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January 2008
AADEP San Antonio
Discography and the
Evaluation of LBP
Eugene J Carragee, MD
Stanford University
LBP Evaluation in Context
• Primary Diagnostic Evaluation (<50% ?)
– LBP short duration (days - weeks)
– Hx, PE, “rule out...
Common MRI Findings and Pain
• DDD
– Poor correlation with sx (Jensen, Boden)
• Anular Disruption and HIZ
– Poor PPV or NP...
Common MRI Findings and Pain
• Modic I - II changes (mod - sev)
– 10% Asx subjects (Weishaupt Rad 98)
– 100% PPV at disocg...
Imaging Findings
• If MRI, CT and Bone Scan are not
specific for LBP illness
• Then, how do we finds the “pain
generator”
But first - Defining a
Clinically Relevant Pain Generator
• The “Pain Generator” in LBP illness
– as an isolated local pat...
Discography GoalDiscography Goal
• To be a reliable, objective test that can
identify a disc as the primary pathology
in p...
The Good Discogram of San Francisco
• 54 yo master chef.
• 3 years severe LBP, radiates to gluteals only.
• No medical pro...
The Good Discogram of San Francisco
• In this case…discography, may be key to
treatment-->
– Nl L2/3
– Anular Disruption L...
Reliability of Pain Reporting in
Discography
Note in this Case #1:
1. No concurrent or history of other
chronic pain proce...
Factors Affecting Reported
Pain on Disc Injections
• Disc
– Anular Disruption
– Pressure Applied
• Local Pain Sensitivity
...
Hypothetical Response to
Pressurization of a Degenerative Disc
Depending on “Pain Sensitivity”
“Normal”
Increasing Injecti...
Evidence for Validity and
Usefulness of Discography
• Sackett and Hayes (Br. Med J: 324) Evidence -base criteria for
Evalu...
Studies of Subjects w/o LBP
• Classic Study - Walsh et al 1990
• Healthy young men, little DDD, no chronic pain
states, nl...
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Walsh (-DDD) Pain Free + DDD ISIS study Chronic Pain Somatization
Pain Intensi...
0
20
40
60
80
Young Men Older+DDD Spine
Society
Chronic Pain Post-op DiscSomatization
low pressure +
medium pressure +
Sub...
Hypothetical Response to
Pressurization of a Degenerative Disc
Depending on “Pain Sensitivity”
“Normal”
Increasing Injecti...
Do discography pts often have
“Risk Factors”?
• Abn Psych Testing
• 80% Discography + (Stanford)
• 79% Discography + (Derb...
Not Really… look at 3 groups with
serious sx for 6 - 18 months
• Discogenic pain
– Positive discography (1-3 levels)
– no ...
VAS (mean)
5
5.5
6
6.5
7
Disc Spondy PVO
Oswestry Scores
0
10
20
30
40
50
Disc Spondy PVO
Discogenic pain / PVO significantly worse than Spondy (0.01)
Psychometric Scores
0
5
10
15
20
25
Disc Spondy PVO ASX
MSPQ Zung
Disc pain
most
abnormal
P = 0.0001
DRAM Catagories in Studies Groups and Controls
0%
20%
40%
60%
80%
100%
Discogram + Spondyl PVO Soldiers/CLBP Asx Control
N...
Chronic LBP Patients with
Non-specific findings = “Discogenic
Pain”*
0
10
20
30
40
50
60
70
80
90
100
Discogenic Pain
Abno...
Profiles in Other Spine Pts
with Severe Chronic Pain
0
10
20
30
40
50
60
70
80
90
100
Discogenic RA Vert
Osteo
Spondy Adul...
Compare Other Chronic Pain
without Clear Local
Pathology
0
10
20
30
40
50
60
70
80
90
100
Fibromyalgia Discogenic TMJ/Faci...
How reliable is “Concordancy”
Experimental LBP Model (Phase 3)
• Subjects scheduled for posterior ICBG
– for non-lumbar pr...
Concordancy Test Model
0
2
4
6
8
10
No Pain Dissimilar Similar Exact
60% painful discs felt similar to / or exactly like I...
Schematic Approach to
Back Pain Perception and
Discography
Muscular
Facet
Bone
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
Perception
DRG
Cord
Thalamus
Cerebral
Vis...
Muscular
Facet
Bone
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain!!!!
DRG
Cord
Thalamus
Cere...
Muscular L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain! ! !
DRG
Cord
Thalamus
Cerebral
Visce...
Facet
Bone
Muscular
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain!!!!
DRG
Cord
Thalamus
Cere...
Case 2
• 35 yo man, severe LBP x 7 mo.
• Unable to work x 3 month.
• VAS 9-10, Oswestry 50,
• Psych “At risk”
• Meds Daily...
Case 2
• Bone Spec Scan, hot at L4
• Excisional biopsy, “osteiod osteoma”
• Fusion L3-4, unilateral pedicle screws.
• RTW,...
Facet
Bone
Muscular
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain!!!!
DRG
Cord
Thalamus
Cere...
Facet
Bone
Muscular
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain!!!!
DRG
Cord
Thalamus
Cere...
Case 3
• 49 yo woman, severe LBP, no WC BUT...
• Disabled for years, conserv. Rx makes worse.
Injections give transient re...
Case 3
• Work up shows collapsing weakness and DDD in
spine, MRI no tumor, infection, cord compression.
• Returns 6 weeks ...
Case 3-- ”She’s Back”
• Returns 2 years later had surgery
• L4-S1 solid 360° fusion
• Still terrible pain but feels surger...
Do people with common backache
have painful disc injections?
• Phase 2 discography protocol...
• 25 volunteers with persis...
Common Backache
Study Protocol
• Full Walsh protocol for experimental
discography.
• Question:
– What kind of pain respons...
Bachache and Discography
•36% “Backache group” had “bad” concordant pain
•Most are low pressure sensitive discs
•It is pos...
Facet
Bone
Muscular
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain!!!!
DRG
Cord
Thalamus
Cere...
Or is it a problem…Case 4
• 48 yo man, long hx LBP, occ. treatment
• MVA 1997, pt claims “different LBP”
since accident an...
Working the system…Case 4
• Diffuse pain.
• Bizarre pain drawing.
• OSW = 62; VAS (mn) = 8; Daily Narc.
• DRAM - Distresse...
Working the System
• Seen 8 months later at request of his attorney.
• Discography done in community:
• L3/4 minor fissuri...
Facet
Bone
Muscular
L3/4
Disc
L4/5
Disc
L5/S1
Disc
Similar
Sclerotomal
Afferents
That’s my
Pain!!!!
DRG
Cord
Thalamus
Cere...
Acid Test
Does discography improve outcomes
• Mixed
– Comparing fusion surgerys in different studies w/ and
w/o discograph...
Outcome as Gold Standard
• Usually Outcome is considered poor diagnostic
gold standard:
– Failure related to patient selec...
Outcome as Gold Standard
• Exclusions:
– > 18 months of current episode
– Not working prior to latest episode
– Abnormal D...
Hypothesis
• IF -- both groups are correctly diagnosing
a single segment pain generator
• AND -- both have equal patient s...
Subjects
• 30 “discography +” DDD
– 5 years to recruit
• 32 unstable spondylolisthesis
– Same time period
• No significant...
Results
0
20
40
60
80
100
Cured Some relief
Spondy disco +
False + = 40%
Summary
– Phase 1 studies were encouraging with low risk of
false positive in completely normal subjects.
– Phase 2 and 3 ...
Practical Usage Guide for
Discography in 2008
• Best case
1. Negative discogram (next to other pathology - spondy etc)
2. ...
Thank you
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Presentation: Discography and the Evaluation of LBP

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  • &amp;lt;number&amp;gt;
    A 49 year old woman had a long history of low back complaints. Several times since her teenage years she had been completely disabled with back complaints for up to two years. She complained of back, buttock and thigh pain with no radiation below the knee. She had not worked in 16 years and was cared for by her family. She was seen in by me in 1992 and had been &amp;quot;unable&amp;quot; to leave her bed at that time for sixteen weeks. She was taking 8-10 Percadan per day. Attempts at physical therapy had increased her symptomatology. She also complained of headaches, palpitations, epigastric pain, upper extremity tingling, and multiple drug allergies. She had undergone hysterectomy and appendectomy for pelvic pain, laparoscopic cholecystectomy for epigastric pain and gallstones, and bilateral carpal tunnel releases. None of these procedures gave lasting relief although each helped transiently. She had recently been seen in an Emergency Department because she &amp;quot;could not move her legs&amp;quot;. She and her sister felt she had a &amp;quot;very high pain threshold.&amp;quot; She had had a number of exhaustive workups revealing only degenerative changes in the low back consistent with her age. She had had epidural, facet and root injections without lasting effect.
    A musculoskeletal evaluation again showed common spinal degenerative changes. No structural reason for her severe illness and pain behavior was found. A diagnosis of somatization disorder was considered and referral for treatment offered. This was refused and the patient left very dissatisfied with her care. Later in 1995 she returned with similar complaints of her back and legs for another consultation. Since last seen she had a CT-discogram which had shown a normal L3/4 disc and degenerative and fissured L4/5 and L5/S1 disks with a severe pain response at L4/5 and L5/S1 on injection of the discs. She felt both injections reproduced her usual discomfort in her back and legs. An anterior and posterior L4-S1 fusion was done in 1993, and she had some relief for three months. Then, she reported her pain returned more severely then pre-operatively. Radiographs showed a solid anterior fusion at 16 months post-operatively. She was contemplating having the screws and rods removed as she felt these were causing her pain.
    The hardware was removed a year later by another surgeon. The posterior fusion appeared solid. Again short term relief after surgery was followed by return of her usual symptoms. She was seen back in my clinic in 1997 with similar complaints as five years earlier and pain around her incision areas and bone graft sites. At this visit she related those all these symptoms to her spinal operations.
  • Transcript of "Presentation: Discography and the Evaluation of LBP"

    1. 1. January 2008 AADEP San Antonio Discography and the Evaluation of LBP Eugene J Carragee, MD Stanford University
    2. 2. LBP Evaluation in Context • Primary Diagnostic Evaluation (<50% ?) – LBP short duration (days - weeks) – Hx, PE, “rule out “red flags” of serious pathology • Secondary Diagnostic Evaluation (<5%) – LBP not improving (weeks to1-2 months) – Add ESR, CRP, MRI, motion study X-Rays – Rule out “Yellow Flags”, psychosocial/neurophysiologic factors that inhibit recovery OR coping. • Teritiary Diagnostic Evaluation (<1%) – Persistent pain, considering specific rx (months to 1 year) – Only common degenerative findings on imaging so far – Consider discography to identify disc as “pain generator”
    3. 3. Common MRI Findings and Pain • DDD – Poor correlation with sx (Jensen, Boden) • Anular Disruption and HIZ – Poor PPV or NPV (Jensen, Boden, Carragee, etc) – Relative > in CLBP vs Asx (50% vs 15 -25%) • Disc Protrusion and Stenosis – Extrusion (large) rarely seen in Asx (< 5%) – SS neural compression less common in Asx (15%) – Sx -> radicular; not a good LBP predictor • Endplate Changes -- latest flavor
    4. 4. Common MRI Findings and Pain • Modic I - II changes (mod - sev) – 10% Asx subjects (Weishaupt Rad 98) – 100% PPV at disocgraphy in sx (Weishaupt Radiology 2000) • Prediction of future LBP – Best but very modest correlation of future LBP • Boos Spine (2000) • Carragee Spine J (2004) – Much worse than: • DRAM, FABQ, Work Comp, Chronic Pain, Smoking
    5. 5. Imaging Findings • If MRI, CT and Bone Scan are not specific for LBP illness • Then, how do we finds the “pain generator”
    6. 6. But first - Defining a Clinically Relevant Pain Generator • The “Pain Generator” in LBP illness – as an isolated local pathoanatomic structure • Not a physiologic process or psychogenic complaint – independent of co-morbid factors • (chronic pain states, depression, somatic distress, litigation, secondary gain, etc) – Reasonable accounts for the chronic LBP illness of the patient • When do “Positive” disc injections identify the true “pain generator”?
    7. 7. Discography GoalDiscography Goal • To be a reliable, objective test that can identify a disc as the primary pathology in patients suffering from significant LBP illness. • How reliably does discography “identify the pathological feature causing Low Back Pain Illness?” -- [specificity] • Or “rule out” a disc as a significant pain source? -- [Sensitivity]
    8. 8. The Good Discogram of San Francisco • 54 yo master chef. • 3 years severe LBP, radiates to gluteals only. • No medical problems (really!). • Barely able to work. • VAS 7-9, Oswestry 45, Daily NSAIDS, occ narcs. • Psychometric: normal psychometrics, pain drawing. • No WC, litigation, high prestige job, stable marriage • X-Ray, collapse and retrolisth L5/S1 • MRI: nl L2/3, DDD L3/4, L4/5
    9. 9. The Good Discogram of San Francisco • In this case…discography, may be key to treatment--> – Nl L2/3 – Anular Disruption L3/4, L4/5 • No pain to 50 p.s.i., mild pain at 100. – L5/S1 not injected. • ALIF L5/S1 -- 1998 • Returned to work, 2 months p-op, full duty 4 months p-op. (regular 50# lift/carry) • 2 yr f/u VAS 0-2, Oswestry 5, occ NSAIDS • 5 yr f/u VAS 1-3, Oswestry 8, no meds • Some further DDD at L4/5 (now 59 yo)
    10. 10. Reliability of Pain Reporting in Discography Note in this Case #1: 1. No concurrent or history of other chronic pain processes. 2. No litigation, WC or secondary gain issues. 3. Normal psychometric, no “reactive depression, anxiety, somatic distress…” 4. Ablation of the suspected “Pain Generator” give high-quality outcome which lasts.
    11. 11. Factors Affecting Reported Pain on Disc Injections • Disc – Anular Disruption – Pressure Applied • Local Pain Sensitivity – Regional chronic pain, previous injury/surgery • Generalized Pain Sensitivity – Narcotics, Central Pain Syndromes, – Incentives (Financial, Social) – Disincentives (Financial Social)
    12. 12. Hypothetical Response to Pressurization of a Degenerative Disc Depending on “Pain Sensitivity” “Normal” Increasing Injection Pressure ----> Pain Hypersensitive Chronic Pain Syndrome Psychological Distress 2° Gain Issues Narcotic Habituation Reduced Social Imperatives Psychological Reserve Cultural Norms
    13. 13. Evidence for Validity and Usefulness of Discography • Sackett and Hayes (Br. Med J: 324) Evidence -base criteria for Evaluation of Diagnostic Tests Four Phases - • 1. Dx test results in completely normals / no sx / no co-morbidities. • 2. Dx test results in subjects w/o the disease BUT w/ sx of disease • 3. Dx test applied in subjects w/o the disease BUT epidemiologically likely to have disease (i.e. co- morbidies of the disease) • 4. Does having the test result improve outcomes • What is the evidence in discography?
    14. 14. Studies of Subjects w/o LBP • Classic Study - Walsh et al 1990 • Healthy young men, little DDD, no chronic pain states, nl psych (Phase 1) • Derby, Chen, et al (2003), ISIS: • Middle-age, nl psych, highly motivated (Spinal Injection Society Members) (Phase 1, 2) • Stanford Group: (2000) (Phase 1 -> 3) • Middle-aged, +DDD, no chronic pain, 80% nl psych. • Middle-aged, +DDD, chronic pain, 40% nl psych • Middle-aged, +DDD, chronic pain, + somatization.
    15. 15. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Walsh (-DDD) Pain Free + DDD ISIS study Chronic Pain Somatization Pain Intensity with Disc Injection in Asymptomatic Subjects > 8/10 >6 - 8 > 4 - 6 >2 - 4 > 0 - 2 0 Increasing Risk Factors
    16. 16. 0 20 40 60 80 Young Men Older+DDD Spine Society Chronic Pain Post-op DiscSomatization low pressure + medium pressure + Subjects w/o LBP Summary Psychometric testing, chronic pain, litigation/contested and anular disruption strongly predict painful injections. Increasing Risk Factors
    17. 17. Hypothetical Response to Pressurization of a Degenerative Disc Depending on “Pain Sensitivity” “Normal” Increasing Injection Pressure ----> Pain Hypersensitive Chronic Pain Syndrome Psychological Distress 2° Gain Issues Narcotic Habituation Reduced Social Imperatives Psychological Reserve Cultural Norms
    18. 18. Do discography pts often have “Risk Factors”? • Abn Psych Testing • 80% Discography + (Stanford) • 79% Discography + (Derby) • 80% DDD fusions (Fritzell) • Compensation Issues • 76% (Schwarzer) • 75% (Derby) • 68% (Carragee) • Chronic Pain • 100% -- by definition CLBP • 70% -- other chronic pain issues (IBS, TMJ, Migraine…) • But don’t all chronic BP patients develop abnormal pain behavior, abnormal psych profiles etc?
    19. 19. Not Really… look at 3 groups with serious sx for 6 - 18 months • Discogenic pain – Positive discography (1-3 levels) – no other pathology known – Carragee et al (Spine 1999, 2000) • Isthmic spondylolisthesis – CLBP + Sciatica – Scheduled for single level fusion – Carragee (JBJB 1997) • Pyogenic Vertebral Osteomyeolitis – Delayed diagnosis – Dx unknown at time of data collection – Carragee (JBJS 1997)
    20. 20. VAS (mean) 5 5.5 6 6.5 7 Disc Spondy PVO
    21. 21. Oswestry Scores 0 10 20 30 40 50 Disc Spondy PVO Discogenic pain / PVO significantly worse than Spondy (0.01)
    22. 22. Psychometric Scores 0 5 10 15 20 25 Disc Spondy PVO ASX MSPQ Zung Disc pain most abnormal P = 0.0001
    23. 23. DRAM Catagories in Studies Groups and Controls 0% 20% 40% 60% 80% 100% Discogram + Spondyl PVO Soldiers/CLBP Asx Control Normal At Risk DD/DS 21% nl 75-85% nl
    24. 24. Chronic LBP Patients with Non-specific findings = “Discogenic Pain”* 0 10 20 30 40 50 60 70 80 90 100 Discogenic Pain Abnormal Psych Narcotic dependency History of Drug/Alcohol Compensation litigation Other Chronic Pain syndrome • Cairns et al 2003; Carragee et al 2001; Schwarzer 1995/96
    25. 25. Profiles in Other Spine Pts with Severe Chronic Pain 0 10 20 30 40 50 60 70 80 90 100 Discogenic RA Vert Osteo Spondy Adult Scoli Abnormal Psych Narcotic dependency History of Drug/Alcohol Compensation litigation Other Chronic Pain syndrome Which one is not like the other? * * - non RA pain
    26. 26. Compare Other Chronic Pain without Clear Local Pathology 0 10 20 30 40 50 60 70 80 90 100 Fibromyalgia Discogenic TMJ/Facial Chronic Fat. Abnormal Psych Narcotic dependency History of Drug/Alcohol Compensation litigation Other Chronic Pain syndrome Coincidence ?
    27. 27. How reliable is “Concordancy” Experimental LBP Model (Phase 3) • Subjects scheduled for posterior ICBG – for non-lumbar problems (fracture non-union, tumor) • Screened for LBP before ICBG – No current of life-time hx of LBP – LBP hx screening 3 x before study • All with normal psychometric testing • Discography done after ICGB – pain concordancy rated at discography to ICBG pain – Will disc stimulation pain reproduce ICBG pain • Completing Study - 8 pts / 24 disc injections » Carragee et al Spine 1999
    28. 28. Concordancy Test Model 0 2 4 6 8 10 No Pain Dissimilar Similar Exact 60% painful discs felt similar to / or exactly like ICBG pain.60% painful discs felt similar to / or exactly like ICBG pain. 50% subjects had + concordant discogram by all criteria.50% subjects had + concordant discogram by all criteria. 25% subj. had at least 1 low pressure sensitive disc.25% subj. had at least 1 low pressure sensitive disc.
    29. 29. Schematic Approach to Back Pain Perception and Discography
    30. 30. Muscular Facet Bone L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents Perception DRG Cord Thalamus Cerebral Visceral Vascular Pelvic Concordancy and The LBP Pathway Pathway Modulation 1 Adjacent tissue injury 2 Local AnaestheticLocal Anaesthetic 3 Nearby tissue injury 4 Regional Chronic Pain 5 Narcotic AnalgesiaNarcotic Analgesia 6 Narcotic Habituation 7 Depression 8 Social ImperitivesSocial Imperitives 9 Social Disincentives 1 2 3 4 5 6 7 8 9
    31. 31. Muscular Facet Bone L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain!!!! DRG Cord Thalamus Cerebral Visceral Pelvic Best Case Scenario One pain source And if you fix it, I’ll feel all better!
    32. 32. Muscular L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain! ! ! DRG Cord Thalamus Cerebral Visceral Pelvic Two equal pain sources And if you fuse it I’ll be a somewhat better...
    33. 33. Facet Bone Muscular L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain!!!! DRG Cord Thalamus Cerebral Visceral Vascular Pelvic 1° Non-discogenic pain source, minor disc pain Hyperalgesic Pain Pathway And if you fuse it I’ll be about the same...
    34. 34. Case 2 • 35 yo man, severe LBP x 7 mo. • Unable to work x 3 month. • VAS 9-10, Oswestry 50, • Psych “At risk” • Meds Daily Narcotics • X-ray nl, MRI DDD + HIZ L5/S1 • Discogram: 10/10 concordant pain L5/S1 • Nl L4/5, L3/4, but CT sclerosis L4 pedicle.
    35. 35. Case 2 • Bone Spec Scan, hot at L4 • Excisional biopsy, “osteiod osteoma” • Fusion L3-4, unilateral pedicle screws. • RTW, 2 month post-op • 3 year f/u – VAS 1-2, Oswestry 10, occ. NSAID – Stanford Score 8.8 (0-10) • Why did the L5/S1 disc have a severe concordant pain with injection?
    36. 36. Facet Bone Muscular L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain!!!! DRG Cord Thalamus Cerebral Visceral Vascular Pelvic Multiply Operated Back Hyperalgesic Pain Pathway Depression Somatization And if you fuse another level, I’ll be as miserable as ever...
    37. 37. Facet Bone Muscular L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain!!!! DRG Cord Thalamus Cerebral Visceral Vascular Pelvic 1° Psychological pain source, common backache Hyperalgesic Pain Pathway Depression Somatization “fibromyalgia ” “And if you fuse it, you should think of moving your practice…”
    38. 38. Case 3 • 49 yo woman, severe LBP, no WC BUT... • Disabled for years, conserv. Rx makes worse. Injections give transient relief. • Also CTS, migraines, pelvic pain, palpitations, irritable bowel syndrome. • CTR, appy, chole (no help) in past • In ER 1 week PTA “unable to move legs”. • Sister says: “ She has a very high pain threshold…”
    39. 39. Case 3 • Work up shows collapsing weakness and DDD in spine, MRI no tumor, infection, cord compression. • Returns 6 weeks later with outside w/u: – Discography L4/5 and L5/S1 10/10 concordant and fissured, low pressure. – L3/4 mild DDD 2/10 discordant pain – Psych interview feels emotiomal sx due to chronic pain. • A surgeon recommends fusion based on the “objective findings on discography…”
    40. 40. Case 3-- ”She’s Back” • Returns 2 years later had surgery • L4-S1 solid 360° fusion • Still terrible pain but feels surgery “helped” for a few months…(would do it again). • Recent Discogram shows 10/10 L3/4 pain. • Negative L2/3 “control” • Another surgeon now recommends to fuse L3/4 based on positive discogram. • How did we get into this mess...
    41. 41. Do people with common backache have painful disc injections? • Phase 2 discography protocol... • 25 volunteers with persistent LBP – > 2 year, OSW < 15 – No work loss, No activity restriction – No meds, not seeking medical rx. – Nl psych – MRI Signal loss in at least 1 lumbar disc • That is: People with “common backache.” – Carragee et al, The Spine Journal, 2002
    42. 42. Common Backache Study Protocol • Full Walsh protocol for experimental discography. • Question: – What kind of pain response? – Will it be concordant if present? – Can we differential using discography CLBP patients from Common Backache?
    43. 43. Bachache and Discography •36% “Backache group” had “bad” concordant pain •Most are low pressure sensitive discs •It is possible discography cannot tell common clinically-irrelevent BP from CLBP illness. 0 10 20 30 40 50 60 70 Negative Positive 2 or more + discs
    44. 44. Facet Bone Muscular L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain!!!! DRG Cord Thalamus Cerebral Visceral Vascular Pelvic Common backache Normal “amplified” Pain Pathway And so what…its not a problem?
    45. 45. Or is it a problem…Case 4 • 48 yo man, long hx LBP, occ. treatment • MVA 1997, pt claims “different LBP” since accident and totally disabled. • Seen after work-up, referred for discography. • MRI shows DDD, L4/5, L5/1 • HIZ at L4/5
    46. 46. Working the system…Case 4 • Diffuse pain. • Bizarre pain drawing. • OSW = 62; VAS (mn) = 8; Daily Narc. • DRAM - Distressed Despressed • Pre-existing “Anxiety Disorder” • Will discography clear up this picture?
    47. 47. Working the System • Seen 8 months later at request of his attorney. • Discography done in community: • L3/4 minor fissuring; 8/10 concord. • L4/5 and L5/S1 anular tear; 10/10 concord. • L2/3 “neg control disc” • Report reads “3 level symptomatic anular tears …caused by recent accident since [injection] only reproduces new pain since accident… causation in legal action clearly determined by discographic findings”.
    48. 48. Facet Bone Muscular L3/4 Disc L4/5 Disc L5/S1 Disc Similar Sclerotomal Afferents That’s my Pain!!!! DRG Cord Thalamus Cerebral Visceral Vascular Pelvic Secondary Gain (litigation) + pre-existing backache Hyperalgesic Pain Pathway “And it never felt like this before that the postal truck hit my car at 3 mph”
    49. 49. Acid Test Does discography improve outcomes • Mixed – Comparing fusion surgerys in different studies w/ and w/o discography – No differences (Cohen, et al 2003) • British retrospective study with very different patient groups (Calhoun) – Modestly improved outcomes in discography group. • New York Group(2003 J Spinal Dis) – Prospective – Historical control – No difference in discography group: using discography did not improve outcomes in this controlled study.
    50. 50. Outcome as Gold Standard • Usually Outcome is considered poor diagnostic gold standard: – Failure related to patient selection – Failure related to operative morbidity • Controlled “Pain Generator” Study – Single Level “Discography +” group versus – An ideal single segment “Pain Generator” • Unstable spondylolisthesis (>4 mm / >11°) – Do identical operation -- 360° fusion – No Comorbidites--
    51. 51. Outcome as Gold Standard • Exclusions: – > 18 months of current episode – Not working prior to latest episode – Abnormal DRAM – More than 1 abnormal segment (adjacent segments are NORMAL discogram) – No work comp / no litigation – No other chronic pain history • No alibi’s! Best case scenario…
    52. 52. Hypothesis • IF -- both groups are correctly diagnosing a single segment pain generator • AND -- both have equal patient selections and surgical risks/morbidity • THEN -- the surgical outcomes should be the same. • IF NOT -- the difference will = false positive rate.
    53. 53. Subjects • 30 “discography +” DDD – 5 years to recruit • 32 unstable spondylolisthesis – Same time period • No significant difference in baseline – VAS, ODI, work loss, smoking, DRAM, FABQ, sx duration, medication use.
    54. 54. Results 0 20 40 60 80 100 Cured Some relief Spondy disco + False + = 40%
    55. 55. Summary – Phase 1 studies were encouraging with low risk of false positive in completely normal subjects. – Phase 2 and 3 studies show higher risk with increasing co-morbidities associated with CLBP illness (30 - 80%) – Phase 4 studies are inconclusive or non-supportive for discography validity at this point. – Still not answer to distinguishing severely painful from common DDD in spine…
    56. 56. Practical Usage Guide for Discography in 2008 • Best case 1. Negative discogram (next to other pathology - spondy etc) 2. Positive, single level, nl psych, nl social (WC, Lit) - 50% PPV • Unclear Utility 1. 2 level Positive, nl psych, nl social 2. Post-operative discs, nl psych, nl social 3. Intermediate (At Risk) psychometrics, single level. • Poor Utility 1. Spine with multilevel pathology 2. Abnormal pain behavior or mutliple chronic pain processes, 3. Abnormal psychometric findings 4. Disputed compensation cases 5. As a forensic tool to establish “injury”
    57. 57. Thank you
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