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          "analyticParaphrase": "Investigators retrospectively assembled 42 German and 23 Brazilian patients labelled with notalgia paraesthetica. The German centre searched its chronic-pruritus database, which included all patients consulting since March 2009; the Brazilian centre identified 23 patients in its local dermatology database. The article calls the combined series consecutive but does not give the selection dates, operational diagnostic criteria, assessor process, or exclusions needed to audit that claim fully.",
          "verifiedDetails": {
            "totalN": 65,
            "germanyN": 42,
            "brazilN": 23,
            "design": "retrospective two-centre descriptive series",
            "germanSamplingFrame": "chronic-pruritus centre database including consultees since March 2009",
            "brazilianSamplingFrame": "local dermatology database",
            "informedConsentAndEthics": "reported"
          },
          "allowableUse": "Describe a selected retrospective clinical series from two different databases.",
          "notSupported": "Population prevalence, incidence, diagnostic accuracy, complete consecutive capture, or representativeness of people presenting with localized back heat."
        },
        {
          "passageId": "PV-22511124-PHENOTYPE-LOCATION",
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              536
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            "sections": [
              "Introduction",
              "Methods",
              "Results"
            ],
            "supplementRow": "NP localization: back divided into quadrants"
          },
          "evidenceLayer": "study-definition-and-observation",
          "analyticParaphrase": "The article frames notalgia paraesthetica as chronic neuropathic pruritus on the back, usually between the shoulders. Location was recorded by upper/lower back quadrants divided at T7 for 63 patients and by a drawn dermatomal chart for 22 German patients. Upper quadrants were much more often involved than lower quadrants, and the commonest recorded dermatomes were T2, T4, and T5. These are pruritic regions, not mapped heat regions.",
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            "upperRight": "37/65 as tabled; 56.9% of total cohort",
            "lowerRight": "7/65 as tabled; 10.8% of total cohort",
            "lowerLeft": "11/65 as tabled; 16.9% of total cohort",
            "multipleRegionsPossible": true,
            "mostFrequentDermatomes": [
              "T2: 13 patients",
              "T4: 15 patients",
              "T5: 13 patients"
            ]
          },
          "allowableUse": "Retain an itch-dominant upper-back syndrome as a competing phenotype when location and accompanying sensory qualities overlap.",
          "notSupported": "Equivalence between the study phenotype and recurrent localized back warmth or burning without itch."
        },
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            "source": "Table SI PDF",
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          "analyticParaphrase": "Pruritus quality was available for 40 patients, all from Germany; it was missing for 25/65, including every Brazilian participant. Six records were classified as pure pruritus and 34 as mixed. Within the table, burning was recorded for 19 patients and warmth for two. Because mixed-quality counts overlap, warmth co-occurrence with burning or other qualities cannot be reconstructed. The article does not report exact prompts, whether terms were volunteered or offered, language or translation handling, or coding rules.",
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            "mixedPruritus": 34,
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              "derivedPercentAmongQualityAssessed": 47.5
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              "derivedPercentAmongQualityAssessed": 5
            },
            "attacks": {
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              "tablePercentTotalCohort": 13.8
            },
            "multiResponseStructure": "The mixed-quality descriptor counts exceed 34 and therefore are not mutually exclusive."
          },
          "denominatorCaveat": "The supplement prints percentages against the full 65-patient or 42-person German denominators while 25 quality records are missing. Any descriptive fraction must state both the two observed warmth records and the 40-person assessed subset; it is not a prevalence estimate.",
          "constructCaveat": "Warmth is a subjective pruritus-quality label in an itch-defined series. It is not burning pain, paradoxical heat, warm-detection threshold, touch warmth, or measured skin temperature.",
          "allowableUse": "Show that some patients in an itch-defined upper-back syndrome had a recorded warmth descriptor, while foregrounding missingness and ascertainment uncertainty.",
          "notSupported": "A 3.1%, 4.8%, or 5% prevalence of localized back heat in any target population; spontaneous patient wording; recurrence pattern; or objective heat."
        },
        {
          "passageId": "PV-22511124-SKIN-FINDINGS",
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            "source": "main article PDF and Table SI",
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          "analyticParaphrase": "Four of 65 patients had neither hyperpigmentation nor scratch lesions; most had hyperpigmentation and many had scratch-related findings. Pruritus duration was not associated with the presence of hyperpigmentation or scratch lesions. Visible skin change was common but not universal in this selected itch cohort.",
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            "noVisibleFindings": "4/65 (6.2%)",
            "hyperpigmentation": "53/65 (81.5%)",
            "scratchLesions": "42/65 (64.6%)",
            "durationAssociation": "not significant; p > 0.05"
          },
          "allowableUse": "Distinguish a potentially normal-appearing itchy area from a visibly altered or scratched area.",
          "notSupported": "A diagnostic rule, a temporal progression from normal skin to a patch, or transfer to a non-pruritic heat complaint."
        },
        {
          "passageId": "PV-22511124-IENF-METHOD",
          "locator": {
            "source": "main article PDF",
            "printedPage": 536,
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          "evidenceLayer": "study-method",
          "analyticParaphrase": "For 21 German patients, investigators processed biopsies from the pruritic/lesional area and an anatomically identical non-pruritic/non-lesional area for PGP 9.5 immunostaining, using a previously published preparation and counting method. They compared the paired intraepidermal nerve-fiber values with a Wilcoxon test. The article does not state biopsy side or distance, sampling order, replicate fields, reader blinding, inter-rater reliability, or whether every pruritic biopsy had a visible lesion.",
          "verifiedDetails": {
            "pairedBiopsyN": 21,
            "cohort": "Germany only",
            "marker": "PGP 9.5",
            "comparison": "within-patient pruritic/lesional versus anatomically identical non-pruritic/non-lesional skin",
            "test": "Wilcoxon",
            "countingRuleReportedInDiscussion": "fibers crossing the basement membrane counted; secondary intraepidermal branching excluded"
          },
          "terminologyCaveat": "The paper alternates between lesional and pruritic area even though four cohort members lacked visible skin findings. The text does not establish that 'lesional' always means a visible lesion rather than the symptomatic sampling site.",
          "allowableUse": "Describe the paired sampling design and its reported laboratory method.",
          "notSupported": "A blinded diagnostic test, a healthy-control comparison, generalized small-fiber neuropathy, or a measurement of thermal sensation."
        },
        {
          "passageId": "PV-22511124-IENF-RESULT",
          "locator": {
            "source": "main article PDF and Table SI",
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              536,
              538
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              "Histological investigation",
              "Discussion"
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          "analyticParaphrase": "Mean intraepidermal nerve-fiber density was lower in the pruritic area than in the paired anatomically identical non-pruritic area (7.15 versus 10.3 fibers/mm; p=0.035). The reduction was not significantly related to pruritus duration, scratch lesions, or hyperpigmentation. The authors interpret the finding as compatible with peripheral sensory neuropathy and potentially contributory to itch, while acknowledging disagreement with earlier small semiquantitative studies.",
          "verifiedDetails": {
            "pruriticArea": "mean 7.15 +/- 4.3 fibers/mm; median 6.95",
            "nonPruriticArea": "mean 10.3 +/- 5.7 fibers/mm; median 9.7",
            "pairedComparisonP": 0.035,
            "nullClinicalCorrelations": [
              "pruritus duration",
              "scratch lesions",
              "hyperpigmentation"
            ],
            "externalHealthyControl": false
          },
          "allowableUse": "Treat reduced local fiber density as a within-person association in 21 selected itch patients and preserve the null clinical correlations.",
          "notSupported": "Causality, directionality, diagnostic accuracy, a mechanism for the two warmth records, or relevance to isolated back heat."
        },
        {
          "passageId": "PV-22511124-RADIOLOGY",
          "locator": {
            "source": "main article PDF",
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              537,
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              "Discussion"
            ],
            "figures": [
              "Figure 2",
              "Figure 3"
            ]
          },
          "evidenceLayer": "study-observation-and-counterevidence",
          "analyticParaphrase": "Radiology was available for 51/65 using heterogeneous MRI, CT, and X-ray methods. Stenosis was reported in 21 patients, degeneration in 31, and normal findings in 13. Exact symptom-imaging comparison was possible only in 19 German patients with dermatomal charts: 11/70 radiologically affected dermatomes coincided with clinical involvement (15.7%), and the authors reported statistically significant dependence for only 5/70 (7.1%). A broader area-level analysis found 9/29 pruritic areas aligned with an MRI lesion. The authors argue that spinal abnormalities may be incidental and do not necessarily explain the symptoms.",
          "verifiedDetails": {
            "radiologyAvailable": "51/65",
            "modalities": {
              "MRI": 25,
              "CT": 1,
              "xRay": 25
            },
            "stenosis": "21/65 as tabled (32.3%)",
            "degeneration": "31/65 as tabled (47.7%)",
            "normal": "13/65 as tabled (20.0%)",
            "exactCorrelationSubset": "19 German patients",
            "radiologicallyAffectedDermatomes": 70,
            "clinicallyAffectedDermatomes": 114,
            "coincidentDermatomes": "11/70 (15.7%)",
            "reportedSignificantDependence": "5/70 (7.1%)",
            "areaLevelAlignment": "9/29 (31%)"
          },
          "denominatorCaveat": "The table percentages use the full 65-patient cohort despite 14 missing radiology records, and the exact concordance analysis is a much smaller German MRI/chart subset.",
          "allowableUse": "Use the low exact concordance and explicit incidental-finding warning as counterevidence to simple scan-to-symptom attribution.",
          "notSupported": "That spinal changes caused notalgia, that imaging is indicated for isolated back heat, or that radiological discordance proves a peripheral-nerve cause."
        },
        {
          "passageId": "PV-22511124-DESIGN-LIMITS",
          "locator": {
            "source": "main article PDF",
            "printedPages": [
              537,
              538
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          "evidenceLayer": "author-limit-and-reviewer-source-criticism",
          "analyticParaphrase": "The authors explicitly list retrospective design, different radiological methods and physicians, absence of a control cohort, and difficulty aligning objective radiology with subjective symptom location. They note that spinal abnormalities are common in asymptomatic people and age-dependent. The study also combines centres with markedly different available measurements: quality, biopsy, and dermatomal chart data were largely or entirely German, while Brazilian radiology was X-ray only.",
          "allowableUse": "Bound all phenotype, biopsy, and radiology interpretations by the study's missingness, centre, modality, and control limitations.",
          "notSupported": "Causal ranking of spinal versus peripheral mechanisms, between-country comparison, or a clinically actionable diagnostic pathway."
        }
      ],
      "interpretation": {
        "studyObservations": [
          "Two warmth labels and 19 burning labels were recorded among 40 German patients with pruritus-quality data; 25/65 quality records were missing and descriptor overlap was possible.",
          "The phenotype was chronic back pruritus, usually upper-back, with visible skin findings common but not universal.",
          "In 21 German patients, local intraepidermal nerve-fiber density was lower in the symptomatic area than in paired anatomically identical non-pruritic skin, without association to duration or visible skin changes.",
          "Exact dermatomal concordance with radiological abnormalities was limited in the small subset where comparison was possible."
        ],
        "authorInterpretation": "The authors favor peripheral nerve damage over spinal changes as an etiological factor, based on reduced local fiber density and weak exact radiological concordance, but explicitly call spinal findings potentially incidental and acknowledge retrospective, heterogeneous, uncontrolled data.",
        "reviewerInterpretation": "This source provides rare participant-level evidence that a recorded warmth descriptor can occur inside an itch-defined localized-back syndrome. It does not characterize warmth itself, establish recurrence, or measure temperature. The paired biopsy association is local and cross-sectional, and weak imaging concordance undermines simple structural attribution without proving the authors' preferred peripheral mechanism.",
        "hypothesesForLaterSynthesis": [
          "When a person says a localized back area feels warm, asking whether itch is primary and whether warmth is one member of a mixed sensory cluster may change phenotype classification.",
          "A normal-looking skin surface does not exclude an itch-dominant sensory syndrome in this selected series, but visible scratching or pigmentation may help characterize chronic rubbing rather than establish cause.",
          "Local neural changes and incidental spinal imaging may coexist; neither should be assumed to explain a warmth complaint without construct-matched measurement and symptom-level concordance."
        ],
        "clinicalImplicationStatus": "No diagnostic, imaging, treatment, or safety recommendation is established. The source only supports a later history-taking distinction among warmth, burning, itch, pain, attacks, visible skin change, and mapped location. Redirect language still requires authoritative safety passages."
      },
      "claimsNotEstablished": [
        "The two warmth records establish prevalence of recurrent localized back heat in notalgia paresthetica, clinic populations, or the public.",
        "Warmth was spontaneous patient language, separately prompted, consistently translated, recurrent, or the dominant complaint.",
        "Warmth, burning, pain, Korean 배열/화끈거림, Literary Sinitic 背熱, paradoxical heat, warm-detection thresholds, touch warmth, and objective skin temperature are equivalent constructs.",
        "The Brazilian and German cohorts were sampled, assessed, or measured comparably.",
        "Reduced intraepidermal nerve-fiber density caused pruritus or warmth, indicates generalized small-fiber neuropathy, or has diagnostic accuracy.",
        "Spinal stenosis or degeneration caused the symptoms, or weak imaging concordance proves a peripheral cause.",
        "The study establishes an imaging indication, safety redirect, prognosis, or treatment recommendation for localized back heat."
      ],
      "unresolvedBlockers": [
        {
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          "analyticParaphrase": "The authors retrospectively analysed routine clinical data from successive adults considered for inclusion at one German chronic-pruritus centre. They included 58 people, 29 labelled brachioradial pruritus and 29 labelled notalgia paraesthetica. Diagnosis used symptom onset location and quality, the ice-pack sign, absence of primary dermatosis, and objective MRI or CT and local nerve-fibre findings. The article does not report the sampling dates, exclusions, number considered but not included, or an independently applied operational case definition.",
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            "design": "retrospective single-centre observational analysis of routine clinical data",
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            "brachioradialPruritusN": 29,
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            "samplingLanguage": "successive adult patients considered for inclusion",
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          "analyticParaphrase": "Clinical pruritus properties were recorded with the Neuroderm questionnaire. At the first visit, burning was recorded for 19/28 assessed brachioradial-pruritus participants and 9/27 assessed notalgia participants; the table reports p=0.01 from a chi-square comparison. The narrative separately states that itch and burning co-occurred in 16/28 brachioradial-pruritus participants, but gives no parallel notalgia co-occurrence count. Seven of 28 assessed notalgia participants were described as having pure itch. These are overlapping symptom descriptors in itch-defined groups, not measures of warmth or temperature.",
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            "itchAndBurningCooccurrence": {
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              "notalgiaParaesthetica": "not reported"
            },
            "pureItchInNotalgia": "7/28",
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          "allowableUse": "Show that burning was not uniform across two selected neuropathic-itch groups and was less often recorded in the notalgia group in this study.",
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          "analyticParaphrase": "All 29 notalgia participants had recorded upper-back involvement spanning C6-T8, and nine also had lower-back involvement spanning T9-T12. Disease duration of at least six weeks was reported for 28/28 assessed participants. Fourteen participants reported itch peaks and 14/28 continuous symptoms; these categories are not presented as mutually exclusive. Bed warmth was recorded as a trigger in 4/26, which is contextual provocation rather than a spontaneous localized warmth descriptor.",
          "verifiedDetails": {
            "upperBackInvolvement": "29/29; C6-T8",
            "additionalLowerBackInvolvement": "9/29; T9-T12",
            "durationAtLeastSixWeeks": "28/28 assessed",
            "itchPeaks": 14,
            "continuousSymptoms": "14/28",
            "bedWarmthTrigger": "4/26"
          },
          "allowableUse": "Retain an itch-defined upper-back dysesthesia phenotype and distinguish its time and trigger fields.",
          "notSupported": "A recurrent isolated back-heat phenotype, objective surface heat, deep heat, a mutually exclusive episodic-versus-continuous classification, or general population frequency."
        },
        {
          "passageId": "PV-28902951-MRI-RESULT-AND-DENOMINATOR-CONFLICT",
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          "evidenceLayer": "study-observation-with-internal-reporting-conflict",
          "analyticParaphrase": "The results say 25 brachioradial-pruritus and 21 notalgia participants underwent MRI. The notalgia pathology-category counts sum to 21, including seven with no pathology. Yet symptom-location concordance is reported as 24/25 for brachioradial pruritus and 11/22 for notalgia, with p<0.001. The article does not reconcile the 21-versus-22 notalgia denominator. Imaging was obtained only in a subset and was also part of the reported diagnostic process.",
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            "reportedMRICompleted": {
              "brachioradialPruritus": 25,
              "notalgiaParaesthetica": 21
            },
            "notalgiaPathologyCategories": {
              "degenerative": 8,
              "stenosis": 2,
              "combined": 4,
              "noPathology": 7,
              "sum": 21
            },
            "reportedSymptomLocalizationConcordance": {
              "brachioradialPruritus": "24/25",
              "notalgiaParaesthetica": "11/22",
              "p": "<0.001"
            },
            "unresolvedConflict": "The notalgia concordance denominator is 22 although only 21 MRIs and 21 pathology classifications are reported."
          },
          "allowableUse": "Use only as selected-cohort comparative evidence that exact scan-to-symptom correspondence was not uniform, while reporting the denominator conflict.",
          "notSupported": "A precise notalgia concordance rate, causation, diagnostic accuracy, an imaging indication, or inference that a normal or discordant scan proves a peripheral mechanism."
        },
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              83,
              84,
              86
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              "Methods: Intraepidermal nerve fibre density determination",
              "Results: Intraepidermal nerve fibre density",
              "Discussion"
            ]
          },
          "evidenceLayer": "local-paired-biopsy-method-observation-and-author-hypothesis",
          "analyticParaphrase": "Four-millimetre biopsies were taken from symptomatic and asymptomatic skin at C6 on the forearm for brachioradial pruritus and on the back for notalgia. PGP 9.5-stained fibres crossing the basement membrane were counted at 400-fold magnification in three specimens per biopsy and averaged per epidermal length. The paper reports lower lesional than non-lesional density for brachioradial pruritus (6.0 versus 12.2 fibres/mm; p=0.01) but no paired difference for notalgia (11.2 versus 9.6 fibres/mm; p=0.47, n=24). No healthy controls were used. The authors' central-versus-peripheral compression explanation is explicitly a hypothesis, not a demonstrated mechanism.",
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              "lesional": "median 6.0 [4.9, 8.4], n=27",
              "nonLesional": "median 12.2 [9.7, 15.3], n=18",
              "p": 0.01
            },
            "notalgiaParaesthetica": {
              "lesional": "median 11.2 [7.9, 17.5], n=25",
              "nonLesional": "median 9.6 [6.3, 17.6], n=24",
              "pairedAnalysisN": 24,
              "p": 0.47
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            "authorNamedLimitation": "higher diabetes frequency in brachioradial pruritus",
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      ],
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        "studyObservations": [
          "Burning was recorded in both selected itch-defined groups and less often in the notalgia group.",
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          "Exact MRI concordance was not uniform and its notalgia denominator is internally inconsistent.",
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        ],
        "authorInterpretation": "The authors argue that brachioradial pruritus has a more pronounced neuropathic component and hypothesize central versus more peripheral compression differences; they call for prospective confirmation.",
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        "title": "Sensory descriptors which identify neuropathic pain mechanisms in low back pain: a systematic review.",
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          "analyticParaphrase": "The review explicitly separates evoked thermal hyperalgesia from pain quality described as hot, burning, or cold. Two painDETECT-based studies asked whether cold or heat in an area was painful and separately asked about burning pain. Five other studies used wording about pain that felt hot, burning, or cold. Because these questions address different constructs and were phrased differently, the review analyzed them in separate subsections.",
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        },
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          "analyticParaphrase": "Descriptor collection varied between offered questionnaire choices and participant-generated language; the availability of a no-match response was unclear. Three studies used the same questionnaire both to classify neuropathic pain and to analyze its component descriptors, creating common-method bias. Temperature questions differed in construct and timeframe across tools. The review notes no gold-standard reference test for neuropathic low-back pain, divergent classification methods, and evidence that studies likely compared non-identical groups.",
          "allowableUse": "Explain why study counts favoring a descriptor do not amount to independent validation and why wording, recall window, and classification method matter.",
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          "allowableUse": "Use the review as counterevidence against single-descriptor mechanism classification and as a source for bounded hypothesis generation only.",
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          "Temperature-related pain-quality findings conflicted across studies, while both thermal-hyperalgesia studies failed to discriminate neuropathic from nociceptive low-back pain.",
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          "Co-occurring numbness, allodynia, dysesthesia, neuroanatomical distribution, and examination findings may be more informative than heat language alone, but this review does not validate a diagnostic rule for the cluster phenotype.",
          "Differences in Korean and English wording, prompted versus volunteered responses, and recall windows may materially change classification and require explicit provenance."
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        "The included populations represent people with isolated, recurrent, skin-normal localized back heat.",
        "The study counts constitute pooled diagnostic accuracy or a prevalence estimate.",
        "Temperature-related descriptor findings generalize across questionnaires, languages, recall periods, anatomical sites, or back-versus-leg distributions.",
        "The review supports imaging, referral, urgency, treatment, or safety-redirect decisions for this cluster.",
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          "analyticParaphrase": "Against the new trunk reference data, participants with postherpetic neuralgia were reported to show thermal and tactile deficits plus dynamic mechanical allodynia, generally without reduced mechanical pain thresholds. The authors say this pattern differs from other neuropathic-pain types and suggest trunk reference data may also be useful in post-thoracotomy or chronic back pain.",
          "allowableUse": "Describe the abstract-reported postherpetic-neuralgia pattern and attribute the proposed broader usefulness to the authors.",
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          "The abstract reports thermal and tactile loss and dynamic mechanical allodynia in a chronic postherpetic-neuralgia application, usually without lowered mechanical pain thresholds."
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        "A universal thermal abnormality cutoff; the abstract reports a parameter-dependent range rather than a single decision threshold.",
        "Diagnostic sensitivity, specificity, likelihood ratios, causal mechanism, prevalence, prognosis, treatment effect, imaging indication, or safety redirect.",
        "That upper and lower trunk sites are equivalent; the abstract reports no systematic difference but full estimates and power are unavailable.",
        "That proposed usefulness in post-thoracotomy or chronic back pain was empirically demonstrated in this study.",
        "Equivalence among evoked QST, objective skin temperature, spontaneous warmth, burning pain, paradoxical heat, Korean 배열/화끈거림, or Literary Sinitic 背熱."
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        "doi": "10.1016/j.jtherbio.2020.102718",
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        "title": "Thermal sensitivity mapping - warmth and cold detection thresholds of the human torso.",
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          "locator": "https://www.researchgate.net/publication/335319932_Thermal_sensitivity_mapping_-warmth_and_cold_detection_thresholds_of_the_torso",
          "title": "Thermal sensitivity mapping - warmth and cold detection thresholds of the torso",
          "dateAndVenue": "July 2019; XXVII Congress of the International Society of Biomechanics",
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          "allowableUse": "Retain precursor consistency, funding provenance, and the distinction between observed thresholds and proposed mechanisms.",
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        "That the exact conference protocol and sites were unchanged in the journal version of record.",
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        "A causal explanation based on receptor density, nerve conduction, sweat-gland density, sex, or thermoregulation.",
        "Equivalence among evoked thermoception, objective skin temperature, spontaneous warmth, burning pain, paradoxical heat, Korean 배열/화끈거림, or Literary Sinitic 背熱."
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          "passageId": "PV-38835743-PHENOTYPE",
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            "section": "2. Methods",
            "htmlSectionId": "s2",
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          "evidenceLayer": "study eligibility and phenotype",
          "verifiedContent": "Fifteen adults were recruited from a university dermatology clinic after dermatologist confirmation. Operational diagnosis required unilateral localized pruritus on the subscapular back without primary skin disease; probable or diagnosed neuropathy, spinal injury, and other clinically relevant sensory deficits were exclusions. The article states that standard diagnostic criteria for notalgia paresthetica do not exist.",
          "supports": "This is an itch-defined, selected clinic sample with a specific dorsal distribution and explicit exclusions.",
          "doesNotSupport": "It does not define or validate recurrent focal back warmth, burning without itch, objective skin heating, prevalence, or diagnostic accuracy."
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          "verifiedContent": "DFNS-standardized QST was applied at the patient-rated itchiest area inferior to the medial scapular border and at the mirror location on the contralateral back at the same dermatomal level. Comparisons were paired within participants and separately made against published age-, sex-, and trunk-site-matched reference data after transformation. Mechanical-evoked itch was separately rated.",
          "supports": "The affected-versus-contralateral comparison is anatomically aligned, and the study distinguishes evoked itch from the other QST modalities.",
          "doesNotSupport": "The main text does not verify the detailed paradoxical-heat stimulus sequence. The published reference comparison is not an internally recruited healthy-control comparison."
        },
        {
          "passageId": "PV-38835743-COHORT",
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            "section": "3. Results",
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            "localHtmlLine": 1438,
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          "verifiedContent": "The pilot included 15 people: 12 women, 9 White participants, mean age 64.0 years, and mean symptom duration 12.0 years with a 1-to-33-year range. Nine cases were right-sided. Itch severity bands were mild in 9 and moderate in 6; no participant was in the little or severe band.",
          "supports": "The observed findings arise from a small, chronic, predominantly female clinic cohort with mild-to-moderate itch burden.",
          "doesNotSupport": "The sample cannot establish population frequency, representativeness, or findings in people whose principal complaint is heat rather than itch."
        },
        {
          "passageId": "PV-38835743-PRIMARY-COMPARISON",
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            "section": "3. Results",
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          "verifiedContent": "The symptomatic and contralateral asymptomatic sites did not differ on the reported sensory measures at P greater than 0.10, except that mechanical-evoked itch was higher at the symptomatic site (mean 4.0 versus 0.8; Z 2.67; P 0.008).",
          "supports": "This is direct counterevidence to assuming that a symptomatic back site must show a site-specific thermal QST abnormality.",
          "doesNotSupport": "A null difference in this pilot does not prove equivalence of the two sites or exclude localized physiological differences not captured by this protocol."
        },
        {
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            "section": "3. Results",
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            "figure": "Figure 2"
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          "evidenceLayer": "external-reference comparison",
          "verifiedContent": "Against published trunk reference data, both the symptomatic and contralateral sites showed lower sensitivity to warm-to-cold-to-warm changes, lower pinprick pain sensitivity, and greater repeated-pinprick wind-up. Cold sensitivity was lower at both sites but reached the study threshold only at the symptomatic site.",
          "supports": "The reported deviations were substantially bilateral rather than confined to the itchy side.",
          "doesNotSupport": "These evoked sensory thresholds do not measure spontaneous felt heat or skin temperature, and the external-reference comparisons may be vulnerable to false-positive findings."
        },
        {
          "passageId": "PV-38835743-PHS",
          "locator": {
            "section": "3. Results",
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            "table": "Table 2"
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          "evidenceLayer": "paradoxical sensation result",
          "verifiedContent": "Table 2 reports paradoxical heat sensations on at least one trial in 4 of 15 symptomatic sites and 2 of 15 contralateral sites. Its footnote states that one participant counted in the contralateral cell described cold during skin warming, which the authors say is not technically paradoxical heat. The article does not supply a corrected table cell after this qualification.",
          "supports": "Paradoxical responses were observed on both sides and were not unique to the symptomatic site.",
          "doesNotSupport": "The table does not establish spontaneous back heat; the exact PHS protocol is in the unacquired supplement, and the footnoted classification ambiguity must not be silently recalculated."
        },
        {
          "passageId": "PV-38835743-DESCRIPTOR",
          "locator": {
            "section": "4. Discussion",
            "htmlSectionId": "s4",
            "localHtmlLine": 1585
          },
          "evidenceLayer": "author-reported symptom descriptor",
          "verifiedContent": "The authors state that Hot ranked third among Short-Form McGill Pain Questionnaire sensory descriptors, after Sharp and Tender, in this cohort.",
          "supports": "Heat-related language can occur within an itch-defined notalgia paresthetica cohort.",
          "doesNotSupport": "The article does not report the count, frequency, timing, depth, touch-temperature relation, or primacy of Hot in the main text; this discussion statement cannot establish a back-heat phenotype or prevalence."
        },
        {
          "passageId": "PV-38835743-LIMITS",
          "locator": {
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          "evidenceLayer": "interpretive limits and counterevidence",
          "verifiedContent": "The authors characterize proposed fiber and central-sensitization mechanisms as plausible or suggestive rather than definitive. They identify the absence of internal healthy controls as the most serious limitation, warn that the external-reference analysis may produce false positives, note uncertain generalization across dermatomal levels and national reference populations, and state that QST alone cannot definitively establish the proposed mechanism.",
          "supports": "Mechanistic interpretation must remain hypothesis-level and the external-reference findings require caution.",
          "doesNotSupport": "The study does not establish etiology, causal spinal impingement, treatment efficacy, or a clinical redirect for isolated recurrent back heat."
        }
      ],
      "interpretation": {
        "directlySupported": [
          "In this 15-person itch-defined pilot, symptomatic and mirrored asymptomatic back sites were broadly similar on QST apart from evoked itch.",
          "Reported thermal and other sensory deviations versus published reference data were mainly bilateral.",
          "Paradoxical sensations occurred on both sides, with a classification caveat in the contralateral table cell.",
          "A heat-related pain descriptor was mentioned in the cohort, but the main article does not quantify it."
        ],
        "hypothesesOnly": [
          "Aδ-pathway dysfunction, reduced cold inhibition, and central sensitization may contribute to notalgia-paresthetica itch.",
          "Any relationship between these findings and spontaneous recurrent localized back heat."
        ],
        "clinicalImplication": "None established for isolated recurrent localized back heat. At most, the study identifies an itch-defined unilateral subscapular phenotype and demonstrates why spontaneous warmth, pain-language Hot, paradoxical heat under QST, and objective temperature must remain separate constructs.",
        "constructBoundary": "Spontaneous localized warmth or burning is not equivalent to evoked paradoxical heat; neither is equivalent to warm-detection threshold, perceived Hot on a pain questionnaire, or measured skin temperature."
      },
      "claimsNotEstablished": [
        "Prevalence, diagnostic accuracy, cause, or treatment efficacy for recurrent localized back heat.",
        "Objective heating of symptomatic skin.",
        "That the symptomatic site has a localized thermal sensory deficit relative to the mirrored back site.",
        "That the reported Hot descriptor was common, primary, spontaneous, recurrent, or specifically localized to the back.",
        "That isolated recurrent back heat is a red flag or indicates notalgia paresthetica, neuropathy, spinal pathology, or central sensitization.",
        "The exact paradoxical-heat stimulus and scoring protocol, because the linked supplement was not lawfully acquired in this environment."
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          "missingWork": "Lawfully acquire and verify the article supplement before making any claim dependent on the exact PHS stimulus sequence, trial count, response definition, or scoring.",
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        "permittedUse": "Indirect phenotype differentiation, within-person null/counterevidence, construct separation, and study-limit support with explicit population and measurement qualifiers.",
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      },
      "nextWorkUnit": "Verify T1-NP-BURN-32416719 as one bounded passage-verification unit, focusing on elicited burning language, dorsal distribution, comparator design, radiology association, treatment-result limits, and non-equivalence to recurrent localized heat."
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        "doi": "10.1016/j.pain.2013.05.031",
        "title": "Relationship between quantitative sensory testing and pain or disability in people with spinal pain-a systematic review and meta-analysis.",
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        "eligibilityReason": "The review pools associations between evoked QST measures and self-reported pain or disability in spinal-pain populations and reports thermal-stimulus and thermal-temporal-summation findings. It informs construct limits but does not study spontaneous recurrent localized back heat, objective skin temperature, or diagnostic performance, and lawful full text was not available in the frozen access state."
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        },
        "targetedRead": {
          "sectionsRead": [
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          "analyticParaphrase": "The authors framed sensory hypersensitivity as a possible contributor to clinical spinal pain but said its relationship with clinical pain was unclear. They reviewed associations between QST-measured pain sensitivity and self-reported pain intensity or pain-related disability, pooled correlations using random-effects models, and examined moderators through subgroup analysis and mixed-effects meta-regression. The meta-analysis contained 145 effect sizes from 40 studies.",
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          "allowableUse": "Support the limited statement that pooled threshold associations with pain and disability were weak and that the abstract did not report evidence of moderation by the named categories.",
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              "pain threshold may be a poor marker of central sensitization",
              "sensitization may not play a major role in reported pain and disability"
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          },
          "allowableUse": "Retain the two sparse outcome estimates, label thermal temporal summation explicitly, avoid labeling pain tolerance as thermal-specific, and attribute the unresolved alternative explanations to the authors.",
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        }
      ],
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        "reviewObservations": [
          "Across the review corpus, pain-threshold correlations with pain intensity and disability were weak.",
          "The abstract did not report evidence that the threshold relationships were moderated by the named testing, region, duration, or stimulus categories.",
          "Thermal temporal summation and pain-tolerance correlations were based on only a few studies, without exact counts in the abstract."
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        "authorInterpretation": "The authors offered two alternatives: pain threshold may poorly mark central sensitization, or sensitization may contribute little to patient reports of pain and disability.",
        "reviewerInterpretation": "This is counterevidence against treating a single evoked QST threshold as a close proxy for reported spinal pain or disability. It is not evidence that spontaneous localized heat is unrelated to thermoception, because the review did not study that phenotype and the abstract withholds thermal subgroup estimates, heterogeneity, and study-level details. The moderator result is absence of demonstrated moderation, not proof that mechanical and thermal tests are equivalent.",
        "hypothesesForLaterSynthesis": [
          "A study of recurrent localized back heat should prespecify spontaneous sensation, evoked detection or pain thresholds, temporal summation, and objective skin temperature as separate constructs rather than using one as a surrogate for another.",
          "Weak group-level threshold correlations make individual-level discordance plausible as a measurement problem worth testing, but this review does not establish its frequency, cause, or clinical meaning."
        ],
        "clinicalImplicationStatus": "No direct clinical recommendation is established. The abstract cannot support diagnosis, reassurance, safety redirection, treatment, imaging, or an individual-patient QST decision rule for recurrent localized back heat."
      },
      "verificationDecision": {
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      },
      "claimsNotEstablished": [
        "That any included participant reported recurrent heat or burning localized to the back.",
        "Any relationship between spontaneous localized back heat and evoked warm detection, heat pain, temporal summation, paradoxical heat, or objective skin temperature.",
        "Thermal subgroup definitions, contributing-study counts, pooled thermal threshold estimates, subgroup-specific heterogeneity, prediction intervals, or small-study effects.",
        "That mechanical and thermal induction methods are equivalent; the abstract reports no evidence of moderation, not equivalence.",
        "That the pain-tolerance estimate was thermal-specific.",
        "That the sparse thermal temporal summation correlation is stable, generalizable, causal, or clinically actionable.",
        "That weak group-level correlations rule out sensitization in an individual or prove that pain thresholds are invalid.",
        "Diagnostic sensitivity, specificity, likelihood ratios, prevalence, prognosis, treatment effect, imaging indication, or safety redirect.",
        "Equivalence among evoked QST, objective skin temperature, spontaneous warmth, burning pain, paradoxical heat, Korean 배열/화끈거림, or Literary Sinitic 背熱."
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    },
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        "eligibilityReason": "The current official guideline gives population-, pattern-, associated-finding-, and urgency-specific neurological referral boundaries. It does not address recurrent heat or burning confined to the back and cannot make that isolated complaint a red flag."
      },
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          "verifiedAt": "2026-08-14T01:29:59Z",
          "versionState": "Official NG127 page recorded as published 2019-05-01 and last updated and reviewed 2023-10-02. The PDF metadata identifies NICE, NG127, the frozen title, and a 2023-10-02 creation date. The rendered footer is © NICE 2025; this record does not infer a substantive 2025 recommendation update from the footer alone.",
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            "section": "Sensory symptoms including tingling or numbness in adults — Numbness and weakness"
          },
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        },
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          "analyticParaphrase": "Persistent altered sensation that is predominantly distal in the limbs is separated by examination context: brisk deep-tendon reflexes prompt assessment for possible brain or spine disease, whereas depressed reflexes prompt consideration of peripheral neuropathy, specified basic cause checks, and neurological referral if no cause is found.",
          "allowableUse": "Show that distribution and reflex findings, rather than a vivid sensory adjective alone, change the next decision.",
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        },
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            "section": "Sensory symptoms including tingling or numbness in adults — Cervical or lumbar radiculopathy"
          },
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          "analyticParaphrase": "Stable cervical radiculopathy of at least six weeks is not routinely referred unless pain is uncontrolled, symptoms are disabling, or specified factors are present: age under 20, gait disturbance, clumsy or weak hands or legs, brisk limb reflexes, extensor plantar responses, or new bladder or bowel disturbance. Stable lumbar radiculopathy of at least six weeks is likewise not routinely referred unless pain is uncontrolled or symptoms are disabling, with management cross-referred to NG59.",
          "allowableUse": "Preserve the guideline's stable-course exceptions, functional threshold, neurological findings, and adult radiculopathy context.",
          "notSupported": "Calling back heat radiculopathy, extending the cervical exception list to all back sensations, or treating six weeks as a universal waiting period."
        },
        {
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            "pdfPage": 14,
            "rationalePdfPage": 56,
            "section": "Limb or facial weakness in adults — Severe low back pain together with other symptoms"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "Immediate assessment for cauda equina syndrome is tied to severe low-back pain radiating into a leg together with newly disturbed bladder, bowel, or sexual function, or new perineal numbness. The rationale identifies that named constellation as a medical emergency.",
          "allowableUse": "State the complete adult symptom constellation and urgency without dropping the radiating-pain and new-onset qualifiers.",
          "notSupported": "Treating isolated recurrent back heat, non-radiating warmth, or a thermal descriptor by itself as evidence of cauda equina syndrome."
        },
        {
          "passageId": "PV-NG127-ADULT-NONREFERRAL-CONTEXTS",
          "locator": {
            "recommendations": [
              "1.10.7",
              "1.10.10",
              "1.10.13"
            ],
            "pdfPages": [
              21,
              22
            ],
            "rationalePdfPage": 61,
            "section": "Adult sensory symptoms — functional neurological disorder, meralgia paraesthetica, and waking sensory disturbance"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "The guideline also names constrained non-referral or reassurance contexts: recurrent numbness or tingling in an adult already diagnosed with functional neurological disorder by a specialist when there are no new neurological signs; outer-thigh symptoms in the lateral cutaneous nerve distribution, with pain referral considered only if severe; and limb tingling or sensory disturbance on waking that lasts under 10 minutes, attributed in the rationale to sleeping-posture compression.",
          "allowableUse": "Demonstrate that a known diagnosis, absence of new signs, precise distribution, trigger, duration, and severity can support non-referral decisions.",
          "notSupported": "General reassurance for undiagnosed back burning or transfer of these narrowly specified contexts to other anatomy or timing."
        },
        {
          "passageId": "PV-NG127-URGENCY-DEFINITIONS",
          "locator": {
            "pdfPage": 49,
            "section": "Terms used in this guideline"
          },
          "evidenceLayer": "guideline-definition",
          "analyticParaphrase": "Within NG127, immediate referral means specialist assessment within hours or faster if needed; urgent referral means within two weeks; unqualified referral and consideration of referral denote routine referral.",
          "allowableUse": "Interpret NG127's urgency verbs according to its own definitions.",
          "notSupported": "Assuming the same time definitions govern other jurisdictions or unrelated guidelines."
        },
        {
          "passageId": "PV-NG127-EVIDENCE-BASIS",
          "locator": {
            "adultPdfPages": [
              60,
              61
            ],
            "childPdfPages": [
              77,
              78
            ],
            "sections": [
              "Rationale — Sensory symptoms including tingling or numbness in adults",
              "Rationale — Sensory symptoms such as tingling or numbness in children"
            ]
          },
          "evidenceLayer": "guideline-rationale-and-evidence-limit",
          "analyticParaphrase": "For both adult and child sensory-symptom sections, NICE states that the committee developed recommendations from its knowledge and experience and that reviewed evidence yielded nothing able to support recommendations. The rationales then explain the clinical reasoning behind specific patterns; these are consensus safety boundaries, not estimates from a directly supportive evidence base.",
          "allowableUse": "Qualify the authority and evidentiary basis of the sensory redirection rules.",
          "notSupported": "Diagnostic-accuracy estimates, prevalence, causal inference, or a claim that trials or comparative studies validated these sensory patterns."
        },
        {
          "passageId": "PV-NG127-CHILD-POPULATION-DISTINCTION",
          "locator": {
            "recommendations": [
              "1.27.1",
              "1.27.2",
              "1.27.3",
              "1.27.4",
              "1.27.5"
            ],
            "pdfPage": 42,
            "rationalePdfPages": [
              77,
              78
            ],
            "section": "Sensory symptoms such as tingling or numbness in children"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "For children, tingling with weakness or bladder or bowel dysfunction, or with motor-impairment features suggesting acute polyneuropathy, prompts urgent assessment. Episodic isolated tingling, altered sensation, or paraesthesia is referred when it is not linked to nerve compression. Temporary symptoms clearly triggered by compression activities are not routinely referred, and transient limb tingling may also follow hyperventilation.",
          "allowableUse": "Keep paediatric thresholds separate and show how associated findings and a clear provocation alter disposition.",
          "notSupported": "Transferring paediatric episodic-sensation recommendations to adults or treating a child's isolated recurrent back-heat descriptor as equivalent to tingling or paraesthesia."
        },
        {
          "passageId": "PV-NG127-THERMAL-NONFINDING",
          "locator": {
            "scope": "Entire 86-page PDF",
            "searchTerms": [
              "back heat",
              "localized heat",
              "localized warmth",
              "warmth",
              "burning",
              "skin temperature",
              "temperature"
            ]
          },
          "evidenceLayer": "structured-negative-finding",
          "analyticParaphrase": "Targeted full-document searches found no passage naming back heat, localized heat or warmth, burning, skin temperature, or temperature as a recognition or referral criterion. Relevant recommendations instead use numbness, tingling, altered sensation, pain, anatomical distribution, tempo, triggers, reflexes, weakness, imbalance, function, and bladder, bowel, sexual, or perineal findings.",
          "allowableUse": "Record that this guideline does not establish isolated recurrent localized back heat as a neurological redirect and identify the dimensions it actually uses.",
          "notSupported": "Proof that isolated back heat is benign, proof that no neurological condition can present with heat or burning, or a claim about all guidelines or evidence."
        }
      ],
      "interpretation": {
        "evidenceRole": "Authoritative but indirect safety-boundary source.",
        "clusterUse": "NG127 can support a discriminating safety framework based on exact population, onset and progression, distribution, provocation, neurological examination, associated functions, severity, and disability. It cannot turn the focal thermal complaint itself into a red flag.",
        "safetyBoundary": "Any later redirect language must reproduce the relevant constellation and urgency faithfully. The absence of a thermal criterion is a source-specific non-finding, not reassurance or exclusion of disease."
      },
      "claimsNotEstablished": [
        "Isolated recurrent heat or burning confined to the back is an urgent or routine neurological referral criterion.",
        "Back heat is equivalent to numbness, tingling, paraesthesia, radiculopathy, neuropathy, myelopathy, epilepsy, or cauda equina syndrome.",
        "Any named sensory pattern has established diagnostic accuracy, prevalence, causal meaning, or predictive value.",
        "Absence of NG127 thermal wording establishes benignity or rules out neurological disease.",
        "Adult and child thresholds are interchangeable.",
        "The guideline evaluates objective skin temperature, deep temperature, spontaneous warmth, burning quality, or subjective-objective thermal discordance."
      ],
      "unresolvedBlockers": [
        "T1-SAFETY-NG234 remains passage-unverified, so the safety-redirect gate cannot yet close.",
        "The companion NG127 full evidence document was not part of this frozen Tier 1 acquisition. The current guideline's own rationale explicitly records no evidence capable of supporting the adult or child sensory recommendations; this unit does not independently reconstruct every evidence review question.",
        "NG127 is UK guidance and does not by itself establish Korean care pathways, service availability, or jurisdiction-specific urgency implementation."
      ],
      "verificationDecision": "verified-for-qualified-pattern-specific-safety-boundaries-and-source-specific-negative-finding",
      "nextWorkUnit": "Verify T1-SAFETY-NG234 as one bounded passage-verification unit from the frozen official guideline PDF, focusing on exact cancer-population qualifiers, spinal pain patterns, neurological signs, urgency, exceptions, evidence basis, and transfer limits to isolated recurrent back heat."
    },
    {
      "artifact": "passage-verification-t1-safety-ng234.json",
      "schemaVersion": 1,
      "clusterId": "BRC-CL-2026-001",
      "slug": "back-heat-subjective-localized-sensation",
      "artifactType": "passage-verification-record",
      "stage": "passage-verification",
      "workUnit": "passage-verification-t1-safety-ng234",
      "workTarget": {
        "kind": "shared-cluster"
      },
      "createdAt": "2026-08-14T01:35:30Z",
      "candidate": {
        "candidateId": "T1-SAFETY-NG234",
        "familyId": "NICE-NG234",
        "reference": "NG234",
        "title": "Spinal metastases and metastatic spinal cord compression",
        "eligibilityDecision": "include-as-authoritative-indirect-safety-and-redirection-boundary",
        "eligibilityReason": "The current official guideline gives cancer-context, pain-pattern, neurological-sign, urgency, imaging, and negative-screening boundaries for spinal metastases and metastatic spinal cord compression. It does not address recurrent heat or burning confined to the back, and heat quality alone is not a listed recognition factor."
      },
      "sourceVerification": {
        "guideline": {
          "locator": "https://www.nice.org.uk/guidance/ng234/resources/spinal-metastases-and-metastatic-spinal-cord-compression-pdf-66143896133317",
          "localPath": "fulltext-nice-ng234.pdf",
          "mediaType": "application/pdf",
          "pages": 77,
          "bytes": 407480,
          "sha256": "2d02e280b74e10a80a0ddf5594b5fe9ec3240108d3498e45e51750ad6786d067",
          "acquiredAt": "2026-08-14T00:45:26Z",
          "verifiedAt": "2026-08-14T01:35:30Z",
          "versionState": "The frozen official NG234 page records publication on 2023-09-06 and review on 2026-03-19, and states that NG234 updates and replaces CG75. The PDF title, subject, keyword, author, and reference identify NG234; the rendered footer is © NICE 2026.",
          "identityCheck": "PDF title, subject, keyword, author, reference, page count, byte count, and SHA-256 match the frozen acquisition record."
        },
        "targetedRead": {
          "searchType": "Targeted within-PDF passage verification of the already acquired official guideline; no new bibliographic retrieval, inventory rebuild, or broad pagination.",
          "queryDate": "2026-08-14",
          "queryTermsWithinFullText": [
            "recognising spinal metastases or MSCC",
            "pain characteristics suggesting spinal metastases",
            "symptoms and signs suggesting cord compression",
            "past or current diagnosis of cancer",
            "suspected diagnosis of cancer",
            "severe unremitting back pain",
            "progressive back pain",
            "mechanical pain",
            "night-time back pain",
            "localised tenderness",
            "radicular pain",
            "numbness",
            "paraesthesia",
            "bladder or bowel dysfunction",
            "gait disturbance",
            "limb weakness",
            "immediately contact",
            "within 24 hours",
            "within 1 week",
            "do not do MRI",
            "back heat",
            "localized heat",
            "localised heat",
            "localized warmth",
            "localised warmth",
            "warmth",
            "burning",
            "skin temperature",
            "temperature"
          ],
          "sectionsRead": [
            "Recommendations 1.3.1-1.3.6 and Box 1: recognising spinal metastases or MSCC",
            "Recommendations 1.5.1-1.5.6: radiologist involvement and MRI assessment",
            "Rationale and impact: recognising spinal metastases or MSCC",
            "Rationale and impact: imaging investigations — radiologist involvement and MRI assessment",
            "Full 77-page document search for thermal wording"
          ]
        }
      },
      "verifiedPassages": [
        {
          "passageId": "PV-NG234-RECOGNITION-FRAME",
          "locator": {
            "recommendation": "1.3.1",
            "box": "Box 1",
            "pdfPages": [
              18,
              19
            ],
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation",
          "analyticParaphrase": "The recognition frame joins three distinct elements: past, current, or suspected cancer; specified back-pain characteristics; and specified symptoms or signs of cord compression. The listed pain patterns are severe unremitting, progressive, mechanical, strain-aggravated, sleep-disturbing nocturnal pain, localised tenderness, or exertional leg claudication. The cord-compression list comprises bladder or bowel dysfunction, gait difficulty, limb weakness, neurological signs of cord or cauda-equina compression, numbness, paraesthesia or sensory loss, and radicular pain.",
          "allowableUse": "Describe the exact cancer, pain-pattern, and neurological dimensions that change concern, without collapsing the three lists or omitting qualifiers.",
          "notSupported": "Treating a vivid sensory adjective, isolated recurrent back heat, or burning without the listed context as evidence of spinal metastases or cord compression."
        },
        {
          "passageId": "PV-NG234-CANCER-CORD-COMPRESSION-EMERGENCY",
          "locator": {
            "recommendation": "1.3.2",
            "pdfPage": 19,
            "rationalePdfPage": 52,
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "Immediate contact with the MSCC coordinator and treatment as an oncological emergency apply when a person with a past or current cancer diagnosis presents with a Box 1 symptom or sign of cord compression. The rationale ties immediate action to that combined cancer and neurological constellation and to prevention of instability and neurological harm.",
          "allowableUse": "State the immediate cancer-context redirect only with the past/current cancer qualifier and a named cord-compression symptom or sign.",
          "notSupported": "Immediate oncological referral for isolated back heat, for back pain alone, or for a person without the specified cancer and neurological context."
        },
        {
          "passageId": "PV-NG234-CANCER-PAIN-WITHIN-24-HOURS",
          "locator": {
            "recommendation": "1.3.3",
            "pdfPage": 20,
            "rationalePdfPages": [
              52,
              53
            ],
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "For a person with a past or current cancer diagnosis whose pain has a Box 1 characteristic suggesting spinal metastases, NICE directs advice through the MSCC coordinator within 24 hours. This pathway is distinct from the immediate emergency pathway for cord-compression signs.",
          "allowableUse": "Preserve the cancer history, qualifying pain pattern, 24-hour advice route, and distinction from the neurological emergency pathway.",
          "notSupported": "Using any back sensation, any back pain, or heat quality alone to trigger the 24-hour MSCC pathway."
        },
        {
          "passageId": "PV-NG234-SUSPECTED-CANCER-URGENT-ONCOLOGY",
          "locator": {
            "recommendation": "1.3.5",
            "pdfPage": 20,
            "rationalePdfPage": 53,
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "For a person without a past or current cancer diagnosis, urgent oncology assessment is directed only when a Box 1 pain characteristic is present and cancer is suspected, with a cross-reference to the separate suspected-cancer guideline.",
          "allowableUse": "State that absence of known cancer does not erase concern when cancer is independently suspected and the specified pain pattern is present.",
          "notSupported": "Inferring suspected cancer from isolated recurrent back heat or from an unqualified burning descriptor."
        },
        {
          "passageId": "PV-NG234-KNOWN-CANCER-NEGATIVE-CLINICAL-EVIDENCE",
          "locator": {
            "recommendation": "1.3.6",
            "pdfPage": 20,
            "rationalePdfPage": 53,
            "section": "Recognising spinal metastases or MSCC"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "When a person with past or current cancer has low-back pain but no clinical evidence of spinal metastases or MSCC, for example after previous imaging, the guideline calls for tailored information about Box 1 changes and urgent contact if symptoms change or worsen. It does not treat one prior negative assessment as permanent reassurance.",
          "allowableUse": "Preserve safety-netting, change-over-time, and prior-assessment context.",
          "notSupported": "Claiming that a prior negative image rules out later disease, or applying cancer-specific safety-netting as a generic explanation for back heat."
        },
        {
          "passageId": "PV-NG234-MRI-TIMING-AND-EXCEPTIONS",
          "locator": {
            "recommendations": [
              "1.5.2",
              "1.5.3",
              "1.5.4",
              "1.5.6"
            ],
            "pdfPage": 22,
            "rationalePdfPages": [
              55,
              56,
              57
            ],
            "section": "Imaging investigations — MRI assessment"
          },
          "evidenceLayer": "guideline-recommendation-and-rationale",
          "analyticParaphrase": "Suspected MSCC under recommendation 1.3.2 leads to MRI as soon as possible and always within 24 hours, ordinarily at a local or directly accessible imaging centre. Clinical suspicion of spinal metastases without suspected MSCC under recommendation 1.3.3 leads to MRI within one week to guide treatment. Overnight MRI is reserved for circumstances in which an urgent diagnosis is needed for immediate treatment. Screening MRI solely to detect early cord compression is not recommended for people with diagnosed spinal metastases who lack cord-compression symptoms or signs.",
          "allowableUse": "Show that imaging timing follows a clinically qualified pathway and that the guideline contains explicit limits on transfer, overnight scanning, and asymptomatic screening.",
          "notSupported": "Routine or urgent MRI for isolated recurrent back heat, imaging based on a thermal adjective alone, or use of the one-week timing outside suspected spinal metastases."
        },
        {
          "passageId": "PV-NG234-EVIDENCE-BASIS-AND-UNCERTAINTY",
          "locator": {
            "recognitionRationalePdfPages": [
              52,
              53
            ],
            "imagingRationalePdfPages": [
              55,
              56,
              57
            ],
            "sections": [
              "Rationale — recognising spinal metastases or MSCC",
              "Rationale — imaging investigations"
            ]
          },
          "evidenceLayer": "guideline-rationale-and-evidence-limit",
          "analyticParaphrase": "The recognition recommendations draw on comparative and undiagnosed-cancer symptom evidence together with committee experience; the guideline states that cancer history was a strong indicator in the context of back pain but provides no diagnostic-accuracy estimate in the recommendation PDF. Imaging recommendations draw on a large imaging evidence base plus expertise; the rationale reports that plain radiographs combined with neurological assessment had very low sensitivity, and that a randomized screening-MRI trial in high-risk people did not materially improve major clinical outcomes. These statements support pathway boundaries, not diagnosis from any single symptom.",
          "allowableUse": "Qualify the guideline as authoritative pathway evidence while retaining its evidence layers and the distinction between recognition factors and diagnostic tests.",
          "notSupported": "A sensitivity, specificity, likelihood ratio, prevalence, or causal estimate for any Box 1 factor or for back heat; proof that a listed factor independently diagnoses malignancy."
        },
        {
          "passageId": "PV-NG234-THERMAL-NONFINDING",
          "locator": {
            "scope": "Entire 77-page PDF",
            "searchTerms": [
              "back heat",
              "localized heat",
              "localised heat",
              "localized warmth",
              "localised warmth",
              "warmth",
              "burning",
              "skin temperature",
              "temperature"
            ]
          },
          "evidenceLayer": "structured-negative-finding",
          "analyticParaphrase": "Targeted full-document searches found none of the thermal terms. The recognition pathways use cancer context, named pain characteristics, neurological symptoms and signs, progression, function, and change or worsening rather than heat, warmth, burning, or temperature language.",
          "allowableUse": "Record that NG234 does not establish isolated recurrent localized back heat as a recognition or referral criterion and identify the dimensions it actually uses.",
          "notSupported": "Proof that isolated back heat is benign, proof that malignancy or cord compression cannot include a thermal complaint, or a conclusion about other guidelines or populations."
        }
      ],
      "interpretation": {
        "evidenceRole": "Authoritative but indirect safety-boundary source.",
        "clusterUse": "NG234 supports a discriminating safety framework in which cancer history or suspicion, specific pain behavior, neurological signs, functional change, and tempo determine the next pathway. It cannot convert the focal thermal complaint itself into a metastatic-spine or MSCC signal.",
        "safetyBoundary": "Any later redirect language must reproduce the relevant population, constellation, and timing. The source-specific absence of thermal wording is neither reassurance nor disease exclusion.",
        "relationshipToNG127": "NG234 adds an oncology-specific pathway to NG127's neurological boundaries. The sources should remain complementary and must not be merged into an unqualified generic red-flag list."
      },
      "claimsNotEstablished": [
        "Isolated recurrent heat or burning confined to the back suggests spinal metastases, MSCC, cancer, or cauda-equina compression.",
        "Heat or burning is equivalent to the listed pain characteristics, numbness, paraesthesia, sensory loss, or radicular pain.",
        "Any Box 1 factor independently diagnoses cancer, spinal metastases, instability, or cord compression.",
        "The recommendation PDF supplies diagnostic-accuracy, prevalence, causal, or prognostic estimates for the focal thermal phenotype.",
        "Absence of thermal wording establishes benignity or excludes malignant, neurological, dermatological, vascular, autonomic, or other causes.",
        "NG234 establishes Korean referral logistics, coordinator availability, or jurisdiction-specific timing.",
        "The guideline evaluates objective skin temperature, deep temperature, spontaneous warmth, or subjective-objective thermal discordance."
      ],
      "unresolvedBlockers": [
        "The companion NG234 evidence reviews were not independently reconstructed in this bounded unit; evidence-detail claims must remain limited to what the official recommendation PDF and its rationale state.",
        "NG234 is UK guidance and does not by itself establish Korean care pathways, MSCC-coordinator access, service configuration, or jurisdiction-specific implementation.",
        "Two frozen Tier 1 research candidates remain passage-unverified: T1-QST-SR-23711482 and T1-NP-COMPARATOR-28902951."
      ],
      "verificationDecision": "verified-for-qualified-cancer-and-cord-compression-safety-boundaries-and-source-specific-thermal-negative-finding",
      "nextWorkUnit": "Verify T1-QST-SR-23711482 as one bounded passage-verification unit from the frozen abstract and lawful-access state, focusing on thermal-QST subgroups, pooled associations with pain or disability, heterogeneity, sparse outcomes, and claims that remain unavailable without full text."
    }
  ]
}