1
|
Méndez-Gutiérrez A, Marín Navas F, Acevedo-González JC. Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:209-222. [PMID: 36906136 DOI: 10.1016/j.recot.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. MATERIAL AND METHODS A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria. RESULTS Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive. CONCLUSIONS Pain in response to contrast medium injection, assessed with the visual analog pain scale≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.
Collapse
Affiliation(s)
- A Méndez-Gutiérrez
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - F Marín Navas
- Semillero de Neurocirugía y Neurología, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - J C Acevedo-González
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| |
Collapse
|
2
|
Méndez-Gutiérrez A, Marín Navas F, Acevedo-González JC. [Translated article] Frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. Systematic review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T209-T222. [PMID: 38508378 DOI: 10.1016/j.recot.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION There are different techniques and interpretations of discography findings to determine it positive for the diagnosis of discogenic pain. This study aims to evaluate the frequency of use of discography findings for the diagnosis of low back pain of discogenic origin. MATERIAL AND METHODS A systematic review of the literature of the last 17 years was performed in MEDLINE and BIREME. A total of 625 articles were identified, 555 were excluded for duplicates, title and abstract. We obtained 70 full texts of which 36 were included in the analysis after excluding 34 for not meeting the inclusion criteria. RESULTS Among the criteria in discography to determine it as positive, 8 studies used only the pain response to the procedure, 28 studies used more than one criterion during discography to consider it as positive, the evaluation of at least one adjacent intervertebral disc with a negative result was necessary in 26 studies to consider a discography as positive. Five studies formally expressed the use of the technique described by SIS/IASP to determine a discography as positive. CONCLUSIONS Pain in response to contrast medium injection, assessed with the visual analogue pain scale ≥6, was the most used criterion in the studies included in this review. Although there are already criteria to determine a discography as positive, the use of different techniques and interpretations of discography findings to determine a positive discography for low back pain of discogenic origin persists.
Collapse
Affiliation(s)
- A Méndez-Gutiérrez
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - F Marín Navas
- Semillero de Neurocirugía y Neurología, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - J C Acevedo-González
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| |
Collapse
|
3
|
Lorio MP, Beall DP, Calodney AK, Lewandrowski KU, Block JE, Mekhail N. Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management. J Pers Med 2023; 13:jpm13050821. [PMID: 37240991 DOI: 10.3390/jpm13050821] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.
Collapse
Affiliation(s)
- Morgan P Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Douglas P Beall
- Clinical Radiology of Oklahoma, 1800 S. Renaissance Blvd., Ste. 110, Edmond, OK 73013, USA
| | | | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, 4787 E. Camp Lowell Drive, Tucson, AZ 85712, USA
| | - Jon E Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
| | - Nagy Mekhail
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| |
Collapse
|
4
|
Korhonen T, Järvinen J, Pesälä J, Haapea M, Niinimäki J. Modic changes associated with greater pain relief following anesthetization of the adjacent lumbar intervertebral disc: A retrospective study of chronic low back pain patients. Eur J Radiol 2022; 157:110589. [DOI: 10.1016/j.ejrad.2022.110589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
|
5
|
Korhonen T, Pesälä J, Järvinen J, Haapea M, Niinimäki J. Correlation between the degree of pain relief following discoblock and short-term surgical disability outcome among patients with suspected discogenic low back pain. Scand J Pain 2022; 22:526-532. [PMID: 35355491 DOI: 10.1515/sjpain-2021-0160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/07/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate how well the degree of pain relief after discoblock predicts the disability outcome of subsequent fusion or total disc replacement (TDR) surgery, based on short-term Oswestry Disability Index (ODI) scores. METHODS We retrospectively analyzed a set of patients who had undergone discoblock and subsequent fusion or TDR surgery of the same lumbar intervertebral disc due to suspected discogenic chronic LBP between 2011 and 2018. We calculated the degree of pain relief following discoblock (ΔNRS) and the changes in both absolute and percentual ODI scores (ΔODI and ΔODI%, respectively) following fusion or TDR surgery. We analyzed the statistical significance of ΔNRS and ΔODI and the correlation (Spearman's rho) between ΔNRS and ΔODI%. The fusion and TDR group were analyzed both in combination and separately. RESULTS Fifteen patients were eligible for the current study (fusion n=9, TDR n=6). ΔNRS was statistically significant in all groups, and ΔODI was statistically significant in the combined group and in the fusion group alone. The parameters of both decreased. We found a Spearman's rho of 0.57 (p=0.026) between ΔNRS and ΔODI% for the combined group. The individual Spearman's rho values were 0.85 (p=0.004) for the fusion group and 0.62 (p=0.191) for the TDR group. CONCLUSIONS We suggest that discoblock is a useful predictive criterion for disability outcome prior to surgery for discogenic LBP, especially when stabilizing spine surgery is under consideration. ETHICAL COMMITTEE NUMBER 174/2019 (Oulu University Hospital Ethics Committee).
Collapse
Affiliation(s)
- Tero Korhonen
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
| | - Juha Pesälä
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
| | - Jyri Järvinen
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Marianne Haapea
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Department of Orthopaedic and Traumatology, Oulu University Hospital, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
6
|
Conger A, Smuck M, Truumees E, Lotz JC, DePalma MJ, McCormick ZL. Vertebrogenic Pain: A Paradigm Shift in Diagnosis and Treatment of Axial Low Back Pain. PAIN MEDICINE 2022; 23:S63-S71. [PMID: 35856329 PMCID: PMC9297155 DOI: 10.1093/pm/pnac081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 05/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Aaron Conger
- Correspondence to: Aaron Conger, DO, Department of Physical Medicine and Rehabilitation, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA. Tel: 801-587-5458; Fax: 801-587-7111; E-mail:
| | - Matthew Smuck
- Department of Orthopaedics, Stanford University, Redwood City, CA, USA
| | - Eeric Truumees
- The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX, USA
| | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, CA, USA
| | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
7
|
Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J 2020; 20:998-1024. [PMID: 32333996 DOI: 10.1016/j.spinee.2020.04.006] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN This is a guideline summary review. METHODS This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.
Collapse
Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
| |
Collapse
|
8
|
Vieli M, Staartjes VE, Eversdjik HAJ, De Wispelaere MP, Oosterhuis JWA, Schröder ML. Safety and Efficacy of Anterior Lumbar Interbody Fusion for Discogenic Chronic Low Back Pain in a Short-stay Setting: Data From a Prospective Registry. Cureus 2019; 11:e5332. [PMID: 31598439 PMCID: PMC6777969 DOI: 10.7759/cureus.5332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction As a possible treatment option for chronic lower back pain (CLBP) due to single-level degenerative disc disorder (DDD), the efficacy of anterior lumbar interbody fusion (ALIF) has been reviewed various times in the existing literature. Nevertheless, a scarcity of data exists pertaining to ALIF procedures carried out in a short-stay setting using an Enhanced Recovery after Surgery (ERAS) protocol, particularly concerning the safety. Methods Prospectively collected data are analyzed to study the efficacy and safety of short-stay ERAS ALIF in treatment of single-level DDD. Visual Analog Scale (VAS) in both back and leg pain along with the Oswestry Disability Index (ODI) were used to collect measure outcomes. The primary endpoint was a minimum clinically important difference (MCID) of ≥30% for the ODI at 12 months. Results Forty-four patients underwent surgery after failed long-term conservative treatment. MCID was achieved in 78%. Age was the only significant factor in association with MCID (p = 0.03), while gender, Modic changes, results of prognostic tests, prior surgery and smoking status had no significant influence on either MCID or change scores for any outcome measure. One complication in the form of transient new radiculopathy occurred in one patient (2.3%). Conclusion With overall positive outcomes in terms of both efficacy and safety, an ALIF procedure with subsequent implementation of an ERAS protocol in a short-stay setting can be an option for strictly selected patients with CLBP. Further study, however, possibly with a larger sample size, would be necessary to substantiate these findings.
Collapse
Affiliation(s)
- Moira Vieli
- Neurosurgery, Bergman Clinics, Amsterdam, NLD
| | | | | | | | | | | |
Collapse
|
9
|
|
10
|
Zeilstra DJ, Staartjes VE, Schröder ML. Minimally invasive transaxial lumbosacral interbody fusion: a ten year single-centre experience. INTERNATIONAL ORTHOPAEDICS 2016; 41:113-119. [PMID: 27553062 DOI: 10.1007/s00264-016-3273-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 08/01/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE Our aim was to evaluate mid- and long-term results in a cohort of patients who underwent minimally invasive transaxial lumbosacral fixation and to identify clinical and other parameters that can aid in proper patient selection. METHODS Over a period of ten years, we assessed 164 patients who had a complete follow-up of a minimum of one year (average 54 months). On follow-up, we recorded clinical status, fusion status, visual analogue scale (VAS), Oswestry Lower Back Pain Disability Index (ODI) scores and patient satisfaction. RESULTS There were no intra- or peri-operative complications. Overall clinical success rate was 73.8 %. Only sex (female), working status (still working), body mass index (BMI) (lower) and presence of Modic II changes (absent) were correlated with a good result. CONCLUSIONS Transaxial fixation is a safe, minimally invasive technique that can offer good results in patients with single-level degenerative disc disease (DDD) at the lumbosacral level, with minimal operative risk.
Collapse
Affiliation(s)
| | - Victor E Staartjes
- Student of the Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | | |
Collapse
|
11
|
In vivo effects of bupivacaine and gadobutrol on the intervertebral disc following discoblock and discography: a histological analysis. Eur Radiol 2016; 27:149-156. [PMID: 27085700 DOI: 10.1007/s00330-016-4358-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/24/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of the present study was to histologically compare chondrotoxicity in surgically harvested intervertebral discs (IVDs) of patients following discoblock, discography, or no preoperative intervention. METHODS Thirty patients (IVD degeneration Modic ≥ 2°, Pfirrmann 3° or 4°) at L4/5 or L5/S1 who were planned for anterior lumbar interbody fusion were randomly assigned to three groups (open MRI: group DG - discography with gadobutrol; group DB - discoblock with bupivacaine at 4 weeks prior to surgery; group C - no intervention). The intervertebral discs were histologically evaluated and compared using ANOVA and Bonferroni tests for cell count, apoptosis, and proliferation. RESULTS A reduced cell count (groups DG vs. DB vs. C: 14.9 ± 7.1, 9.2 ± 3.8, and 16.6 ± 5.2 cells/mm2, respectively; p ANOVA = 0.016), increased apoptosis (groups DG vs. DB vs. C: 34.9 ± 10.2, 47.4 ± 16.3, 32.6 ± 12.2 %, respectively; p ANOVA = 0.039) and increased cell proliferation (post hoc pDB vs. DG or C p < 0.001; for 3-7 cell monoclonal cell nests: groups DG vs. DB vs. C: 2.4 ± 1, 3.9 ± 1, 2.2 ± 1.1, respectively; p interventionx nest size = 0.006) were found in the IVDs of patients in group DB. CONCLUSIONS This in vivo study suggests that chondrotoxic effects occur in IVD cells after the intradiscal injection of bupivacaine but not after gadobutrol administration. KEY POINTS • Local bupivacaine administration to intervertebral discs leads to cell toxicity and proliferation. • Gadobutrol demonstrated no significant effect on cell count, apoptosis, or cell proliferation. • In vivo cytotoxicity was demonstrated histologically in humans for the first time. • Addition/administration of bupivacaine during discographies must be judged critically.
Collapse
|
12
|
Polly D, Cher D, Whang PG, Frank C, Sembrano J. Does Level of Response to SI Joint Block Predict Response to SI Joint Fusion? Int J Spine Surg 2016; 10:4. [PMID: 26913224 DOI: 10.14444/3004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The degree of pain relief required to diagnose sacroiliac joint (SIJ) dysfunction following a diagnostic SIJ block (SIJB) is not known. No gold standard exists. Response to definitive (i.e., accepted as effective) treatment might be a reference standard. METHODS Subgroup analysis of 320 subjects enrolled in two prospective multicenter trials evaluating SIJ fusion (SIJF) in patients with SIJ dysfunction diagnosed by history, physical exam and standardized diagnostic SIJB. A 50% reduction in pain at 30 or 60 minutes following SIJB was considered confirmatory. The absolute and percentage improvements in Visual Analog Scale (VAS) SIJ pain and Oswestry Disability Index (ODI) scores at 6 and 12 months after SIJF were correlated with the average acute improvement in SIJ pain with SIJB. RESULTS The average pain reduction during the first hour after SIJB was 79.3%. Six months after SIJF, the overall mean VAS SIJ pain reduction was 50.9 points (0-100 scale) and the mean ODI reduction was 24.6 points. Reductions at 12 months after SIJF were similar. Examined in multiple ways, improvements in SIJ pain and ODI at 6 and 12 months did not correlate with SIJB findings. CONCLUSIONS The degree of pain improvement during SIJB did not predict improvements in pain or ODI scores after SIJF. A 50% SIJB threshold resulted in excellent post-SIJF responses. Using overly stringent selection criteria (i.e. 75%) to qualify patients for SIJF has no basis in evidence and would withhold a beneficial procedure from a substantial number of patients with SIJ dysfunction. LEVEL OF EVIDENCE Level 1. CLINICAL RELEVANCE The degree of pain improvement during an SIJ block does not predict the degree of pain improvement after SIJ fusion.
Collapse
Affiliation(s)
- David Polly
- Departments of Orthopedic Surgery and Neurosurgery, University of Minnesota, Minneapolis, MN
| | | | - Peter G Whang
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven CT
| | | | - Jonathan Sembrano
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | | |
Collapse
|
13
|
Putzier M, Strube P. Answer to the Letter to the Editor of Jianqiang Ni et al. concerning "ALIF and total disc replacement versus 2-level circumferential fusion with TLIF: a prospective, randomized, clinical and radiological trial" by Hoff EK, Strube P, Pumberger M, et al. (2015) Eur Spine J. doi:10.1007/s00586-015-3852-y. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:2347-9. [PMID: 25913363 DOI: 10.1007/s00586-015-3972-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 04/14/2015] [Accepted: 04/14/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Michael Putzier
- Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Patrick Strube
- Klinik für Orthopädie, Campus Waldkrankenhaus "Rudolf Elle" gGmbH, Friedrich-Schiller-Universität Jena, Klosterlausnitzer Str. 81, Eisenberg, 07607, Germany
| |
Collapse
|
14
|
Hebelka H, Brisby H, Hansson T. Comparison between pain at discography and morphological disc changes at axial loaded MRI in patients with low back pain. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:2075-82. [PMID: 24957259 DOI: 10.1007/s00586-014-3408-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 06/06/2014] [Accepted: 06/07/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE Discogenic pain is induced by axial load, but there are no studies evaluating the influence of dynamic MRI in relation to provoked pain at discography. The aim of this study was to investigate the relationship between discography-induced pain and morphological disc changes, occurring during axial loaded MRI (alMRI). A secondary aim was to compare and register the frequency of provoked concordant pain at alMRI and discography. METHODS 41 patients with assumed discogenic pain were investigated with MRI, alMRI and pressure-controlled discography (PCD) (119 discs). Provoked pain at both discography and alMRI was classified as concordant or discordant with daily pain as reference. A concordant discogram required pain intensity ≥5/10 (numerical rating scale) at ≤50 psi and one negative control disc. A concordant provocation at alMRI required pain intensity ≥5/10. The relationship between concordant pain at discography and morphological disc measures (degeneration, height, bulge, angle, area, and circumference) at MRI/alMRI was investigated. RESULTS Changes in the morphological appearance occurred in at least one disc level in all patients when loaded and unloaded MRI were compared. However, no significant differences between concordant and discordant discograms in terms of morphological disc features at conventional MRI or alMRI were found. 78 % of the patients reported concordant provoked pain during the alMRI. CONCLUSIONS In the majority of patients with low back pain, discography as well as alMRI provoked concordant pain. Loading of the spine, alMRI, revealed however no clinically useful morphological characteristics in the discs with concordant discograms. Alternative or more sensitive diagnostic methods are needed to understand load-induced discogenic pain.
Collapse
Affiliation(s)
- Hanna Hebelka
- Department of Radiology, Sahlgrenska University Hospital, Smörslottsgatan 1, 416 85, Gothenburg, Sweden,
| | | | | |
Collapse
|
15
|
Abstract
STUDY DESIGN Observational in vivo clinical study. OBJECTIVE To investigate whether intradiscal pressure is transferred to adjacent discs during clinical discography in subjects with discogenic pain. SUMMARY OF BACKGROUND DATA Despite the introduction of pressure registration in discography, the validity of the method remains controversial. Discography in vivo in anesthetized pigs has shown that the pressure increase during disc injection is transmitted to adjacent discs. If pressure transmission is confirmed in human spines, it could be a potential source of false-positive discography responses. METHODS Twenty-five discograms were performed in 9 consecutive patients. A pressure sensor was introduced through a 22-gauge needle into the nucleus pulposus in 2 adjacent discs. Contrast was injected with a manometer (∼0.05 mL/s) into one of the discs, whereas intradiscal pressure was measured simultaneously in both discs. The injection continued until one of the endpoints was reached; concordant pain with an intensity of 5/10 or more, intradiscal pressure of 80 psi (absolute pressure), and/or 3.5-mL contrast volume. RESULTS Intradiscal pressure was successfully measured in 22 adjacent discs of which 7 were not filled with contrast and 15 were prefilled from the previous discogram. A mean pressure increase of 13 psi (range, 3-42 psi) was recorded in 55% (12) of the adjacent discs, corresponding to an increase of 62% above baseline. Of discograms inducing pressure transmission, all had Pfirrmann degeneration grade of 3 or more and, of adjacent discs with increased pressure, 75% had degeneration of 3 or more. Maximum pressure in injected discs averaged 35 psi above opening pressure (range, 10-69 psi). CONCLUSION Clinical discography induces a pressure increase in adjacent discs. The induced pressure increase was of a clinically relevant magnitude and was evident despite low absolute pressures in the injected disc. Pressure transmission during discography constitutes a potential major source of false-positive responses, questioning the ability of discography to provoke pain at just a single disc level. LEVEL OF EVIDENCE 1.
Collapse
|
16
|
Abstract
STUDY DESIGN In vivo experimental porcine study. OBJECTIVE To investigate if discography induced pressure increase in adjacent degenerate discs. SUMMARY OF BACKGROUND DATA Despite refinements in the past 2 decades, the validity of discography is debated. Discography in healthy pigs has shown that the pressure increase during disc injection transmits to adjacent discs, a potential source for false positive responses. METHODS Degeneration in 1 lumbar disc was induced in 10 pigs by drilling a hole through the endplate. Intradiscal pressure was recorded using a 0.36-mm fiber-optic pressure transducer inserted into nucleus pulposus through a 22-gauge needle. The pressure was measured simultaneously in 2 adjacent discs during slow (0.03 mL/s) automated contrast injection into 1 of the discs up to 8 bar (116 psi). Ten adjacent discs were prefilled with contrast from previous discogram. A pressure increase 2 psi or more above baseline was defined as increased pressure in adjacent discs. Pressure was recorded until 15 minutes after injection. RESULTS A total of 28 discograms were successfully performed. A pressure increase during injection was detected in 57% (16) of the 28 adjacent discs with mean 3.2 psi (1.7-8.2; standard deviation, 1.8), corresponding to a mean increase above baseline of 11%. Of those 16 adjacent discs, 4 were nondegenerate and 12 degenerate, of which 7 were prefilled. Fifteen minutes after injection, 89% of adjacent discs displayed increase in pressure of mean 14% above baseline. CONCLUSION Discography induced pressure increase in adjacent discs in a degenerate disc model, something not reported earlier. If present, also in human spine pressure transmission, may be a potential cause for false positive discography responses.
Collapse
|
17
|
Putzier M, Streitparth F, Hartwig T, Perka CF, Hoff EK, Strube P. Can discoblock replace discography for identifying painful degenerated discs? Eur J Radiol 2013; 82:1463-70. [DOI: 10.1016/j.ejrad.2013.03.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/22/2013] [Accepted: 03/25/2013] [Indexed: 10/26/2022]
|