015&#44; was similar to this study in terms of methodology&#46; This article was the product of a multi-institutional consensus on the clinical assessment of joint facet pain and therapeutic intra-articular facet joint injection techniques&#44; among other topics&#46; Based on clinical and physical examination&#44; the proposed scale covers the classic signs and symptoms of FP&#44; although few tests&#47;assessments were included based on the evidence described in the literature&#46; The scale was found to have a sensitivity of 80&#37; and a positive predictive value of 74&#37; in the combined movement pattern to identify patients with FP&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">56</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Currently&#44; percutaneous block is still the gold standard for definitive diagnosis of lumbar pain of facet origin&#46; However&#44; the rate of false positive vary according to the published literature&#58; 17&#8211;63&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">61</span></a> 33&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">62</span></a> 38&#37; false positives and a positive predictive value of 31&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">63</span></a> between 25&#37; and 41&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">64</span></a> and between 25&#37; and 44&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">65</span></a> The rate of false positives may be due to the presence of underlying lumbar pathologies&#46; In the study published by Cohen et al&#46;&#44; a possible explanation in patients with negative discography and false positives in facet blocks was myofascial pain&#44; which accounted for a larger proportion of symptoms in these patients&#46; It is well known that myofascial pain is a common cause of lumbar pain&#44; especially in patients in whom other causes have been ruled out &#40;i&#46;e&#46; negative facet blocks and discography&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">62</span></a> On the other hand&#44; Dreyfuss et al&#46; demonstrate that with only 0&#46;5<span class="elsevierStyleHsp" style=""></span>ml of contrast there is an aberrant propagation of contrast medium to adjacent neural structures such as the epidural space and intervertebral foramina&#44; occurring in 16&#37; of cases&#44; which may be denser in patients with discogenic or radicular pain &#40;the symptoms of which are likely to be alleviated once local anaesthetic leaks into these areas&#41;&#44; who may have increased false positives in facet blocks compared to those without discopathy or radiculopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">66</span></a> Finally&#44; factors have been studied that might influence response to facet blocks&#46; These are&#58; age&#44; psychological factors&#44; body mass index&#44; previous spinal surgery&#44; gender&#44; smoking&#44; influence of previous sedation and exposure to opiates and anaesthetic volume injected&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">65</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">This study is limited by the restriction of the search to a single language&#44; as this precludes signs and symptoms described in other languages&#46; As an additional consideration&#44; based on the explanation and individual criteria provided by the experts in the consensus of signs and symptoms&#44; the decisions could be biased&#44; as is the case of the new lumbar facet sign&#44; devised by a member of the evaluating committee and belonging to our hospital&#39;s neurosurgery group&#46; Thirdly&#44; as it is a prospective work&#44; it was found that between the surgical procedure and the postoperative control&#44; patients tended to overlook the complex notion of absolute improvement&#44; which could limit real assessments of pain&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We aim to continue this work in a second phase&#44; and are considering carrying out prospective cohort studies with a larger&#44; inter-institutional population&#44; calculating sensitivity&#44; specificity and <span class="elsevierStyleItalic">p</span>-values&#44; among others&#44; for each sign and symptom&#44; thereby validating the scale proposed above internally and externally&#46; We also aim to perform comparisons of cost-effectiveness of clinical diagnostic criteria vs&#46; imaging vs&#46; percutaneous surgical management&#46; We aim to compare our criteria with those proposed by Revel and make other proposals for diagnostic scales that might follow this work&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclusion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Although the joint facet has been known as a pain generator for a century&#44; diagnosis based on medical history and physical examination remains inconclusive&#46; The literature is heterogeneous with regard to diagnostic proposals&#44; so we must therefore rely on non-invasive methods such as X-rays&#44; MRI and SPECT bone scans to arrive at an approximate diagnosis&#46; The only currently validated diagnostic gold standard is the lumbar facet block&#46; However&#44; this article proposes a diagnostic scale based on 3 symptoms and 3 clinical signs&#44; which can be correlated with imaging studies and postoperative confirmatory percutaneous blocks&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lumbar pain affects between 60 and 90&#37; of people&#46; It is a frequent cause of disability in adults&#46; Pain may be generated by different anatomical structures such as the facet joint&#46; However&#44; nowadays pain produced by the facet joint has no clinical diagnosis&#46; Therefore&#44; the purpose of this article is to propose a clinical diagnostic scale for lumbar facet syndrome&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study was conducted by means of 6 phases as follows&#44; Phase 1&#44; a systematic review of the literature was performed regarding the clinical diagnosis of facet-based lumbar pain based on the PRISMA checklist&#59; Phase 2&#44; a list of signs and symptoms proposed for diagnosis lumbar pain of facet origin was made&#46; Phase 3&#44; the list of signs and symptoms found was submitted to a committee of experts to discriminate the most significant signs and symptoms&#44; these were linked to general sociodemographic variables to develop an evaluation questionnaire&#59; Phase 4&#44; the evaluation questionnaire was applied&#44; including those selected signs and symptoms to a group of patients with clinical diagnosis of facet disease lumbar pain and who underwent a selective facet block&#46; Phase 5&#44; under standard technique selective facet block and subsequent postoperative clinical control at 1 month&#46; Phase 6&#44; given pre and postsurgical results associated with signs present in the patients we propose a clinical scale of diagnosis scale&#46; Descriptive statistics and Stata 12&#46;0 were used as statistical software&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 36 signs and symptoms were found for the diagnosis of lumbar facet syndrome that were submitted to the group of experts&#44; where a total of 12 &#40;8 symptoms and 4 signs&#41; were included for the final survey&#46; 31 patients underwent selective lumbar facet blockade&#44; mostly women&#44; with an average of 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;5 years&#44; analogous visual scale of preoperative pain of 8&#47;10&#44; postoperative of 1&#46;7&#47;10&#44; the signs and symptoms most frequently found included in a diagnostic scale were&#58; 3 symptoms &#40;1&#41; axial or bilateral axial lumbar pain&#44; &#40;2&#41; improvement with rest&#44; &#40;3&#41; absence of root pattern&#44; may have pseudoradicular pattern&#44; however&#44; the pain is greater lumbar than pain in the leg and 3 clinical signs &#40;1&#41; Kemp sign&#44; &#40;2&#41; pain induced in joint or transverse process&#44; &#40;3&#41; facet stress sign or Acevedo sign&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The clinical diagnosis of lumbar facet pain is still debated&#46; Few diagnostic scales have been postulated&#44; with little or no external validity&#44; so the present study proposes a diagnostic scale consisting of 3 symptoms and 3 clinical signs&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El dolor lumbar afecta entre el 60 y 90&#37; de la poblaci&#243;n y es una causa frecuente de incapacidad en adultos&#46; Puede ser generado por diferentes estructuras anat&#243;micas&#44; entre las cuales se encuentra la faceta articular&#46; Actualmente&#44; el diagn&#243;stico de dolor lumbar de origen facetario depende de la realizaci&#243;n de un procedimiento invasivo &#40;bloqueo selectivo&#41; y no puede hacerse exclusivamente con los hallazgos cl&#237;nicos&#46; Por lo cual&#44; nuestro objetivo es desarrollar una escala de diagn&#243;stico cl&#237;nico para el dolor lumbar de origen facetario&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El estudio fue realizado por medio de 6 fases de la siguiente manera&#58; Fase 1&#44; se realiz&#243; una revisi&#243;n sistem&#225;tica de la literatura respecto al diagn&#243;stico cl&#237;nico del dolor lumbar de origen facetario basado en la lista de chequeo PRISMA&#46; Fase 2&#44; se realiz&#243; una lista de los signos y s&#237;ntomas propuestos para diagn&#243;stico de dolor lumbar de origen facetario&#46; Fase 3&#44; se someti&#243; la lista de signos y s&#237;ntomas encontrados a un comit&#233; de expertos para discriminar aquellos que son m&#225;s significativos para los mismos&#44; estos fueron unidos a variables generales sociodemogr&#225;ficas para desarrollar un cuestionario de evaluaci&#243;n&#46; Fase 4&#44; se aplic&#243; el cuestionario de evaluaci&#243;n que inclu&#237;a aquellos signos y s&#237;ntomas seleccionados a un grupo de pacientes con diagn&#243;stico cl&#237;nico de dolor lumbar secundario a enfermedad facetaria y que fueron sometidos a un bloqueo facetario selectivo&#46; Fase 5&#44; bajo t&#233;cnica est&#225;ndar se realiz&#243; bloqueo facetario selectivo y posterior control cl&#237;nico postoperatorio a un mes&#46; Fase 6&#44; se relacionaron los resultados pre- y posquir&#250;rgicos con los signos positivos y se propone una escala cl&#237;nica de evaluaci&#243;n diagn&#243;stica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se encontraron un total de 36 signos y s&#237;ntomas para el diagn&#243;stico de s&#237;ndrome facetario lumbar que fueron sometidos al grupo de expertos&#44; donde fueron incluidos para la encuesta final un total de 12 &#40;8 s&#237;ntomas y 4 signos&#41;&#46; Treinta y un pacientes fueron sometidos a bloqueo facetario lumbar selectivo&#44; en su mayor&#237;a mujeres&#44; con un promedio de 60&#177;11&#44;5 a&#241;os&#44; escala visual an&#225;loga del dolor prequir&#250;rgica &#40;EVAD&#41; de 8&#47;10&#44; posquir&#250;rgica de 1&#44;7&#47;10&#44; los signos y s&#237;ntomas m&#225;s frecuentemente encontrados incluidos en una escala diagn&#243;stica fueron&#58; 3 s&#237;ntomas&#44; 1&#41; dolor lumbar axial unilateral o bilateral&#44; 2&#41; mejor&#237;a con el reposo&#44; 3&#41; ausencia de patr&#243;n radicular&#44; puede tener patr&#243;n pseudorradicular&#44; sin embargo&#44; el dolor es mayor el lumbar que dolor en la pierna&#46; Y 3 signos cl&#237;nicos&#44; 1&#41; signo Kemp&#44; 2&#41; dolor inducido en ap&#243;fisis articular o transversa&#44; 3&#41; signo de estr&#233;s facetario o signo de Acevedo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico cl&#237;nico del dolor facetario lumbar no es a&#250;n claro&#46; Pocas escalas diagnosticas han sido postuladas&#44; con poca o baja validez externa&#44; por lo cual&#44; el presente estudio propone una escala diagn&#243;stica conformada por 3 s&#237;ntomas y 3 signos cl&#237;nicos&#46;</p></span>"
        "secciones" => array:4 [
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez Vega JC&#44; Acevedo-Gonz&#225;lez JC&#46; Escala de diagn&#243;stico cl&#237;nico para dolor lumbar de origen facetario&#58; revisi&#243;n sistem&#225;tica de la literatura y estudio piloto&#46; Neurocirugia&#46; 2019&#59;30&#58;133&#8211;143&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Lumbar facet block at levels L3&#8211;4&#8211;5&#8211;S1&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Lumbar quadrant test or Kemp&#39;s test&#46; Patient performs extension combined with rotation of the spinal region of interest&#44; a positive test is considered with reproduction of the patients&#8217; pain that is reduced by walking&#44; standing up or resting&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">New lumbar facet sign&#46; Phase 1&#58; patient lies in the supine decubitus position with lower limbs in a resting position&#46; Phase 2&#58; forced flexion of the hip joint is performed with the leg extended&#44; supporting the lower leg&#46; Phase 3&#58; the patient is asked to apply force downwards&#44; and with the hand on the lower leg&#44; the examiner applies an opposing force in the anterior direction&#46; Phase 4&#58; the examiner suddenly discontinues the opposing force on the lower leg&#44; causing the limb to fall suddenly&#46; Phase 5&#58; before the leg falls onto the surface of the examination table&#44; the examiner stops it from touching the table and lifts it again&#44; holding the lower leg&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Presence of pain</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Unilateral&#47;bilateral lumbar&#47;paraspinal pain</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Axial pain</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pseudoradicular irradiation patterns</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pain irradiating to above the knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Upper joints irradiate to the sides&#44; groin&#44; hip&#44; lateral thigh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Lower joints irradiate to posterior thigh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>More lumbar pain than leg pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Irradiation may be unilateral or bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pain worsens with extension</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pain worsens with axial rotation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pain worsens with torsion movements &#40;lateral flexion&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pain in transition from sitting to standing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Increases when walking uphill</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Increases with prolonged standing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Increases with prolonged sitting</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Time-based pattern</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Greater stiffness in the morning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Settles down somewhat during the day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Stiffness may return later in the day or at night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dull&#44; deep pain</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Increases with stress factors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Revel&#39;s criteria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Improvement or absence of pain</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Absence of radicular pattern</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No pain or improvement with flexion&#44; forward flexion or when seated</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Improves when walking</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Normal gait</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Absence of pain in legs or muscle spasm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pain improves or is alleviated at rest</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleBold">Sign</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No signs of neurological impairment &#40;sensory or motor&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">New lumbar facet sign</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pain induced by pressure on the ipsilateral facet or transverse process</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Evidence of unilateral paravertebral muscle spasm in the affected joint</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Localised paraspinal sensitivity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Range of motion</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Spinal percussion test</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Springing test</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Segmental rotation test</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Kemp Sign&#47;lumbar Quadrant test and Extension-Rotation test</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2018879.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">List of the 36 signs and symptoms&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Date&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ID card no&#46;&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#58; &#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender&#58; M&#95;&#95;&#95; F&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contact telephone no&#46;&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prior procedures&#58; facet &#95;&#95;&#95;&#95; sacroiliac &#95;&#95;&#95;&#95; epidural &#95;&#95;&#95;&#95; other &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current procedure&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bone scan&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre-surg&#46; VAS&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-surg&#46; VAS&#58; &#95;&#95;&#95;&#95;&#95;&#95;&#95;&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sign&#47;symptom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unilateral&#47;bilateral lumbar&#47;paraspinal pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axial pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain irradiating to above the knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More lumbar pain than leg pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain worsens with extension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain worsens with axial rotation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absence of radicular pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Alleviated or improves at rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">New lumbar facet sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain induced by pressure on the facet joint or transverse process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Range of motion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kemp&#39;s Sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2018880.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Assessment questionnaire&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sociodemographic characteristics <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Gender &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;6 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Prior procedures &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;2 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;7 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;7 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8805;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;45 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Bone scan &#37; &#40;n&#41;&#58;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;3 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;7 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Procedure &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L1-2-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L2-3-4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L3-4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L3-4-5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L4-5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L4-5-S1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L5-S1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Sociodemographic characteristics&#46;</p>"
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      10 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Visual analogue scale for pain <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>31</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Pre-surgical</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Overall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Post-surgical</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Overall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 5"
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            "detalle" => "Table "
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">General population signs and symptoms &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pos&#46; &#37; &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Neg&#46; &#37; &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral&#47;bilateral lumbar&#47;paraspinal pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;4 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;6 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axial pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain irradiating to above the knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;4 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;6 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More lumbar pain than leg pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&#46;3 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;7 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with extension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;4 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;6 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with axial rotation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;4 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;6 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of radicular pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;4 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;6 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alleviated or improves at rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;4 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;6 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New lumbar facet sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;4 &#40;13&#41; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;9 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain induced by pressure on the facet joint or transverse process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;1 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;9 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Range of motion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;9 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#46;1 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kemp&#39;s sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#46;1 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;9 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Positive blocks &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral&#47;bilateral lumbar&#47;paraspinal pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;5 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Axial pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain irradiating to above the knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;4 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More lumbar pain than leg pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&#46;1 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with extension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain worsens with axial rotation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;5 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of radicular pattern&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;3 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New lumbar facet sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;9 &#40;9&#41; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain induced by pressure on the facet joint or transverse process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;2 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Range of motion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#46;6 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kemp&#39;s sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#46;8 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Positive signs and symptoms in patients with positive blocks&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Symptoms</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;2&#41; Induced pain in the articular or transverse apophysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#40;3&#41; Sign of facet stress or new lumbar facet sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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          "bibliografiaReferencia" => array:66 [
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                  "contribucion" => array:1 [
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                  "host" => array:1 [
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            1 => array:3 [
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Article information

ISSN: 25298496
Original language: English

DOI:10.1016/j.neucie.2018.07.001

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