Back Pain: Resnick DK

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.

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.

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.

Resnick DK, Watters WC. · Department of Neurosurery, University of Wisconsin School of Medicine, Madison, Wisconsin, USA. · Clin Neurosurg. · Pubmed #18504901 No free full text.

Abstract: Lumbar disc arthroplasty may be the most innovative and exciting development in the history of spinal surgery. Manufacturers and proponents cite the ability of these devices to relieve pain while preserving motion at the disc space. The preservation of motion is hypothesized to lower the risk of adjacent segment disease and, thereby, improve long-term outcomes. However, the devices are expensive and their use is associated with the potential for significant complications above and beyond those seen with lumbar fusion. At the present time, there is no evidence to suggest that the use of disc arthroplasty results in better short- or long-term functional outcomes than fusion in properly selected patients. Furthermore, there is little if any evidence to support the hypothesis that adjacent segment degeneration is an important clinical entity. Although the absence of proof is not the same as the proof of absence, greater efficacy must be demonstrated to offset the increased costs and complications associated with these devices. Therefore, these devices require further long-term study in a controlled environment before widespread application.

Resnick DK. · Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA. · Spine (Phila Pa 1976). · Pubmed #17495580 No free full text.

Abstract: STUDY DESIGN: Literature review. OBJECTIVE: To describe the state of the literature regarding the performance of lumbar fusion for low back pain due to degenerative disease of the spine. SUMMARY OF BACKGROUND DATA: The effectiveness and costs associated with spinal surgery have been a topic of significant debate in both the popular press and professional literature. METHODS: Evidence-based medicine techniques have been applied to many areas of spinal surgery. The results of these analyses are being used by practicing physicians, payors, and others to determine what procedures are appropriate for certain patient populations. RESULTS: This manuscript describes the methodology, strengths, and weaknesses of evidence-based medicine approaches to spinal surgery. The case for lumbar fusion as a treatment for chronic low back pain due to degenerative disc disease is described as an example. CONCLUSION: Evidence-based medicine is a useful tool for summarizing and grading the evidence available in the literature for or against a particular treatment strategy. Its utility is limited by the quality of the primary literature, and the absence of proof cannot be equated with the proof of absence.

Resnick DK. · Department of Neurological Surgery, University of Wisconsin, Madison, USA. · Clin Neurosurg. · Pubmed #17380763 No free full text.

This publication has no abstract.

Resnick DK, Groff MC. · Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA. · Prog Neurol Surg. · Pubmed #17033151 No free full text.

Abstract: Lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. The safety, efficacy, and cost of these procedures have been questioned in the professional and lay press. Recently, evidence based medicine techniques have been used to investigate the role of lumbar fusion for the treatment of a variety of spinal disorders. This chapter describes the general principles and procedures used for the development of evidence based guidelines for the performance of lumbar fusion.

Resnick DK, Malone DG, Ryken TC. · Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin 53792, USA. · Neurosurg Focus. · Pubmed #15916396 No free full text.

Abstract: OBJECT: Discography has been used as a diagnostic test in the evaluation of patients with recalcitrant low-back pain. Recently, its usefulness has been questioned because of the occurrence of false-positive results as well as the influence of psychological factors on test results. The purpose of this review is to establish the literature support for and against the use of discography. A search of the English-language literature published between 1966 and 2001 was performed. Papers were selected based on inclusion criteria described in the text, and the quality of information was graded using previously described methods. CONCLUSIONS: The authors propose a set of practice parameters based on the literature. Although the data were not judged adequate for the determination of a treatment standard, parameters for the use of discography are provided at a guideline and option level.

Haughton VM, Rogers B, Meyerand ME, Resnick DK. · Department of Radiology, University of Wisconsin, Madison, USA. · AJNR Am J Neuroradiol. · Pubmed #12169466 links to  free full text

Abstract: BACKGROUND AND PURPOSE: Flexion-extension radiography is neither sensitive nor specific in the diagnosis of degenerative spinal instability, a presumed cause of back pain and an indication for spinal fusion. We tested the hypothesis that with MR imaging and a device to rotate the torso, axial rotations of lumbar vertebrae can be measured with sufficient accuracy and that significantly different rotations can be detected between lumbar segments with degenerated disks and those with normal disks. METHODS: We studied five volunteers without back pain (group 1), five patients who underwent MR imaging because of back pain but were not considered candidates for fusion (group 2), and five patients in whom diskography identified one or more disks with concordant pain (group 3). Each participant was placed on a specially built table that provided separate supports for the torso and for the hips and legs. Series of sagittal images were acquired with a T2-weighted fast spin-echo sequence, with the torso rotated clockwise and then counterclockwise. The amount of rotation was calculated from axial images with use of an automated program. RESULTS: In the five volunteers, rotations of the lumbar motion segments varied between -1.8 degrees and 5.7 degrees, with an average of 0.8 degrees. The abnormal disks in five patients in group 2 rotated from -0.9 degrees to 5.6 degrees, with an average of 3.2 degrees. In group 3, the disks in which concordant pain was elicited rotated from 0.8 degrees to 4.4 degrees, with an average of 2.2 degrees. Difference in rotation between abnormal and normal disks was statistically significant. CONCLUSION: Measurements of rotations of lumbar vertebrae with MR imaging may have value for determining levels that move abnormally in axial rotation.

Resnick DK. · Department of Neurological Surgery, University of Wisconsin School of Medicine, Madison 53792, USA. · J Neurosurg. · Pubmed #10761653 No free full text.

Abstract: OBJECT: Economic, demographic, and political pressures have mandated that medical schools increase the number of primary care physicians. The goal of this study was to determine the nature of the average medical student's exposure to neurosurgical issues. METHODS: Surveys were sent to every neurosurgical program director in the United States and to the dean of every medical school in North America, querying the extent of neurosurgical involvement in medical student education. Specifically, the respondents were asked how medical students were educated about the management of low-back pain and radiculopathy, carotid artery disease, head and spine trauma, and headache. Survey results were obtained from 65 (67%) of 97 neurosurgery program directors and from 57 (40%) of 143 medical school deans. Only one program in North America reported having a required neurosurgical rotation for all medical students, and just over 50% (29 of 57 deans and 34 of 65 program directors) reported that neurosurgery was an option in a required neuroscience or surgical subspecialty course. Neurosurgeons were not listed among the top three sources for medical student education in the topics of low-back pain and radiculopathy or carotid artery disease. Neurosurgeons were the most frequently cited source of education regarding head and spinal injuries, despite the fact that the majority of medical schools do not have any required medical student exposure to neurosurgery. CONCLUSIONS: With rare exceptions, neurosurgeons are not significantly involved in the education of medical students concerning the management of common neurosurgical issues. As a result, most emerging primary care physicians are taught about these issues by other specialists or not at all. The implications of this situation are discussed.