Meggie Lynn and others,
I watched the video where he talks about fusions, and says that a study he thought was well designed out of Stanford compared spondy vs discogenic pain pts and success rate of fusion. the guy who did that study - a Dr Carragee - seems to be on a mission to debunk discograms, using some pretty suspect methodology imho. this prompted me to investigate Dr Carragee, current literature, and just to think. everything i found is readily available on the web. i used google and combinations of search terms including "discography", "carragee", "spondylolisthesis", and names of the articles to find a whole host of literature.
i also found aetna's clinical policy on discograms to have a surprisingly useful summary of recent studies related to discography.
Discography.
some thoughts:
1. this summary also explains the #'s i have been cited for success rates - looks like what your surgeon will tell you about surgical outcome depends on what study they like. had one guy tell me 50-60% (rate cited in Carragee study as "minimal acceptable outcome" - same Stanford guy as the one Hanscom cites), then another say 80% (from Hao study - apparently done in China, article in Chinese, and I can't find the abstract on the web).
2. also found this review of ADR vs fusion
http://www.cns.org/publications/clin...0107000083.pdf
3. and this about side of pain and discogram
http://www.kalindra.com/annular_tear.pdf
4. in relation to Meggie's post - i totally agree with the premise that chronic pain and depression are comorbid and can drive each other. i have such issues myself and try to be very, very cognizant of what is psych vs physical. i know that my brain responds differently to pain than before i started w/ this disc problem.
this same guy out of stanford (carragee) did another study where he says that discogenic pain pts have a disproportionately worse psychosocial profile than those w/ spondy, infection, or "other" mechanical lbp. he seems quite confident in his conclusions BUT -- if you look at the study pts.... 57% of those w/ discogenic pain were WC. much lower in the other groups. every doc i have seen has mentioned WC as a poor prognostic indicator for surgery, and all have said that they will not operate on WC for lbp.
http://www.kinesiouba.com.ar/docs/5/...-back-pain.pdf
fwiw, 2 of the clinics i've been to won't see people even for even no-fault accidents if they don't have their own insurance that will pay them.
6. more on Carragee and discograms... how are people with an entirely different diagnosis a "gold standard"? see abstract:
abstract:
A gold standard evaluation of the "discogenic pain" diagnosis as determined by
provocative discography.
Carragee EJ, Lincoln T, Parmar VS, Alamin T.
Orthopaedic Surgery Division, Stanford School of Medicine, Stanford, CA 94305,
USA.
carragee@leland.stanford.edu
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.
ok so this post has become a repository for links. the aetna CP document has a lot of really interesting articles. i like reading them myself b/c i'm trained to do so... i haven't done my own stats analysis on any of them yet, but i probably will (w/ the help of my research attending from residency) and will let ya'll know if i come up w/ anything interesting. MOST articles that make it to a major journal/textbook are good studies, b/c they have been peer reviewed - but there are notable exceptions (ie, study now retracted from Lancet that linked vaccines to autism). i know an orthopedist in the bay area, will talk to him about what he thinks of Dr Carragee - though this ortho isn't a spine guy.
[special thanks to whomever scanned some of these articles and posted them under various strangely named domains. i don't subscribe to all of these journals and don't feel like trekking to the nearest med school and begging them for access.]