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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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Slide1 l.jpg

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


Lbp evaluation in context l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    Evidence for Validity and Usefulness of Discography Disc

    • 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 l.jpg
    Studies of Subjects w/o LBP Disc

    • 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 l.jpg
    Subjects w/o LBP Summary Disc

    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 l.jpg
    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 l.jpg
    Do discography pts often have Disc“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 l.jpg
    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)


    Vas mean l.jpg
    VAS (mean) months


    Oswestry scores l.jpg
    Oswestry Scores months

    Discogenic pain / PVO significantly worse than Spondy (0.01)


    Psychometric scores l.jpg
    Psychometric Scores months

    Disc pain most abnormal

    P = 0.0001


    Slide23 l.jpg

    75-85% nl months

    21% nl


    Chronic lbp patients with non specific findings discogenic pain l.jpg
    Chronic LBP Patients with monthsNon-specific findings = “Discogenic Pain”*

    • Cairns et al 2003; Carragee et al 2001; Schwarzer 1995/96


    Profiles in other spine pts with severe chronic pain l.jpg
    Profiles in Other Spine Pts with Severe Chronic Pain months

    Which one is not like the other?

    *

    * - non RA pain



    How reliable is concordancy experimental lbp model phase 3 l.jpg
    How reliable is “Concordancy” monthsExperimental 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 l.jpg
    Concordancy Test Model months

    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 l.jpg

    Perception months

    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 l.jpg

    That’s my months

    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 l.jpg

    That’s my months

    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 l.jpg

    That’s my months

    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 l.jpg
    Case 2 months

    • 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 l.jpg
    Case 2 months

    • 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 l.jpg

    That’s my months

    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 l.jpg

    That’s my months

    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 l.jpg
    Case 3 months

    • 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 l.jpg
    Case 3 months

    • 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 l.jpg
    Case 3-- ”She’s Back” months

    • 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 l.jpg
    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 l.jpg
    Common Backache injections?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 l.jpg
    Bachache and Discography injections?

    • 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 l.jpg

    That’s my injections?

    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 l.jpg

    48 yo man, injections?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 l.jpg

    Diffuse pain. injections?

    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 l.jpg

    Seen 8 months later at request of his attorney. injections?

    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 l.jpg

    That’s my injections?

    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 l.jpg
    Acid Test injections?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.


    Outcome as gold standard l.jpg
    Outcome as Gold Standard injections?

    • 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 l.jpg
    Outcome as Gold Standard injections?

    • 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 l.jpg
    Hypothesis injections?

    • 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 l.jpg
    Subjects injections?

    • 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 l.jpg
    Results injections?

    False + = 40%


    Summary l.jpg
    Summary injections?

    • 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 l.jpg
    Practical Usage Guide for Discography in 2008 injections?

    • 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”


    Thank you l.jpg
    Thank you injections?