Back Pain: Choudhri TF

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00068. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028742 No free full text.

Abstract: Although conflicting reports have been presented in the literature regarding the utility of lumbar braces for the prevention of low-back pain, most Class III medical evidence suggests that these supports used prophylactically do not reduce the incidence of low-back pain or decrease the amount of time lost from work in the general working population. Among workers with a history of a back injury, their use appears to decrease the number of work days lost due to back pain. Lumbar braces appear to be an effective treatment for acute low-back pain in some populations. They do not appear to be effective in the chronic low-back pain population. If a brace is used, rigid braces offer some benefit over soft braces. There are no data to suggest that relief of low-back pain with preoperative external bracing predicts a favorable outcome following lumbar spinal fusion. No information is available on the benefit of bracing for improving fusion rates or clinical outcomes following instrumented lumbar fusion for degenerative disease.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00067. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028741 No free full text.

Abstract: In summary, there is no meaningful evidence in the medical literature that the use of epidural injections is of any long-term value in the treatment of patients with chronic low-back pain. The literature does indicate that the use of lumbar epidural injections can provide short-term relief in selected patients with chronic low-back pain. There is evidence that suggests that facet joint injections can be used to predict outcome after RF ablation of a facet joint. The predictive ability of facet joint injections does not appear to apply to lumbar fusion surgery. No evidence exists to support the effectiveness of facet injections in the treatment of patients with chronic low-back pain. There is conflicting evidence suggesting that the use of local TPIs can be effective for the short-term relief of low-back pain. There are no data to suggest that TPIs with either steroids or anesthetics alone provide lasting benefit for patients suffering from chronic low-back pain.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00066. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028740 No free full text.

Abstract: This review focused on an examination of the literature on the surgical treatment of low-back pain in patients with DDD or low-grade degenerative spondylolisthesis treated with PLF, with or without the use of pedicle screw fixation. All Class I and the majority of Class II and Class III medical evidence on this topic indicates that the addition of pedicle screw fixation to PLF increases fusion success rates when assessed based on plain x-ray films with dynamic imaging. Although there does appear to be a positive relationship between radiographic fusion and clinical outcome, no convincing correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence sources (primarily Class II and III). Furthermore, the largest contemporary randomized controlled study on this topic failed to demonstrate a significant beneficial effect for the use of pedicle screw fixation in patients treated with PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as a proof of absence. For example, in this same study, patient satisfaction scores improved from approximately 60% to approximately 70% with the addition of pedicle screw fixation. This difference in outcome may be clinically relevant. Similarly, the improvement in ODI scores was 40% greater in the group of patients treated with pedicle screw fixation compared with those treated with PLF alone. If an analysis to determine the sample size necessary to ensure a power of 0.8 (or an 80% chance of detecting a significant effect) in a study in which the good outcome rate is 60% in the control group and 70% in the treatment group is performed, approximately 355 patients would be needed in each treatment group (http://department.obg.cuhk.edu.hk). Alternatively, if a similar analysis is performed using the differential scores obtained in the ODI measurements reported in the paper by Fritzell, et al., approximately 225 patients would be needed per treatment group (http://calculators.stat.ucla.edu/powercalc). Although Fritzell, et al., did not detect a significant benefit associated with the use of pedicle screw fixation as an adjunct to PLF, their sample size severely limited the power of their study to detect such a benefit. All studies reviewed suffer from similar lack of power. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with PLF. High-risk patients include, but are not limited to patients who smoke, who are undergoing revision surgery, or who suffer systemic diseases known to be associated with poor bone healing.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00065. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028739 No free full text.

Abstract: The majority of reviewed medical evidence suggests that interbody techniques are associated with higher fusion rates compared with PLF when applied to patients with low-back pain due to DDD limited to one or two levels. The evidence is generally of poor quality and retrospective in nature. Conflicting evidence exists supporting the role of interbody graft placement for improvement of functional outcomes; however, there is no Class I or II evidence to suggest that the use of an interbody graft is associated with worse outcomes, and Class II evidence exists to suggest that outcomes are improved. Complication rates of interbody graft placement, particularly of circumferential procedures, are higher in most series. Many complications, however, are associated with pedicle screw fixation and not with interbody graft placement per se. In the context of a single-level stand-alone ALIF or ALIF with posterior instrumentation, there does not appear to be a substantial benefit to the addition of a PLF. The addition of a PLF to a construct that already includes an interbody graft is, however, associated with increased costs and complications. Therefore, although the addition of supplemental fixation (a 270 degrees fusion) may be necessary for biomechanical reasons, it may not be appropriate to subject the patient to the morbidity of a full posterior exposure for placement of graft material. Significant differences in clinical outcomes between the various interbody techniques have not been convincingly demonstrated. No general recommendation can therefore be made regarding the technique that should be used to achieve interbody fusion.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00062. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028736 No free full text.

Abstract: There is no convincing medical evidence to support the routine use of lumbar fusion at the time of a primary lumbar disc excision. There is conflicting Class III medical evidence regarding the potential benefit of the addition of fusion in this circumstance. Therefore, the definite increase in cost and complications associated with the use of fusion are not justified. Patients with preoperative lumbar instability may benefit from fusion at the time of lumbar discectomy; however, the incidence of such instability appears to be very low (< 5%) in the general lumbar disc herniation population. Patients who suffer from chronic low-back pain, or are heavy laborers or athletes with axial low-back pain, in addition to radicular symptoms may also be candidates for fusion at the time of lumbar disc excision. Patients with a recurrent disc herniation have been treated successfully with both reoperative discectomy and reoperative discectomy combined with fusion. In patients with a recurrent lumbar disc herniation with associated spinal deformity, instability, or associated chronic low-back pain, consideration of fusion in addition to reoperative discectomy is recommended.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00061. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028735 No free full text.

Abstract: Class I medical evidence exists in support of the use of lumbar fusion as a treatment standard for carefully selected patients with low-back pain intractable to the best medical management. There is Class III medical evidence that suggests that a course of intensive cognitive and physical therapy may be an efficacious treatment option for the treatment of patients with chronic disabling low-back pain.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00060. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028734 No free full text.

Abstract: Discography is an exquisitely sensitive but not specific diagnostic test for the diagnosis of discogenic low-back pain. The restriction of the definition of a positive discographic study to one that elicits concordant pain from a morphologically abnormal disc improves the definition's accuracy. Fusion surgery based on discography alone, however, is not reliably associated with clinical success. Therefore, discography is not recommended as a standalone test for treatment decisions in patients with low-back pain. Magnetic resonance imaging is a sensitive and noninvasive test for the presence of degenerative disc disease. Discography should not be attempted in patients with normal lumbar MR images. Discography appears to have a role in the evaluation of patients with low-back pain, but it is best limited to the evaluation of abnormal interspaces identified on MR imaging, the investigation of adjacent-level disc disease, and as a means to rule out cases of nonorganic pain from surgical consideration.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN, Anonymous00056. · Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA. · J Neurosurg Spine. · Pubmed #16028730 No free full text.

Abstract: Functional disability secondary to acute low-back pain, chronic low-back pain, lumbar stenosis, and lumbar disc disease may be reliably and validly assessed using functional outcome surveys that are valid, reliable, and responsive. Outcome instruments supported by Class I and Class II medical evidence for the evaluation of low-back pain include the Spinal Stenosis Survey of Stucki, Waddell-Main, RMDQ, DPQ, QPDS, SIP, Million Scale, LBPR Scale, ODI, and CBSQ. Many of these outcome measures have been applied to patients who have been treated with lumbar fusion for degenerative lumbar disease and have proven to be valid and responsive; however, the reliability of these instruments has never been specifically assessed in the lumbar fusion patient population. Patient satisfaction surveys have been used to measure outcome following lumbar fusion. Their usefulness resides in their insight into patient attitudes toward the treatment experience but is limited because of their inability to measure responsiveness and the lack of information on their reliability.