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January 2008 AADEP San Antonio Discography and the Evaluation of LBP Eugene J Carragee, MD Stanford University

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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 “red flags” of serious pathology

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January 2008AADEP San AntonioDiscography and the Evaluation of LBPEugene J Carragee, MDStanford University

lbp evaluation in context
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”
common mri findings and pain
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
common mri findings and pain4
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
imaging findings
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
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”?
discography goal
Discography 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]
the good discogram of san francisco
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
the good discogram of san francisco9
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)
reliability of pain reporting in discography
Reliability of Pain Reporting in Discography

Note in this Case #1:

  • No concurrent or history of other chronic pain processes.
  • No litigation, WC or secondary gain issues.
  • Normal psychometric, no “reactive depression, anxiety, somatic distress…”
  • Ablation of the suspected “Pain Generator” give high-quality outcome which lasts.
factors affecting reported pain on disc injections
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)

?

3 /10 vs 7 /10

hypothetical response to pressurization of a degenerative disc depending on pain sensitivity
Hypothetical Response to Pressurization of a Degenerative Disc Depending on “Pain Sensitivity”

“Normal”

Hypersensitive

Chronic Pain Syndrome

Psychological Distress

2° Gain Issues

Narcotic Habituation

Reduced

Social Imperatives

Psychological Reserve

Cultural Norms

Pain

Increasing Injection Pressure ---->

evidence for validity and usefulness of discography
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?
studies of subjects w o lbp
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.
subjects w o lbp summary
Subjects w/o LBP Summary

Psychometric testing, chronic pain, litigation/contested

and anular disruption strongly predict painful injections.

Increasing Risk Factors

hypothetical response to pressurization of a degenerative disc depending on pain sensitivity17
Hypothetical Response to Pressurization of a Degenerative Disc Depending on “Pain Sensitivity”

“Normal”

Hypersensitive

Chronic Pain Syndrome

Psychological Distress

2° Gain Issues

Narcotic Habituation

Reduced

Social Imperatives

Psychological Reserve

Cultural Norms

Pain

Increasing Injection Pressure ---->

do discography pts often have risk factors
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?
not really look at 3 groups with serious sx for 6 18 months
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)
oswestry scores
Oswestry Scores

Discogenic pain / PVO significantly worse than Spondy (0.01)

psychometric scores
Psychometric Scores

Disc pain most abnormal

P = 0.0001

slide23

75-85% nl

21% nl

chronic lbp patients with non specific findings discogenic pain
Chronic LBP Patients with Non-specific findings = “Discogenic Pain”*
  • Cairns et al 2003; Carragee et al 2001; Schwarzer 1995/96
profiles in other spine pts with severe chronic pain
Profiles in Other Spine Pts with Severe Chronic Pain

Which one is not like the other?

*

* - non RA pain

how reliable is concordancy experimental lbp model phase 3
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
concordancy test model
Concordancy Test Model

60% painful discs felt similar to / or exactly like ICBG pain.

50% subjects had + concordant discogram by all criteria.

25% subj. had at least 1 low pressure sensitive disc.

concordancy and the lbp pathway

Perception

Concordancy and The LBP Pathway

7

8

9

Cerebral

Thalamus

6

5

Cord

Pathway Modulation

1 Adjacent tissue injury

2Local Anaesthetic

3 Nearby tissue injury

4 Regional Chronic Pain

5 Narcotic Analgesia

6 Narcotic Habituation

7 Depression

8 Social Imperitives

9 Social Disincentives

DRG

4

Similar

Sclerotomal

Afferents

3

2

Visceral

Vascular

Muscular

Facet

Bone

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

1

best case scenario one pain source

That’s my

Pain!!!!

Best Case ScenarioOne pain source

Cerebral

Thalamus

And if you fix it, I’ll feel all better!

Cord

DRG

Similar

Sclerotomal

Afferents

Visceral

Muscular

Facet

Bone

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

two equal pain sources

That’s my

Pain! ! !

Two equal pain sources

Cerebral

Thalamus

And if you fuse it I’ll be a somewhat better...

Cord

DRG

Similar

Sclerotomal

Afferents

Visceral

Muscular

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

1 non discogenic pain source minor disc pain

That’s my

Pain!!!!

1° Non-discogenic pain source, minor disc pain

Cerebral

Hyperalgesic

Pain Pathway

Thalamus

And if you fuse it I’ll be about the same...

Cord

DRG

Similar

Sclerotomal

Afferents

Visceral

Vascular

Facet

Bone

Muscular

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

case 2
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.
case 235
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?
multiply operated back

That’s my

Pain!!!!

Multiply Operated Back

Cerebral

Hyperalgesic

Pain Pathway

Thalamus

Depression

Somatization

Cord

DRG

And if you fuse another level, I’ll be as miserable as ever...

Similar

Sclerotomal

Afferents

Visceral

Vascular

Facet

Bone

Muscular

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

1 psychological pain source common backache

That’s my

Pain!!!!

1° Psychological pain source, common backache

Cerebral

Hyperalgesic

Pain Pathway

Thalamus

Depression

Somatization

“fibromyalgia”

Cord

DRG

Similar

Sclerotomal

Afferents

“And if you fuse it, you should think of moving your practice…”

Visceral

Vascular

Facet

Bone

Muscular

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

case 3
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…”
case 339
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…”
case 3 she s back
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...
do people with common backache have painful disc injections
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
common backache study protocol
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?
bachache and discography
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.
common backache

That’s my

Pain!!!!

Common backache

Cerebral

Normal “amplified”

Pain Pathway

Thalamus

And so what…its not a problem?

Cord

DRG

Similar

Sclerotomal

Afferents

Visceral

Vascular

Facet

Bone

Muscular

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

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

Or is it a problem…Case 4
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?

Working the system…Case 4
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 levelsymptomatic anular tears …caused by recent accident since [injection] only reproduces new pain since accident…causation in legal action clearly determined by discographic findings”.

Working the System
secondary gain litigation pre existing backache

That’s my

Pain!!!!

Secondary Gain (litigation) + pre-existing backache

Cerebral

Hyperalgesic

Pain Pathway

Thalamus

“And it never

felt like this before that the postal truck hit my car at 3 mph”

Cord

DRG

Similar

Sclerotomal

Afferents

Visceral

Vascular

Facet

Bone

Muscular

Pelvic

L4/5 Disc

L5/S1 Disc

L3/4 Disc

acid test does discography improve outcomes
Acid TestDoes 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.
outcome as gold standard
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--
outcome as gold standard51
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…
hypothesis
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.
subjects
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.
results
Results

False + = 40%

summary
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…
practical usage guide for discography in 2008
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”

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