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          "verifiedContent": "A NEC TVS-200 ISS camera and InfReC Analyzer NS9500 Lite software were used. Cork markers at Th12, both posterior superior iliac spines, both costal arches, and both iliac crests supported repeat placement. Four rectangular dorsal regions represented upper and lower treatment-side and non-treatment-side back; four analogous ventral regions were also defined. Mean skin temperature per region per image was analysed, and left-handed participants' data were inverted to align treatment-side categories. The article does not report camera accuracy, thermal sensitivity, image resolution, emissivity, camera distance or angle, calibration, assessor blinding, measurement repeatability, or a smallest detectable or clinically meaningful difference.",
          "supports": "The paper defines regional mean surface-temperature comparisons anchored to anatomical markers and harmonized by treatment side.",
          "doesNotSupport": "It does not establish measurement precision, within-person repeatability, a diagnostic asymmetry threshold, exact symptom localization, or bilateral anatomical side effects because handedness inversion removes native left-right direction."
        },
        {
          "passageId": "PV-35324650-BACK-RESULTS",
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            "table": "Table 2"
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          "evidenceLayer": "objective back-temperature results and counterevidence",
          "verifiedContent": "All four back-region means were lower at 10 minutes post-exercise than at baseline and approximately 24 hours, while baseline and follow-up did not differ in post hoc testing. Table 2 reports upper treatment-side means of 31.48, 30.42, and 31.44 degrees Celsius at pre, post, and follow-up versus 31.48, 29.88, and 31.48 on the upper non-treatment side; lower treatment-side means were 31.38, 30.04, and 31.22 versus 31.43, 29.72, and 31.26 on the lower non-treatment side. Thus, the treated back was relatively warmer than the untreated back at 10 minutes, by 0.54 degrees Celsius upper and 0.32 degrees Celsius lower from the reported group means, despite both sides being cooler than baseline. Post-exercise upper and lower side comparisons were reported as statistically significant, while no side asymmetry was reported before exercise or at follow-up.",
          "supports": "A transient relative side asymmetry can coexist with an absolute bilateral temperature fall after exercise, and the asymmetry was absent at the other measured times.",
          "doesNotSupport": "Relative warmth of one exercised side does not mean objective heating above baseline, subjective warmth, deep-muscle heating, persistence, pathology, diagnostic localization, or clinical importance. The 0.54 and 0.32 degree differences are transparent calculations from reported group means, not author-defined thresholds."
        },
        {
          "passageId": "PV-35324650-SUBJECTIVE-DISCORDANCE",
          "locator": {
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          "evidenceLayer": "subjective measures and temporal discordance",
          "verifiedContent": "The study collected general POMS fatigue and seven-point delayed-onset muscle soreness rather than localized warmth or burning. It reports average exercise exertion and fatigue/soreness scores but no participant-level or region-level association between those ratings and thermographic back temperature. The authors note that soreness was highest at 48 hours, whereas thermography was not performed then; at about 24 hours, back temperature had returned near baseline.",
          "supports": "The subjective and objective constructs and their measurement times were not aligned well enough to establish a symptom-temperature relationship.",
          "doesNotSupport": "The paper cannot show that felt fatigue, soreness, warmth, or burning covaries with back skin temperature or that a normal thermogram excludes a subjective symptom."
        },
        {
          "passageId": "PV-35324650-LIMITS",
          "locator": {
            "section": "3. Results, 4. Discussion, and 5. Conclusions",
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          "evidenceLayer": "interpretive, reporting, and generalizability limits",
          "verifiedContent": "The authors explicitly state that infrared thermography measures body-surface temperature, which is shaped by skin blood flow and sweat activity, and that temperature change cannot be directly inferred from the activity of deep trunk muscles. They identify body-fat distribution, training condition, daily oscillations, possible exercise-form error, and laboratory-to-real-world transfer as limitations. The reported final-analysis count is 33, yet the post-exercise asymmetry tests report n=35 for back and n=34 for abdomen without explaining the discrepancy. The conclusion proposes possible diagnostic and rehabilitation applications and calls for comparison with EMG, but the study supplies no clinical comparator, diagnostic-accuracy analysis, injury outcome, or validated threshold.",
          "supports": "Surface, depth, context, precision, analysis-denominator, and external-validity limits must accompany any use of the observed asymmetry.",
          "doesNotSupport": "The authors' proposed applications do not establish diagnostic validity, screening benefit, causal muscular localization, injury prevention, rehabilitation efficacy, or clinical use for recurrent localized back heat."
        }
      ],
      "interpretation": {
        "directlySupported": [
          "Under controlled laboratory conditions, a unilateral trunk-fatigue challenge produced a transient side difference in mean back skin-surface temperature 10 minutes later.",
          "Both treatment and non-treatment back regions were cooler than baseline at the post-exercise measurement; the treatment side was only relatively warmer than the non-treatment side.",
          "No back asymmetry was reported at baseline or approximately 24 hours, when region means were near baseline.",
          "The study measured general fatigue and delayed soreness, not spontaneous localized warmth or burning, and did not test their association with regional temperature."
        ],
        "hypothesesOnly": [
          "Skin-blood-flow, sweat-gland, systemic inflammatory, cross-training, training-status, body-fat, or exercise-form explanations for the observed pattern.",
          "Any relationship between experimentally provoked surface-temperature asymmetry and recurrent spontaneous localized back heat or burning.",
          "Any diagnostic or rehabilitation value of the observed asymmetry."
        ],
        "clinicalImplication": "None established for isolated recurrent localized back heat. The study is useful chiefly as a measurement caution: objective skin-surface temperature depends on preparation, environment, timing, region definition, exercise, sweating, and body composition, and relative side difference must not be confused with heating above baseline or with subjective sensation.",
        "constructBoundary": "Objective infrared skin-surface temperature is not deep-muscle temperature, spontaneous perceived warmth, burning pain, evoked thermal threshold, fatigue, soreness, or a diagnosis. A statistically significant group side difference is not a validated individual abnormality threshold."
      },
      "claimsNotEstablished": [
        "That recurrent localized back heat or burning is accompanied by elevated skin-surface temperature.",
        "That subjective warmth, burning, fatigue, or soreness tracks regional thermographic temperature.",
        "A normal range, repeatability estimate, precision bound, clinically meaningful difference, or diagnostic asymmetry threshold for back thermography.",
        "Deep-muscle temperature, causal muscular localization, injury detection or prevention, diagnostic accuracy, treatment selection, rehabilitation efficacy, prevalence, or safety redirection.",
        "Persistence beyond the measured 10-minute post-exercise window or a 48-hour thermographic pattern.",
        "Native left-right asymmetry, because data were reoriented into treatment-side categories.",
        "That the reported post-exercise inferential denominators are consistent with the stated 33-person final analysis."
      ],
      "unresolvedBlockers": [],
      "nextWorkUnit": "Verify T1-SAFETY-NG127 as one bounded passage-verification unit from the frozen official guideline PDF, focusing on exact population and symptom context, associated neurological findings, urgency and referral wording, exceptions, evidence basis, and the explicit non-finding that isolated recurrent back heat is not itself an established redirect."
    },
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        "doi": "10.1016/j.pain.2014.02.004",
        "title": "Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): reference data for the trunk and application in patients with chronic postherpetic neuralgia",
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        "eligibilityReason": "The abstract directly reports back-site QST reference work in healthy volunteers and an application to chronic postherpetic neuralgia. It is relevant to site effects and the limits of evoked thermal measurement, but it does not study spontaneous recurrent localized back heat or objective skin temperature, and no lawful stable full text was identified."
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        "authorInterpretation": "The authors present the data as trunk reference values and propose possible usefulness for post-thoracotomy and chronic back pain.",
        "reviewerInterpretation": "This source supports construct and site caution: experimentally evoked thresholds on the back cannot be replaced by limb norms, and even within QST the useful comparison depends on modality and safety limits. It does not connect a spontaneous report of back heat to measured skin temperature, a warm-detection threshold, paradoxical heat, lesion mechanism, or diagnosis. Abstract-level 'sensitivity' refers to reference classification capability, not diagnostic sensitivity, reliability, or symptom correlation.",
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        "The exact upper-back and lower-back landmarks, laterality, device, thermode area, baseline temperature, ramp rates, trial counts, instructions, ambient conditions, acclimatization, transformations, or missing-data handling.",
        "Test-retest reliability, interobserver reliability, agreement limits, measurement error, longitudinal responsiveness, or ranking stability.",
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        "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": "10.1097/PR9.0000000000001162",
        "title": "Quantitative sensory testing in notalgia paresthetica reveals small fiber-type-specific differences in non-pruritic sensitivity: a pilot study.",
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        "eligibilityReason": "The study directly compares symptomatic and contralateral back sites and reports thermal QST and paradoxical sensations, but the recruited phenotype is dermatologist-diagnosed unilateral subscapular itch rather than recurrent localized subjective back heat."
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          "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.",
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          "supports": "The observed findings arise from a small, chronic, predominantly female clinic cohort with mild-to-moderate itch burden.",
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        },
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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).",
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          "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.",
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          "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.",
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          "supports": "Mechanistic interpretation must remain hypothesis-level and the external-reference findings require caution.",
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        "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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        "That the exact conference protocol and sites were unchanged in the journal version of record.",
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        "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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        "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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          },
          "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."
    }
  ]
}