Back Pain: Carragee EJ

Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM, Anonymous00055. · Department of Medicine, Oregon Evidence-based Practice Center, Oregon Health and Science University, Portland, OR, USA. · Spine (Phila Pa 1976). · Pubmed #19363457 No free full text.

Abstract: STUDY DESIGN: Clinical practice guideline. OBJECTIVE: To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain. SUMMARY OF BACKGROUND DATA: Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain. METHODS: A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. RESULTS: Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations. CONCLUSION: Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

Carragee EJ. · No affiliation provided · Spine J. · Pubmed #16291096 No free full text.

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Carragee EJ. · No affiliation provided · Spine (Phila Pa 1976). · Pubmed #11598502 No free full text.

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Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. · Department of Medicine, Oregon Evidence-based Practice Center, OR Health and Science University, Portland, OR, USA. · Spine (Phila Pa 1976). · Pubmed #19363455 No free full text.

Abstract: STUDY DESIGN: Systematic review. OBJECTIVE: To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. SUMMARY OF BACKGROUND DATA: Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions. METHODS: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS: For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms. CONCLUSION: Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

Cohen SP, Argoff CE, Carragee EJ. · Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA. · BMJ. · Pubmed #19103627 No free full text.

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Carragee EJ. · Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, Calif 94305, USA. · N Engl J Med. · Pubmed #15872204 No free full text.

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Carragee EJ, Hannibal M. · Stanford University School of Medicine, 300 Pasteur Drive, Room R171, Stanford, CA 94305, USA. · Orthop Clin North Am. · Pubmed #15062713 No free full text.

Abstract: The diagnostic evaluation of chronic LBP is at best a complex and involved undertaking. The most important part of the process lies in the knowledge of the patient and a solid history and physical examination. From there, most of the serious and life-threatening causes of LBP can be elucidated and studies may be used for confirmation. Imaging studies are used most practically as confirmation studies once a working diagnosis is determined. MRI, although excellent at defining tumor, infection, and nerve compression, can be too sensitive with regard to degenerative disease findings and commonly displays pathology that is not responsible for the patient's symptoms. As an example, the high-intensity zones (HIZ) seen on MRI are reliable in determining annular defects in the disc but are not reliable in establishing internal disc disruption as the cause of LBP. Discography is the primary tool used by many physicians to determine the true pain generator when discogenic LBP is suspected. Because the reliability of the patient response is fundamental to discography, interpreting the test in different settings must be considered. In individuals with disc degeneration and annular defects, discography may elicit LBP with injection whether the patient is symptomatic with serious LBP or not. The pain response may be amplified in those subjects with issues of chronic pain, social stressors, such as secondary gain or litigation claims, or psychologic distress disorder. These factors have been shown experimentally to be associated with an increased risk for a false positive injection. The ability of an individual to differentiate the true site of LBP by the quality of sensation with disc injection (concordancy) of pain produced by the injected disc also may not be reliable. In fact, individuals may not have the neural discrimination to differentiate sclerotomal pain originating from different sites in the low back and pelvis. One may realize that chronic LBP illness may not stem from a mechanical spinal disorder alone. In fact, the mechanical pathology may be just a portion of the problem with amplification by neurophysiologic, social, and psychologic issues. Chronic disabling LBP commonly is confounded by chronic pain, emotional troubles, poor job satisfaction, alcohol and narcotic abuse, and compensation issues, just to identify a few. It would follow that expecting to identify a single cause for this symptom complex is impractical and any single test may not be a reasonable approach. Furthermore, surgical correction of the mechanical portion of chronic LBP. even if correctly identified, then can be expected only to relieve a portion of a patient's symptoms as long as the confounding issues continue to be significant or have become life long adaptive mechanisms. In the end, the discogram and other diagnostic tests are tools that have clear limitations. In this field, clinical judgment begins and ends with an understanding of a patient's life and circumstances as much as with their specific spinal pathology.

Carragee EJ, Alamin TF. · Stanford University School of Medicine, 300 Pasteur Drive, Room R171, Stanford, CA 94305, USA. · Spine J. · Pubmed #14588317 No free full text.

Abstract: BACKGROUND CONTEXT: Discography is used today as the basis of the diagnosis of discogenic back and neck pain. As such, it plays a pivotal role in the formulation of treatment plans for patients complaining of chronic axial spine pain. PURPOSE: A brief history of discography is described here, followed by a discussion of the current uses of discography, the technique involved, and recent studies questioning its validity. STUDY DESIGN/SETTING: A selective review of discography articles from peer-reviewed literature from 1967 to 2000 is provided. We included articles analyzing the validity of discography as well as those concerning its proper use, technique, and complications. METHODS: Articles relevant to the subject of discography were systematically reviewed for recommendations regarding technique, the interpretation of results, and conclusions regarding its validity. RESULTS: The specificity of discography is dramatically affected by the characteristics of the patient examined. In a patient with chronic pain states and psychiatric risk factors, the specificity was determined to be at most 20%. In healthy patients with no chronic pain states and a normal psychiatric profile, the specificity was found to be at most 90%. The ability of a patient to determine reliably the concordance of pain provoked during discography is poor. We could find no data addressing the sensitivity of the study. CONCLUSIONS: Clinicians who use discography to determine treatment pathways for their patients need to critically examine the validity of the test. Recent studies examining the specificity of discography have led us to proceed much more cautiously in interpreting the results of discography.

Carragee EJ. · Division of Orthopedic Surgery, Stanford University School of Medicine, California 94305, USA. · Clin J Pain. · Pubmed #11587111 No free full text.

Abstract: The specific use of psychological screenings to determine appropriateness for lumbar discectomy surgery and predict outcomes is not well understood. Data from spine surgery as a whole are not likely generalizable to the patient with a significant disc herniation considering surgery. As opposed to most "back pain syndromes," acute and subacute sciatica from disc hemiation has a very high chance of dramatic and lasting improvement with surgery. Recent studies have shown standard psychometric tests used as preoperative screening in this situations fail to predict outcomes in most subgroups. Data from the author's institution suggest severe emotional distress in those patients coming to early surgical intervention does not correlate with adverse outcomes. However, the same psychometric profile in those patients with chronic sciatica pain and disability does predict worse outcomes compared with chronic pain in less emotionally distressed patients. The data suggest that the ability to rapidly relieve pain in the case of disc herniation may limit the morbid effects of psychological distress seen in many back pain syndromes. With prolonged pain and emotional distress, however, adverse and possibly self-perpetuating psychological and social changes may significantly decrease the impact of disc surgery.

Carragee EJ. · Stanford University School of Medicine, R-171 Orthopedic Surgery, Stanford, CA 94305, USA. · Curr Rev Pain. · Pubmed #10953278 No free full text.

Abstract: Provocative lumbar discography was investigated in a series of clinical studies at the Stanford University of Medicine, Stanford, CA. This work demonstrated that pain intensity during disc injection is strongly influenced by the subject's emotional and psychological profiles, chronic pain behavior, and ongoing compensation claims whether the patient has any back pain illness or not. Pain reproduction was also primarily related to penetration of the dye through the outer annulus and could not reliably be used to confirm the location of the pain source.

Carragee EJ, Lincoln T, Parmar VS, Alamin T. · Orthopaedic Surgery Division, Stanford School of Medicine, Stanford, CA 94305, USA. · Spine (Phila Pa 1976). · Pubmed #16915099 No free full text.

Abstract: STUDY DESIGN: This is a prospective study of the validity of a positive test result in provocative lumbar discography for the diagnosis of "discogenic pain." OBJECTIVE: To investigate the hypothesis that provocative discography by strict criteria accurately identifies a low back pain illness due to a primary disc lesion. SUMMARY AND BACKGROUND DATA: According to the Sackett and Haynes criteria for establishing diagnostic test validity, no test without a gold standard external standard can be meaningfully applied. Provocative discography as a test for determining "discogenic pain" has, to date, not been compared against a gold standard. Absent a gold standard reference, there can be no validity assessment or systematic improvement of test accuracy. This is the first study to apply an external gold standard evaluation of the diagnostic validity of discography in any manner. METHODS: Over a 5-year period using a strict enrollment protocol, 32 patients with low back pain and a positive single-level low-pressure provocative discogram, underwent spinal fusion. Subjects with known patient selection comorbidities were excluded. Generic surgical limitations/morbidity were controlled by comparison to the clinical outcomes of a strictly-matched cohort of 34 patients having a well-accepted single-level lumbar pathology (unstable spondylolisthesis). Treatment success was compared between groups. RESULTS: In the control-spondylolisthesis group, 23 of 32 patients (72%) met the highly effective success criteria compared with 8 of 30 in the presumed discogenic pain cohort (27%). The proportion of patients who met the "minimal acceptable outcome" was 29 of 32 (91%) in the spondylolisthesis group and 13 of 30 (43%) in the presumed discogenic pain group. Adjusting for surgical morbidity and dropout failure, by either criteria of success, the best-case positive predictive value of discography was calculated to be 50% to 60%. CONCLUSIONS: Positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness in this first study comparing discography results to a gold standard.

Carragee EJ, Barcohana B, Alamin T, van den Haak E. · Orthopaedic Surgery Department, Stanford University, Stanford, CA 94305, USA. · Spine (Phila Pa 1976). · Pubmed #15131439 No free full text.

Abstract: STUDY DESIGN: A prospective controlled longitudinal study. OBJECTIVES: To determine whether subjects, asymptomatic for lower back problems, who undergo experimental discography, will develop lower back problems during the medium term to the full term. SUMMARY OF BACKGROUND DATA: Previous work has shown significant pain on discographic injection in approximately 40% of asymptomatic subjects. It has been suggested that those subjects with painful injections would soon develop lower back pain (LBP) syndromes in the near future: that is, the experimental discography was detecting an imminent "pain generator" before clinically symptomatic. METHODS.: Fifty subjects without low back pain were recruited for clinical and psychometric testing, MRI scanning, and experimental lumbar discography to determine the rate of painful lumbar disc injections in select subjects without LBP history. After determining which subjects had painful injections, all subjects completing the discography protocol were prospectively followed at yearly intervals to determine the occurrence of LBP and LBP disability over time. Statistical methods were then used to determine the correlation, if any, between the asymptomatic subjects' clinical, MRI, and discography findings, and the subsequent LBP measures. Controls, not participating in the lumbar discography study, were also followed. Controls were matched for clinical features, sex, age, and occupational/recreational exposure. Follow-up examinations were performed at yearly intervals by blinded researchers using a scripted interview and completing standard questionnaires. RESULTS: A total of 46 of 50 completed the discogram, and all 46 subjects completed the final 4-year follow-up examination. There was a low incidence of LBP episodes in the experimental groups and control. A painful disc injection, independent of psychological profile, did not predict LBP or any other functional outcome measure at follow-up on multivariate analysis. The presence of an anular fissure seen on discography was weakly associated with the cumulative incidence of LBP episodes after discography (P = 0.08). The presence of high intensity zone on MRI in any disc was also weakly associated with the development of LBP episodes (P = 0.09). Psychometric profiles at the start of the study strongly and independently predicted future back pain (P = 0.01), medication usage (P = 0.002), and work loss (P = 0.01) over the 4-year study. Compared with controls not having undergone discography, there was no significant difference in back pain, function, work loss, doctors visits for back pain, or medication intake in any group. A subset in the injection group with somatization disorder had a higher LBP visual analog score compared with somatization disorder controls at 1 year,but this was not significant at 4 years after testing. CONCLUSIONS: Painful disc injections are poor independent predictors of subsequent LBP episodes in subjects initially without active lower back complaints. Anular disruption is a weak predictor of future LBP problems. Psychological distress and preexisting chronic pain processes are stronger predictors of LBP outcomes.

Carragee EJ, Alamin TF, Miller J, Grafe M. · Stanford University School of Medicine, Stanford, CA 94305, USA. · Spine J. · Pubmed #14588285 No free full text.

Abstract: BACKGROUND CONTEXT: Whether discographic injections would be positive in subjects with benign persistent "backache" who are not seeking treatment is unknown. This information is important, because benign backache undoubtedly co-exists in patients with chronic low back pain (CLBP) illness that is not discogenicin origin. If these subjects had a high rate of positive discography, the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness. Conversely, if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections, the basic tenet of discographic diagnosis would be strengthened. PURPOSE: To compare, using a strict experimental design, the relative pain and concordancy response to provocative discography in subjects with clinically insignificant "backache" and clinical subjects with CLBP illness considering surgical treatment. STUDY DESIGN: Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain (CLBP) illness. PATIENT SAMPLE: Twenty-five subjects with mild persistent low back pain (LBP) were recruited for an experimental discography study. Subjects were recruited from a clinical study of patients having had cervical spine surgery. Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP, be taking no medications for backache, have no activity restrictions because of LBP, and have normal psychometric scores. To more closely approximate the pain behavior in CLBP illness, 50% (12) of the "backache" group were recruited with a chronic painful condition (neck/shoulder) unrelated to the low back. CLBP subjects, patients coming to discography for consideration of surgical treatment, were used as control subjects. OUTCOME MEASURES: Results of discography were determined using the criteria of Walsh et al.: pain response of 3 or greater, two or more pain behaviors, a negative "control" discographic injection, and a similar or exact concordancy rating. METHODS: Discography was performed on experimental subjects and control patients. Experienced raters, who were blinded to control versus experimental status of the subjects, scored the magnetic resonance image, discogram, psychometric tests and discography videotapes of the subjects' pain behavior. RESULTS: Thirteen of 25 volunteer subjects had pain rated as "bad" or worse with disc injection. There were 12 painful and fully concordant disc injections in 9 of these 25 "backache" subjects (36%). These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain. All positive discs had annular disruption to or through the outer annulus. Of the 9 subjects with positive discograms, 3 had no chronic pain states and 6 did. All subjects with positive injections had negative control discs. In comparison, in 52 subjects with CLBP illness 38 (73%) had at least one positive disc injection. CONCLUSIONS: In a group of volunteer subjects with persistent "backache," 36% were found to have significant pain on disc injection, which is reported to be concordant with their usual pain. The presence of positive concordant pain responses and negative control discs in 33% of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinically relevant spinal pathology.

Carragee EJ, Chen Y, Tanner CM, Truong T, Lau E, Brito JL. · Stanford University School of Medicine, Stanford, California 94305, USA. · Spine (Phila Pa 1976). · Pubmed #11145818 No free full text.

Abstract: STUDY DESIGN: This was a prospective observational study of patients with low back pain and those without after laminotomy and discectomy. OBJECTIVES: To determine, using a strict experimental design, the relative pain intensity response to provocative discography in symptomatic and asymptomatic subjects after lumbar discectomy for intervertebral disc herniation. BACKGROUND: Provocative discography frequently is used to evaluate persistent or recurrent low back pain syndromes in patients who have undergone posterior discectomy. The validity of interpreting painful injections during this procedure has not been critically assessed. The prevalence of significantly painful disc injections in a group with good outcomes after surgery is not known. Knowing the rates of significantly painful injections in asymptomatic patients after lumbar discectomy may clarify the meaning of painful injections in symptomatic patients. METHODS: From a cohort of 240 patients who had undergone single-level limited discectomy for sciatica, 20 asymptomatic volunteers were recruited for experimental three-level lumbar discography. Inclusion criteria required nearly perfect scores on standardized back pain rating instruments, no other spinal pathology, and normal psychometric screening. A control group of 27 symptomatic patients, after single-level discectomy with intractable low back pain syndrome, and without other spinal pathology, underwent discography. Seven patients in the control group had normal psychometric tests. Experienced raters who were blinded to control versus experimental status of the subjects scored the magnetic resonance imaging, discogram, psychometric tests, and discography videotapes of the subjects' pain behavior. RESULTS: There were 8 of 20 (40%) positive injections of discs that had previous surgery in the asymptomatic group and 17 of 27 (63%) positive injections in the symptomatic group. Specifically with regard to the symptomatic group, there were 3 of 7 (43%) positive injections (all concordant) in patients with normal psychometric scores, as compared with 14 of 20 (70%) positive injections (12 concordant) in patients with abnormal psychometric scores. Injections of discs that had previous surgery resulted in a mean pain score of 2.1 of 5 in the asymptomatic group, 2.1 in the symptomatic group with normal psychometric scores, and 3.4 in the symptomatic group with abnormal psychometric scores. Of the discs not treated with surgery, 2 were positive in the asymptomatic group (10%), 3 in 2 symptomatic subjects with normal psychological testing (29), and 18 in 13 symptomatic subjects with abnormal psychometric testing (76%). CONCLUSIONS: A high percentage of asymptomatic patients with normal psychometric testing who previously have undergone lumbar discectomy will have significant pain on injection of their discs that had previous surgery (40%). This is not significantly different from the experience of symptomatic patients with normal psychometric testing undergoing discography on discs that had previous surgery. Patients with abnormal psychological profiles have significantly higher rates of positive disc injections than either asymptomatic volunteers or symptomatic subjects with normal psychological screening.

Carragee EJ, Chen Y, Tanner CM, Hayward C, Rossi M, Hagle C. · Departments of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California 94305, USA. · Spine (Phila Pa 1976). · Pubmed #10888949 No free full text.

Abstract: STUDY DESIGN: A prospective controlled study of patients without low back pain observed after experimental lumbar discography. OBJECTIVES: To determine whether discography may cause long-term low back symptoms in selected patients. BACKGROUND: Lumbar discography is generally considered safe, although controversial, with few complications. There is little information on long-term follow-up of asymptomatic patients after experimental discography. METHODS: Twenty-six patients without pre-existing low back pain were observed for 1 year after lumbar discography to determine the effects of lumbar discography in three experimental groups: 10 patients who had remote cervical spine surgery with excellent results (pain-free group); 10 patients who had the same surgery with poor results (chronic pain group); and 6 patients who had primary somatization disorders. Two control groups were also observed: a group of patients with somatization disorder who were similarly evaluated but without discography, a group of patients with low back pain observed for 1 year after discography without surgery. RESULTS: In the three experimental groups (no back pain before discography) no subject with normal psychometric testing had persistent pain after discography (0/11), whereas 6 (40%) of 15 with abnormal psychometric test results reported significant new low back pain. None of the pain-free group (0/10), 20% of the chronic neck pain group (2/10), and 66% of the somatization group (4/6) continued to have significant back pain 1 year after injection. Psychological testing and occupational disability strongly predicted continued pain after discography. The control groups had no significant change in low back symptomatology during the year of observation. CONCLUSION: Discography in a subject group without low back pain but with significant emotional and chronic pain problems may result in reports of significant back pain for at least 1 year after injection. Subjects with normal psychometric test results had no reports of significant long-term back pain after discography.

Carragee EJ, Cohen SP. · Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA. · Spine (Phila Pa 1976). · Pubmed #19532006 No free full text.

Abstract: STUDY DESIGN: A 5-year prospective observational study in US Army Reserve soldiers. OBJECTIVES: The aims of this study were 2-fold: to evaluate the prevalence of soldiers reporting no previous back pain (BP) on 3 consecutive annual assessments, and to compare these findings to those obtained from a subsequent monthly detailed BP assessment. SUMMARY OF BACKGROUND DATA: BP history is a risk factor for future BP and disability. Conversely, subjects reporting a negative history of back troubles are thought to be at low risk for future BP events. Reporting of previous BP is assumed to have high validity. Few studies have critically evaluated the validity of the self-reported "lifetime asymptomatic" status in civilian or military populations. METHODS: Two hundred eighty-five special operations reserve soldiers were queried annually using standardized US Army Medical Questionnaires, among whom 154 (54%) reported no BP or history thereof over 3 consecutive years. Over the next 18 months these soldiers completed annual US Army Medical Questionnaires, as well as monthly numerical rating scale pain scores, Oswestry Disability Indexes, and questions regarding back injuries. At the study's conclusion, soldiers again completed the annual medical certificate, and the results of this final BP assessment were compared with those from monthly surveillance reports. RESULTS: During monthly surveillance of purported "lifetime asymptomatic" soldiers, the 18-month cumulative percentages reporting BP scores > or = 2, > or = 4, and > or = 6 were 84%, 64%, and 14%, respectively. For Oswestry Disability Index scores, these percentages were 25% for scores > or = 10, and 12% for scores > or = 20. Yet, at the conclusion of the 5-year study, 97% soldiers still described themselves as being "asymptomatic for BP problems." CONCLUSION: In physically active soldiers self-identified as without back problems, the report of BP using frequent surveillance tools is extremely common. The overwhelming majority of these soldiers appeared to have high resilience to common BP episodes (i.e., returned to usual duties). Episodic BP should be considered a normative rather than exceptional occurrence. Similar to other conditions, long-interval surveys of BP history may underestimate the true prevalence of BP.

Don AS, Carragee EJ. · Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA. · Spine J. · Pubmed #19111258 No free full text.

Abstract: BACKGROUND CONTEXT: A patient's self-reported history has, in general, assumed to be accurate. Clinical management of individuals with persistent axial pain after a motor vehicle accident (MVA) and measures to prevent future MVA, spinal cord injury, and traffic deaths often depend on a presumed accurate report of preexisting axial pain, drug, alcohol, and psychological problems to initiate intervention. In addition, research efforts to determine the effects of MVA on subsequent health are often predicated on a presumed accurate history from the patient of past medical and psychosocial problems. Despite so many clinical, public health, and research efforts being dependent on an accurate assessment of pre-injury health, the validity of the self-reported history after MVA has not been systematically investigated. PURPOSE: To determine the validity of self-reported history in subjects with axial neck or back pain attributed to a recent MVA. STUDY DESIGN: A prospective, multiclinic validation study examining the critical elements of a patient's self-reported history after an MVA judged against an audit of his or her medical records. PATIENT SAMPLE: A cohort of consecutive patients with persistent axial pain after an MVA was prospectively identified from five spine-specialist's outpatient clinics. Of 702 patients, 335 subjects were randomly selected for auditing of their medical records. OUTCOME MEASURES: Self-reported demographic and clinical features were recorded by standardized questionnaires and clinical interviews. Audits compared these responses to an extensive medical record search. METHODS: The self-reported prevalence of preexisting axial pain, at-risk comorbidities (psychological distress, alcohol, and drug abuse), and control conditions (hypertension and diabetes) was recorded. The medical records of a random sample of 50% of the enrolled cohort underwent auditing of their medical records in a wide search of network paper and electronic and archived records, and compared with the self-reported history of pre-accident health. RESULTS: Overall, approximately 50% of the subjects were found to have previous axial pain problems at audit when none was reported to the spine-specialist after an MVA. Similarly, approximately 75% of the subjects were found to have one or more preexisting comorbid conditions at audit that were not reported during the evaluation after the MVA (alcohol abuse, illicit drug use, and psychological diagnosis). For those who perceived that the accident was the fault of another, as opposed to their own or no one's fault, the documented previous back and neck pain troubles in the medical records was more than twice the self-reported rate of these problems (p<.01). The rate of previously documented psychological problems was more than seven times that of the self-reported rate (p = 0.001). In those subjects who perceived that the accident was their own or no one's fault, a lesser degree of under-reporting of axial pain and comorbid conditions was found. CONCLUSION: The validity of the patient's self-reported history when presenting with persistent axial pain after an MVA appears poor in this large multiclinic random sample.The self-reported rates of alcohol abuse, illicit drug use, and psychological diagnosis, as well as prior axial pain were significantly lower than that seen in the medical records, especially in thosewho perceive that the MVA was another's fault. The failure to recognize this under-reporting may seriously compromise clinical care, public health efforts at injury prevention, and research protocols dependent on accurate pre-accident morbidity assessments.

Carrino JA, Lurie JD, Tosteson AN, Tosteson TD, Carragee EJ, Kaiser J, Grove MR, Blood E, Pearson LH, Weinstein JN, Herzog R. · Section of Musculoskeletal Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 5165, Baltimore, MD 21287, USA. · Radiology. · Pubmed #18955509 No free full text.

Abstract: PURPOSE: To characterize the inter- and intraobserver variability of qualitative, non-disk contour degenerative findings of the lumbar spine at magnetic resonance (MR) imaging. MATERIALS AND METHODS: The case accrual method used to perform this institutional review board-approved, HIPAA-compliant retrospective study was the random selection of 111 interpretable MR examination cases of subjects from the Spine Patient Outcomes Research Trial. The subjects were aged 18-87 years (mean, 53 years +/- 16 [standard deviation]). Four independent readers rated the cases according to defined criteria. A subsample of 40 MR examination cases was selected for reevaluation at least 1 month later. The following findings were assessed: spondylolisthesis, disk degeneration, marrow endplate abnormality (Modic changes), posterior anular hyperintense zone (HIZ), and facet arthropathy. Inter- and intraobserver agreement in rating the data was summarized by using weighted kappa statistics. RESULTS: Interobserver agreement was good (kappa = 0.66) in rating disk degeneration and moderate in rating spondylolisthesis (kappa = 0.55), Modic changes (kappa = 0.59), facet arthropathy (kappa = 0.54), and posterior HIZ (kappa = 0.44). Interobserver agreement in rating the extent of Modic changes was moderate: kappa Values were 0.43 for determining superior anteroposterior extent, 0.47 for determining superior craniocaudal extent, 0.57 for determining inferior anteroposterior extent, and 0.48 for determining inferior craniocaudal extent. Intraobserver agreement was good in rating spondylolisthesis (kappa = 0.66), disk degeneration (kappa = 0.74), Modic changes (kappa = 0.64), facet arthropathy (kappa = 0.69), and posterior HIZ (kappa = 0.67). Intraobserver agreement in rating the extent of Modic changes was moderate, with kappa values of 0.54 for superior anteroposterior, 0.60 for inferior anteroposterior, 0.50 for superior craniocaudal, and 0.60 for inferior craniocaudal extent determinations. CONCLUSION: The interpretation of general lumbar spine MR characteristics has sufficient reliability to warrant the further evaluation of these features as potential prognostic indicators.

Carragee EJ. · Stanford University School of Medicine, 800 Pasteur Drive, #R171, Stanford, California 94305, USA. · Spine J. · Pubmed #17662666 No free full text.

Abstract: BACKGROUND CONTEXT: Determining the presence of comorbid conditions in patients with persistent axial pain after motor vehicle accident (MVA) is important to direct appropriate care and as a public health measure against future traffic injuries. In the clinical care of patients after MVA, they are usually asked about previous axial pain problems and relevant comorbid conditions (psychological distress and drug and alcohol abuse). The accuracy of self-reported previous axial pain history and comorbid conditions after MVA has not been systematically evaluated but has been assumed to be high. PURPOSE: To establish the validity of certain elements of the self-reported history in patients with back or neck pain attributed to an MVA. STUDY DESIGN: A validation study of crucial elements of the patient history obtained after MVA using internal (chart audit) and external (age- and sex-matched population data) as gold standard references. PATIENT SAMPLE: Medium-sized (n>400) clinical cohort of patients without fracture or dislocation seen within 3 months after an MVA in a university spine clinic. OUTCOME MEASURES: Responses to standardized questionnaires included previous back or neck pain, previous psychological distress, previous illicit drug usage, previous alcohol abuse, other chronic pain conditions, perceived fault of the MVA, and whether a compensation claim has been filed. METHODS: A consecutive cohort of patients seen from 1998 to 2004 for evaluation of back or neck/shoulder pain reportedly caused by an MVA was enrolled. All clinic patients completed standardized questionnaires. The prevalence of self-reported pre-MVA axial pain and at-risk conditions (drug, alcohol, and psychological problems) and control conditions (hypertension and diabetes) were compared against the age- and sex-matched prevalence determined by the 2005 US Department of Health and Human Services National Surveys on Drug Use and Health (external gold standard). Randomly selected previous medical records were also audited (internal gold standard) and compared with post-MVA description of preaccident health. RESULTS: Four hundred twenty-two subjects were enrolled, and random audits of 100 subjects were completed. In 68% of the random audits, comorbid conditions denied in the postaccident history (previous axial pain, drug or alcohol abuse, and psychological diagnoses) were documented. In subjects perceiving the MVA to be another's fault (but not their own), the reported prevalence of previous axial pain was markedly below matched data for population prevalence and audited data. Similar findings were observed for psychological problems, illicit drug use, and alcohol abuse. In subjects pursuing compensation claims and retaining an attorney, 80% had significant past axial pain history or serious comorbidities in their records not disclosed in the spine clinic evaluation. In subjects reporting that the MVA was either one's "own fault" or "no one's fault," this effect was seen but was smaller in all dimensions. CONCLUSIONS: In patients being seen for continued pain related to an MVA, the validity of self-reported previous axial pain and comorbid conditions appeared poor. The self-reported prevalence of previous axial pain and drug, alcohol, and psychological problems is much less than the documented prevalence in prior medical records. These rates were also markedly below the expected prevalence in age- and sex-matched populations. This effect was seen most prominently in patients perceiving the accident to be another party's fault and in those filing compensation claims. The failure to appreciate previous axial pain problems and drug, alcohol, and psychological problems may compromise patient care and public health opportunities.

Cohen SP, Shockey SM, Carragee EJ. · Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA. · Anesth Analg. · Pubmed #17646511 links to  free full text

Abstract: Nine consecutive patients with discogenic low back pain who obtained excellent pain relief from intradiscal electrothermal therapy were treated with a repeat procedure after the beneficial effects had diminished. Although 4 of 9 patients obtained > or =50% pain relief and were satisfied with the results, both the degree and duration of benefit were less pronounced than after the first procedure. Prospective studies are needed to identify the best candidates for repeat intradiscal electrothermal therapy.

Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. · Division of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA. · Spine (Phila Pa 1976). · Pubmed #16540869 No free full text.

Abstract: STUDY DESIGN: Prospective observational study with historical control. The prospective study population consisted of 30 patients undergoing a posterior lumbar subtotal discectomy for lumbar disc herniation. This group was compared to a historical cohort of 46 patients treated with limited discectomy alone. OBJECTIVE: To compare clinical outcomes after limited versus subtotal discectomy for lumbar disc herniations. SUMMARY OF BACKGROUND DATA: Large posterior anular defects found at posterior discectomy have been associated with more frequent reherniation when treated with limited discectomy (i.e., removing only extruded or loose intervertebral fragments). A trial of more aggressive discectomy (subtotal) was undertaken to determine if the rate of reherniation could be decreased with this technique. METHODS: A total of 30 patients undergoing a posterior lumbar discectomy for lumbar disc herniation were treated with an aggressive (subtotal) resection of intervertebral disc material after removal of the extruded or protruded fragments. This group was compared against a historical cohort of 46 patients treated with limited discectomy alone. Reherniation rates and clinical outcomes were determined by independent evaluation at 6, 12, and 24 months after surgery. RESULTS: The reherniation rate in the limited discectomy group was 18% versus 9% in the subtotal discectomy group at follow-up (P = 0.1). However, the back pain (visual analog scale) (P = 0.02) and Oswestry scores (P = 0.06) were worse in the subtotal discectomy group at 12-month follow-up. Time to return to work was longer, and pain medication usage was higher in the subtotal discectomy group at 12-month follow-up. Despite a trend toward a higher reherniation rate, the patient satisfaction at 2-year follow-up was higher in the limited discectomy group. CONCLUSIONS: The more aggressive removal of remaining intervertebral disc material may decrease the risk of reherniation, but the overall outcome was less satisfactory, especially during the first year after surgery.

Carragee EJ, Alamin TF, Carragee JM. · Orthopaedic Surgery Division, Stanford University, Stanford, CA 94305, USA. · Spine (Phila Pa 1976). · Pubmed #16508542 No free full text.

Abstract: STUDY DESIGN: Retrospective data review of positive disc injections at low pressures among subjects without chronic low back pain (LBP) illness compared to patients with chronic LBP undergoing Discography. OBJECTIVE: To test the hypothesis that false-positive injections during Discography can effectively be eliminated by defining the positive injection criteria to include only those discs in which pain is produced with low injection pressure injections. SUMMARY OF BACKGROUND DATA: The use of lumbar Discography as a diagnostic tool remains controversial. Studies have shown that disc injections among subjects asymptomatic of clinical LBP will produce painful injections in a significant proportion of subjects, rendering the interpretation of positive diskograms in clinical practice problematic. It has been argued that lumbar disc injections at low pressure may be clinically different from those at higher pressure and that a guideline accepting only of low-pressure injections will effectively eliminate false positives. METHODS: A total of 69 volunteers with no clinically significant LBP undergoing experimental lumbar Discography were analyzed. There were 4 subgroups of this study cohort: no LBP, no chronic pain (n = 10); no LBP, chronic pain (n = 14); no LBP, previous lumbar discectomy (n = 20); and minor benign "backache" (n = 25). Pressure measurements during injection were made, and the pressure at which a significant pain response was elicited was recorded. This result was compared to the pain response and pressure profiles of 52 patients undergoing Discography for chronic LBP illness in consideration of treatment. Raters who were blinded to the subject's study group scored the studies. Diskogram morphology, pain response, and concordance, as well as magnetic resonance imaging, plain radiographs, psychometric testing (Distress and Risk Assessment Method), and compensation history were documented for each group. A low-pressure positive was defined as significant pain elicited less than 22 psi more than opening pressure. RESULTS: The number and percent of individuals with at least 1 low-pressure positive disc in the experimental group were 17 of 69 (25%) and in the clinical LBP group 14 of 52 (27%). The percentage of subjects with positive pain in the different experimental subgroups was: no LBP, no chronic pain 0/10 (0%); no LBP, chronic pain 5/14 (36%); no LBP, previous lumbar discectomy 5/20 (25%); and minor benign "backache" 7/25 (28%). Positive injections correlated with anular disruption, abnormal psychometric findings, and chronic pain states. CONCLUSIONS: The analysis shows that the rate of low-pressure painful injections in subjects without chronic LBP illness is approximately 25%, and correlates with both anatomic and psychosocial factors. In certain subgroups, this may represent an unacceptable risk of false-positive results.

Carragee EJ, Alamin TF, Miller JL, Carragee JM. · Stanford University School of Medicine, 300 Pasteur Drive, Room 171, Stanford, CA 94305, USA. · Spine J. · Pubmed #15653082 No free full text.

Abstract: BACKGROUND CONTEXT: A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain (LBP) illness. Although the relative contributions of structural and psychosocial variables are intensely debated, the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects. These factors dictate the requirement for large sample sizes, extensive structural imaging and extended longitudinal study. Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline. PURPOSE: To establish, using a strict patient sample design, the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness. STUDY DESIGN/SETTING: A prospective, longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics. PATIENT SAMPLE: One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic (non-lumbar) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease, to undergo baseline examination, testing and 5-year follow-up. OUTCOME MEASURES: Observations were made at 6-month intervals over 4 to 6 years (mean, 5.3) for the after primary outcomes measures: episodes of serious back pain (visual analogue scale [VAS] > or =6), episodes of occupational disability less than 1 week, episodes of occupational disability for 1 week, remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment. METHODS: Lumbar magnetic resonance imaging (MRI), lumbar provocative discography (in psychometrically normal subjects), physical examinations, medical and work histories and psychometric testing were performed at baseline. Imaging and psychometric testing were graded by blinded examiners. A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data. The interview covered interval medical, occupational and accident or injury histories. RESULTS: Psychosocial variables strongly predicted both long- and short-term disability events, duration and health-care visits for LBP problems (p<0.0001-0.004). The likelihood of a sustained remission from the baseline persistent (subclinical) LBP appeared to be linked to occupation factors (leaving a heavy labor occupation; p=0.0001), neurophysiologic variables (chronic nonlumbar pain; p=0.0002) and psychometric profiles at baseline (DRAM and FABQ-PA; p=0.003-0.002). Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome. A positive provocative discogram at baseline did not predict any future adverse event. CONCLUSION: The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables. Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care.

Fredericson M, Lee SU, Welsh J, Butts K, Norbash A, Carragee EJ. · Division of Physical Medicine and Rehabilitation, Stanford University Medical School, Stanford, CA 94305-5336, USA. · Spine J. · Pubmed #14588361 No free full text.

Abstract: BACKGROUND CONTEXT: No previous study has used magnetic resonance imaging (MRI) to evaluate changes of posterior disc bulging and intervertebral foraminal size in the normal spine with flexion-extension movement, comparing L4-5 versus L5-S1 intervertebral levels. PURPOSE: To determine changes in posterior disc bulging and intervertebral foraminal size with flexion-extension movement, comparing L4-5 versus L5-S1 intervertebral levels. STUDY DESIGN: An in vivo study of magnetic resonance kinematics with spine flexion extension. METHODS: Spines of three volunteers with no history of low back pain were scanned in neutral, flexion, and extension positions in a vertically open MRI system. MRI was repeated after 6 hours of normal activity and an additional 4 hours of heavy activity with a weighted vest. Posterior bulging of the intervertebral disc and the size of intervertebral foramen were measured at the L4-5 and L5-S1 levels. RESULTS: With spine flexion, posterior bulging of the discs increased at L4-5 in eight of nine measurements (three different spine-loading states for each of three subjects) and L5-S1 discs in six of nine measurements. In most cases, posterior bulging decreased with extension. No significant difference was noted in the degree of disc bulge between levels. Foraminal size at L4-5 increased with flexion and decreased with extension, and the extent of these changes was greater at the L4-5 level than at L5-S1. CONCLUSIONS: This pilot study demonstrates two distinct behavior characteristics of the normal spine with flexion-extension movement.

Carragee EJ. · Stanford University School of Medicine, 300 Pasteur Drive, Room 171, Stanford, CA 94305, USA. · Spine J. · Pubmed #14588348 No free full text.

Abstract: BACKGROUND CONTEXT: Some researchers have found a correlation of poor treatment outcomes in patients with low back pain and abnormal psychological profiles, whereas others have failed to confirm this correlation. A critical feature of this debate has been whether abnormal psychological profiles seen in patients with back pain are the result of the ongoing back pain or whether pre-existing psychological features predispose to a poor clinical outcome. PURPOSE: To determine the relationship of psychometric testing scores to the presence and duration of back pain of differing causes. STUDY DESIGN/SETTING: This was a prospective observational study of the psychological profiles of groups of patients with low back pain and controls. PATIENT SAMPLE: Subjects having a variety of painful back conditions (n=310) were compared with a control group of subjects without low back complaints who had undergone cervical spine surgery (n=73). OUTCOMES MEASURES: Psychometric testing (Modified Zung and Modified Somatic Pain Questionnaire) was performed along with pain scores (visual analog scale [VAS]), a standardized Low Back Pain Questionnaire, and the Oswestry Low Back Pain Disability Questionnaire in the evaluation of back pain and control subjects. METHODS: The subjects with painful back conditions included patients with presumed discogenic pain undergoing discography (n=95); patients with symptomatic isthmic spondylolisthesis coming to fusion (n=61); patients with chronic vertebral osteomyelitis before diagnosis and treatment (n=39). There was also a nonpatient group of soldiers with chronic low back pain not seeking medical care (n=115). The control subjects without low back pain consisted of a group who had undergone cervical spine surgery (n=73). Psychometric testing was performed and compared in the evaluation of subjects having these different painful back conditions. Analysis was done comparing pain scores, function scores, and psychological testing scores between the symptomatic and asymptomatic groups. RESULTS: The VAS maximum in last week score for the entire group was 7.1, and scores were not significantly different in all low back pain groups. The Oswestry scores were poorest in the discography group compared to spondylolisthesis and osteomyelitis. Functional scores were similar in the soldiers with low back pain and controls without low back pain. Both Depression and Somatic Pain scores were most abnormal in the discogenic low back pain group. Only 21% of this group had normal scores, compared with 71% of the spondylolisthesis group, 79% of osteomyelitis group, and 88% of the group with chronic low back pain not seeking treatment (p<.001 in all groups). The asymptomatic control group had 85% normal scores. CONCLUSIONS: Despite similar pain levels and pain duration, patients with the discographic diagnosis of discogenic back pain have poorer functional scores and very abnormal psychological scores compared with other subjects with chronic low back pain resulting from spondylolisthesis requiring surgery or chronic pyogenic osteomyelitis. Chronic moderately severe mechanical low back pain in healthy subjects was not associated with abnormal psychological scores or functional disability.