Suboxone - NYTimes cover article 11/17/13

[101N]

Private forum please. Somebody needs a trip to the woodshed.

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Members don't see this ad.

 

[lobelsteve]

Amp and I both spent time at Dartmouth. Him in the 70's and me 89-90.

Go big green (Indians).

Instead of running through the Dartmouth database, how about some EBA's? http://ebas.com/serious-sandwiches/ I'll have the original chicken sandwich.

 

[ampaphb]

Wait, have we suddenly accepted SPORT and Jim Weinstein as the arbiter of our field? News to me.

Sounds like gibberish to me to justify doing discography. Show me outcome data at 12 month for these patients and how it correlates with your discogram. Or has this been done in any studies in the past?

If it really sounds like gibberish to you, then you Dartmouth education has not served you as well as mine has served me.

 

[101N]

You are just digging yourself a deeper hole. I live in an outlier area both for total surgeries and surgeries plus fusions. But, I've done maybe
10 discograms in the past 2yrs. Surgeons don't need us to annoint a fusion with a discogram. They are more than happy to upcode the decompression
to decompression with fusion sans discography. In my area - 2008 BC/BS data - fusions were performed on dx 721.x-724.x (Note this excludes
spondylolisthesis) 80% of the time for commercial insurance and 73% of the time for Medicare Advantage.

BTW: benchmarking comes from Wennberg, not Weinstein.

 

[clubdeac]

This thread has me cracking up... Peter! Do we need to talk, hahaha. I quit doing disco's at the VA b/c they were too much work. If a procedure takes me more than 10min I peace out. Well I lie...I love, love the results I get from SIJ RFA and that takes a little longer. But, I would argue that I get FAR better results from that relatively tedious procedure than one gets from the fusion that was a result of your disco. In fact, many of my most successful SIJ RFAs are on prior L5-S1 fusion patients. Ah but I digress....

 

[Ducttape]

This thread has me cracking up... Peter! Do we need to talk, hahaha. I quit doing disco's at the VA b/c they were too much work. If a procedure takes me more than 10min I peace out. Well I lie...I love, love the results I get from SIJ RFA and that takes a little longer. But, I would argue that I get FAR better results from that relatively tedious procedure than one gets from the fusion that was a result of your disco. In fact, many of my most successful SIJ RFAs are on prior L5-S1 fusion patients. Ah but I digress....

If we are to continue the tenor of this thread, someone please step up and throw a tirade at clubdeac about the futility of sij rfas...

This thread is like the river of slime in ghostbusters 2...

 

[ampaphb]

You are just digging yourself a deeper hole. I live in an outlier area both for total surgeries and surgeries plus fusions. But, I've done maybe
10 discograms in the past 2yrs. Surgeons don't need us to annoint a fusion with a discogram. They are more than happy to upcode the decompression
to decompression with fusion sans discography. In my area - 2008 BC/BS data - fusions were performed on dx 721.x-724.x (Note this excludes
spondylolisthesis) 80% of the time for commercial insurance and 73% of the time for Medicare Advantage.

So because your surgeons over-utilize, you assume all surgeons do?

Because all surgeons in a geographic region over-utilize, you assume no surgeon relies on discography?

And because your practice pattern has lead you to do 10, presumably lumbar discographies in 2 years, you conclude that anyone who does more than you do, even if they do cervical and lumbar, over-utiliize the proceuudre if they do more that 10/yr?

 

[101N]

So because your surgeons over-utilize, you assume all surgeons do?

Because all surgeons in a geographic region over-utilize, you assume no surgeon relies on discography?

And because your practice pattern has lead you to do 10, presumably lumbar discographies in 2 years, you conclude that anyone who does more than you do, even if they do cervical and lumbar, over-utiliize the proceuudre if they do more that 10/yr?

It's clear from your posts in defence of discography
that you are a 'believer' in the technique. Your initial posts on the thread suggest you use it more frequently than some of your peers here. You worked with a known champion of the technique, and it reimburses well.

Post your numbers and we'll be done with the interrogation.

 

[ampaphb]

I trained with one of the best discographers in the world. In my training, I spent time with Drs. Charluie Aprill, Rick Derby, Ray Baker, Paul Dreyfuss, the Drs of the Florida Spine Institute, Aaron Calodney, Rob Windsor, Curtis Slipman, Michael Depalma, and Greg Lutz. All of them utilize discography similarly to my practice pattern. If yours is different, more power to you, but just because you methodology is different doesn't make it right. The above mentioned docs have been thought leaders

It's clear from your posts in defence of discography
that you are a 'believer' in the technique. Your initial posts on the thread suggest you use it more frequently than some of your peers here. You worked with a known champion of the technique, and it reimburses well.

Post your numbers and we'll be done with the interrogation.

Being a "believer" implies there is no good evidence the procedure is useful. Feel free to cite any articles from someone other than Carragee that bolsters your position

 

[101N]

Just cut to the chase and post your number. You are acting defensive - like you have something to hide - and we are all
picking up on it.

BTW: Maybe all those guys are overusing discography as well. As we are seeing with opioid prescribing, founder effects die hard.

 

[lobelsteve]

I trained with one of the best discographers in the world. In my training, I spent time with Drs. Charluie Aprill, Rick Derby, Ray Baker, Paul Dreyfuss, the Drs of the Florida Spine Institute, Aaron Calodney, Rob Windsor, Curtis Slipman, Michael Depalma, and Greg Lutz. All of them utilize discography similarly to my practice pattern. If yours is different, more power to you, but just because you methodology is different doesn't make it right. The above mentioned docs have been thought leaders

Being a "believer" implies there is no good evidence the procedure is useful. Feel free to cite any articles from someone other than Carragee that bolsters your position

Some of those guys are thought leaders akin to Portenoy, Passik, et al.

 

[ampaphb]

Just cut to the chase and post your number. You are acting defensive - like you have something to hide - and we are all
picking up on it.

BTW: Maybe all those guys are overusing discography as well. As we are seeing with opioid prescribing, founder effects die hard.

Answer my questions, and I'll be happy to answer yours. Ignore my questions, call me names, and it discredits your position. That is not defensive - it is reason and logic. I've watched your nonsense regarding opioids for several months. Your problem here is that the literature does not support your position.

 

[ampaphb]

Steve,

You are talking out of your ass. Back it up with some literature

 

[SSdoc33]

Some of those guys are thought leaders akin to Portenoy, Passik, et al.

goddammit, you beat me to the punch

 

[SSdoc33]

Being a "believer" implies there is no good evidence the procedure is useful. Feel free to cite any articles from someone other than Carragee that bolsters your position

what? no it doesnt

 

[ampaphb]

Zhonghua Yi Xue Za Zhi. 2013 Jun 18;93(23):1806-10.
Retrospective and comparative analysis of therapy for degenerative chronic discogenic low back pain with end plate Modic changes with discography and intradiscal injection blockage.
[Article in Chinese]
Sun CH, Zheng T, Chen Z, Zheng YH, Cao P, Zhang ZW, Lu J, Zou L.
Source
Department of Orthopaedics, Rui Jin-Lu Wan Hospital, Shanghai 200020, China.

Abstract
OBJECTIVE:
To evaluate the prognosticating effects of discography and intradiscal injection blockage for patients with degenerative chronic discogenic low back pain and end plate Modic changes when posterior lumbar interbody fusion (PLIF) was adopted.

METHODS:
Patients who received diagnostic discography for suspected degenerative discogenic low back pain were recruited. A total of 60 patients (42 males and 18 females) with positive discography and end plate Modic changes at a single level were enrolled in the study and allocated into Groups A and B: Group A was both positive sign of discography and negative sign of intradiscal injection blockage twe weeks later, which further was subdivided into Group A1 (Modic I endplate change) and Group A2 (Modic II endplate change). Group B was both positive sign of discography and intradiscal injection blockage twe weeks later, which further was subdivided into Group A1 (Modic I endplate change) and Group A2 (Modic II endplate change). There were 15 cases in each subgroup, with a mean age of 43.2 years old (29 to 62 years old). The lumbar decompression combined with interbody fusion was performed for these patients. The clinical outcome of each patient was evaluated and recorded by using the VAS and ODI before operation and at 24 months after the procedure. The bone fusion state was evaluated by both dynamic X-ray and CT reconstruction films.

RESULTS:
There was no statistical difference of the scales of VAS and ODI before operation.Compared with the scales before operation, although the scales of VAS and ODI of both group A and group B at 24 months after the procedure were significantly improved, the scales of both VAS and ODI of group B were significantly superior to group A. The statistics analysis showed that comparing the improvement rate of VAS and ODI before and after operation, group B was significantly superior to group A, but there was no obviously correlations between the type of Modc endplate change and the the improvement rate of VAS and ODI.

CONCLUSION:
The combination the discography with intradiscal injection blockage before operation would effectively prognosticate the therapy of posterior lumbar interbody fusion. There was no obviously correlations between the type of Modc endplate change and the improvement rate of VAS and ODI.

PMID: 24124714

 

[ampaphb]

Wien Klin Wochenschr. 2013 Oct;125(19-20):600-610. Epub 2013 Aug 30.
Provocative discography screening improves surgical outcome.
Margetic P, Pavic R, Stancic MF.
Source
Department of Radiology, Clinic for Traumatology, University Hospital Sisters of Mercy, Draskoviceva 19, 10000, Zagreb, Croatia, [email protected].

Abstract
OBJECTIVE:
The objective of this study was to compare the surgical outcomes of patients operated on, with or without discography prior to operation.

METHODS:
The study was designed as a randomized controlled trial, using power analysis with McNemar's test on two correlated proportions. The study comprised of 310 patients divided into trial (207) and control (103) groups. Inclusion criteria were low back pain resistant to nonsurgical treatment for more than 6 months and conventional radiological findings showing degenerative changes without a clear generator of pain. Exclusion criteria were red flags (tumor, trauma, and infection). After standard radiological diagnostic imaging (X-ray, CT, and MR), patients filled in the Oswestry Disability Index (ODI), SF-36, Zung, and MSP questionnaires. Depending on their radiological findings, patients were included and randomly placed in the trial or control group. At the 1-year follow-up examination, patients filled in the ODI, SF-36, and Likert scale questionnaires.

RESULTS:
The difference between preoperative and postoperative ODI in the control group degenerative disc disease (DDD) subgroup was 22.07 %. The difference between preoperative and postoperative ODI in the trial group DDD subgroup was 35.04 %. Differences between preoperative and postoperative ODI in the control group other indications subgroup was 26.13 %. Differences between preoperative and postoperative ODI in the trial group other indications subgroup was 28.42 %.

CONCLUSIONS:
DDD treated surgically without discography did not reach the clinically significant improvement of 15 ODI points for the patients treated with fusion. Provocative discography screening with psychological testing in the trial group made improvement following fusion clinically significant.

 

[ampaphb]

Pain Physician. 2013 Apr;16(2 Suppl):SE55-95.
An update of the systematic appraisal of the accuracy and utility of lumbar discography in chronic low back pain.
Manchikanti L, Benyamin RM, Singh V, Falco FJ, Hameed H, Derby R, Wolfer LR, Helm S 2nd, Calodney AK, Datta S, Snook LT, Caraway DL, Hirsch JA, Cohen SP.
Source
Pain Management Center of Paducah, Paducah, KY, USA. [email protected]

Abstract
BACKGROUND:
The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool.

STUDY DESIGN:
A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature.

OBJECTIVE:
To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography.

METHODS:
The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles.

RESULTS:
Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%.

CONCLUSION:
This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain.
PMID: 23615887

 

[101N]

Pain Physician. 2013 Apr;16(2 Suppl):SE55-95.
An update of the systematic appraisal of the accuracy and utility of lumbar discography in chronic low back pain.
Manchikanti L, Benyamin RM, Singh V, Falco FJ, Hameed H, Derby R, Wolfer LR, Helm S 2nd, Calodney AK, Datta S, Snook LT, Caraway DL, Hirsch JA, Cohen SP.
Source
Pain Management Center of Paducah, Paducah, KY, USA. [email protected]

Abstract
BACKGROUND:
The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool.

STUDY DESIGN:
A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature.

OBJECTIVE:
To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography.

METHODS:
The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles.

RESULTS:
Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%.

CONCLUSION:
This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain.
PMID: 23615887

 

[lobelsteve]

Steve,

You are talking out of your ass. Back it up with some literature

From Nik himself:

Clinical Utility
Clinical utility can be cast or measured in various ways. One domain, often invoked for assessing the utility of disc stimulation, is therapeutic utility. It asks if making the diag-nosis of discogenic pain leads to improved outcome after
treatment; but this is only one domain of clinical utility; and it can be cast as positive therapeutic utility. A converse domain is negative therapeutic utility, which asks if making the diagnosis prevents misadventure through inappropri-
ate treatment. An additional domain is diagnostic utility, which asks if making the diagnosis serves a useful purpose even if treatment is not available.

Positive Therapeutic Utility
The experiment to prove positive therapeutic utility for disc
stimulation is demanding and has not been conducted. It
would require patients to undergo disc stimulation, but the
results would be masked, yet the patients would then
nevertheless proceed to treatment. Thereafter, their
response to treatment would be correlated with their
response to disc stimulation (Table 13). Positive therapeu-
tic utility would arise if it emerged that success rates of
treatment were significantly higher in those patients in
whom the correct disc, according to disc stimulation, had
been treated.
Several difficulties apply to such a study. It would require
patients to agree to undergo disc stimulation. Those who
treat the patients must be prepared and able to do so
without the results of the diagnostic test. The treatment
must be target specific, i.e., designed to treat selectively
only a painful disc; treatments that do not target specific
discs do not require a specific, segmental diagnosis. The
treatment must have a reasonable chance of success, in
order to generate the required numbers in the first column
of the contingency table (Table 13); its success rate would
have to be substantially greater than that of a placebo.
Large numbers of patients would be required in order to
overcome the potential influence of chance. Given that
most symptomatic discs occur at L4-5 and L5-S1, there is
a 0.50 probability that treatment could be directed at the
correct disc by chance alone.
Of the treatments currently available for discogenic pain,
the most widely practiced is surgery, in the form of arthro-
desis. Other inventions, such as disc arthroplasty and
various intradiscal therapies are purportedly specific for
symptomatic discs, but their success rates are either low
or have not been established.
One study purported to show that disc stimulation did not
influence surgical outcome [83], but it was not an appro-
priate test of disc stimulation. It compared the outcomes
from arthrodesis in earlier patients in whom disc stimula-
tion had not been undertaken and later patients who had
undergone disc stimulation. Notwithstanding the limita-
tions of using historical controls, this study did not comply
with contemporary standards of disc stimulation. Pain
scores were not recorded and manometric controls were
not applied. Indeed, the report states that all discs were
subjected to high-pressure injections. Consequently, the
validity of the response to disc stimulation comes
into question.
One study did not provide usable data [84] because it did
not compare the outcomes of patients whose discogra-
phy was positive or negative. Rather, it compared the
outcomes of two different types of surgical treatment. It
reported that patients with positive discography at low
pressures of injection more often had better outcomes
when treated with interbody fusion than when treated with
intertransverse fusion. Although this study hints that dis-
cography is a useful test, the study is more a test of two
types of treatment than a test of the predictive validity
of discography.
Only one study has provided usable data [85]. It compared
the success rates of arthrodesis in patients with positive
responses or negative responses to disc stimulation.
Success was defined as complete or significant improve-
ment in symptoms, resumption of work or normal duties,
and no requirement for analgesics. For predicting this
success, disc stimulation had a sensitivity of 0.88, a speci-
ficity of 0.48, and a positive likelihood ratio of 1.7 (95%
confidence intervals: 1.2–2.4) (Table 14).
This study provides prima facie evidence that discography
is predictive of a successful response to surgical treat-
ment; but a positive likelihood ratio of 1.7 indicates only a
low strength of prediction. This low value arises because
most of the patients were positive to discography and
most had a successful outcome; too few patients who
were negative to discography underwent treatment, prob-
ably because the surgeons were reluctant to operate on
such patients. The validity of discography would have
been stronger had more patients negative to discography
been treated and if more of them failed treatment. As the
data stand, they indicate that patients with negative dis-
cography have essentially a 50% chance of successful
outcome, whereas those with positive discography have
an 88% chance.
Another study, published only in abstract form [86], com-
pared the outcomes of surgery in patients whose
responses strictly satisfied, or not, the criteria for a positive
response to disc stimulation, as prescribed by the Inter-
national Spine Intervention Society [87], i.e., exact repro-
duction of pain, upon stimulating a disc at a pressure of
less than 15 psi, provided that adjacent discs are not
painful. Patients were three times more likely to have a
favorable outcome from surgery if their responses strictly
satisfied the criteria.

Negative Therapeutic Utility
In principle, disc stimulation has potentially great, negative
therapeutic utility. If disc stimulation is negative, or if it is
indeterminate because too many levels are positive,
surgery would not be indicated. Identifying such
responses should prevent gratuitous surgery and, thereby,
protect patients from failed surgery.
The negative therapeutic utility of disc stimulation has not
been quantified. Either patients with negative responses
do not participate further in studies or they undergo
surgery, despite negative responses, but their outcomes
are not reported.
Disc stimulation has been deprecated on the grounds that
it only leads to more surgery. This may be an impression
held by some critics, but it has not been validated. It may
be that some surgeons are intent on operating, regardless
of the results of disc stimulation, and undertake the test
only as a routine ritual. In that event, disc stimulation is not
at fault, for the decision to operate has already been
taken. In contrast, however, disc stimulation serves to
inform surgeons and is more often likely to be negative
than positive. A negative outcome, if reported and
heeded, should lead to less surgery being undertaken.

Diagnostic Utility
It is distressing for patients, with any disease, not to know
why they are suffering. In such cases, making a diagnosis
provides an explanation. Doing serves to allay distress
over not knowing, and serves to terminate the continued
pursuit of a diagnosis, which is likely to be futile. In the
case of back pain, patients face an additional risk. In the
absence of a diagnosis, they risk being accused of malin-
gering or having psychogenic pain (or some euphemism
thereof). Establishing a diagnosis protects them from
such false accusations. In these respects, diagnostic
utility arises even if there is no treatment available for
the condition.
There are many conditions known to medicine, and many
more in the past, for which there has been no proven or
successful treatment. Examples include motor neuron
disease and multiple sclerosis. For such conditions, the
absence of a treatment has not, and does not, preclude
pursuing and determining the diagnosis. Establishing the
correct diagnosis protects patients from undergoing treat-
ments that are not appropriate for the condition diag-
nosed; it also opens up future possibilities.
As research continues, new treatments for particular con-
ditions arise. Patients with the condition become eligible
to participate in trials of the new treatment, or eligible to
have the treatment if and once it is proven. In the case of
lumbar discogenic pain, various therapies, involving
devices or injections, are under development. None is
suitable for indiscriminate application to all discs, symp-
tomatic and normal; each is designed to target symptom-
atic discs. Under these circumstances, establishing a
diagnosis of discogenic pain serves two purposes on
behalf of patients. They might avail themselves of trials of
these new interventions, or they can be informed that
research is being undertaken to look for a treatment for
the particular condition that they have.
Pivotal to all of these merits of diagnostic utility is the
balance between necessity and the stress of undergoing
disc stimulation. The procedure is not pleasant and should
not be undertaken presumptuously or gratuitously. The
treating physician and the patient should discuss and
determine if they need to know if the patient has disco-
genic pain when the options for treatment may be limited
or only speculative.
When the certainty of diagnosis is not crucial, disc stimu-
lation may not be warranted. In such cases, MRI can
provide a diagnostic confidence of 70% if Modic changes
or HIZs are evident. Whereupon, MRI constitutes a suit-
able substitute or surrogate to disc stimulation.

Synopsis
Disc stimulation is often accused of having not clinical
utility because it does not influence management. This
accusation is false because it is based on a limited inter-
pretation of clinical utility. Disc stimulation provides
information and virtually by definition that information influ-
ences management. That information may not lead to a
cure for the patient but influence management it does.
Discstimulationhasintrinsicdiagnosticutility.Itestablishes
that the patient has a genuine, detectable reason for their
pain. This allays the distress of not knowing and protects
patients from false accusations and from the continued
pursuit of a diagnosis. It brings about closure. Thereafter,
having a diagnosis protects patients from the futile pursuit
of inappropriate treatment that has no chance of relieving
discogenic pain; or it may open up the possibility of appro-
priate treatment. That treatment may be of a conventional
nature, such as arthrodesis, or it may be a recent innova-
tion.None of these benefits arise if the patient has not been
tested and the diagnosis remains unknown.


My thoughts are this: If we do an SIJ and an MBB without relief, we can assume it is discogenic pain or the patient is malingering, though other non-spinal diagnoses can be present they are unlikely or are worked up if hisotry or imaging dictates. So you are left with a painful disc....Is surgery the answer? A hundred days of ABX? GRC? I do not think that knowing by testing alters management at all for this situation. I agree there is a narrow role for discography that includes patient consented for surgery and we want to include or exclude a single level from a single or two level fusion. If surgery is going to happen then we may have a role in helping ensure increased success. But the literature on that is not promising. If 3 levels are going to be fused the success rates for pain are approaching zero.

Evidence? Medscape review of surgery after discogram:​

Lumbar surgery
Derby et al completed a multicenter retrospective study of long-term surgical and nonsurgical outcomes after lumbar discography in 96 patients.[9] After positive lumbar discogram, patients underwent interbody fusion alone, combined fusion, intertransverse fusion, or no surgery. Those who underwent interbody/combined fusion had significantly better outcomes than those who underwent intertransverse fusion. Nonsurgical patients had the worst outcomes overall.

Parker et al prospectively studied 23 patients treated by a single surgeon.[10] All underwent preoperative discography and were monitored for an average of 4 years postoperatively. Thirty-nine percent had a good-to-excellent result, 13% a fair result, and 48% a poor result.

Smith et al did a study of 25 patients who had a positive discogram of disk L4-5 or L5-S1; the analysis was retrospective, with mean follow-up of 5 years.[11] Sixty-eight percent had improved, 8% were the same, and 24% had worsened. Outcome was not correlated with disk level, gender, or smoking history. Patients who had improved had a shorter history of low back pain and an older age of onset (45 y vs 33 y). Of patients who had worsened, 67% had psychiatric disease. Eighty percent of those receiving workers compensation had improved.

Knox and Chapman performed a study in which 22 patients undergoing anterior lumbar interbody fusion for discogram-concordant lower back pain were evaluated retrospectively.[12] Results were poor in all 2-level fusions. In single-level fusions, 35% had good, 18% fair, and 47% poor results.

Wetzel et al did a retrospective review of 48 patients with low back pain who had discogram/CT then lumbar arthrodesis.[13] Forty-six percent were judged to have satisfactory clinical outcome at final follow-up.

 

[101N]

Not arguing that there is no roll for discography, just a much more limited one than Charlie, Rick, and you all seem to think.

Why are you unwilling to share your numbers? As I've said, I perform discography - both cervical and lumbar - and I've done about 10 in the last two years in a town that had the highest spine surgery rate - per capita - in the US in 2010. It's not that I don't enjoy doing them, like you I do. I'm really fast too and they are fun. But they just don't seem to add any useful information except in very limited cases.

Interestingly enough, I think my town still has the highest rate of spine surgery in the US, in spite of a low rate of discography. The insurers around here have gotten savvy and are starting to limit both discography and fusion for anything but spondylolisthesis. I'm pretty sure everyone reading this is now wondering what is going on in Metairie, LA. I know I am.

This is a discussion of variation in the rate of a procedure, not the utility of the procedure. We don't have variation scatter graphs of the procedures we do and pain doctors are very, very reluctant for that information to be made public. But it should be. I'm pretty sure that folks who trained with Charlie and Rick are 'believers' who perform way more discography that the rest of us. Kinda like adhesiolysis and folks who trained with Racz. (1)

1. Hoffman’s Glasses: Evidence-Based Medicine and the Search for Quality in the Literature of Interventional Pain Medicine. Regional Anesthesia and Pain Medicine, Vol 28, No 6, 547-560.

 

[emd123]

Discos?

Trends in medicine change over time. You were right if you did MILD in 2012, in 2014 you're wrong.

You were wrong if you were a big opiate guy in 1976, right in 1986, and wrong again in 2013.

Hyperventilation was standard for brain injury in 1976, and harmful in 1996.

There's hundred of examples of this in Medicine.

Considering how poor the evidence is in Pain, on most everything, to argue too strongly about much of anything is theoretical, or at best could have an expiration date attached.

FWIW, hardly anyone does discos in my area, and the surgeons sure are not shy about fusing. I think I've done one in the past year, not that that should mean anything to anyone.

It's definitely "safest" to follow trends and stay with the heard in Medicine. but that doesn't always mean the heard or "the trend" is right (see today's epic opiate debacle, courtesy of the past heard mentality following "the trend.")

So what does that mean about discos?

I don't know, but what certain people may stake their life on today, may lead to the same people changing their tune tomorrow.

 

[101N]

More on suboxone, this time from the Washington Post: http://www.washingtonpost.com/blogs...in-heroin-addiction-so-why-isnt-it-used-more/

 

[Ducttape]

an explanation (imho, not that enlightened, but one nevertheless), why maintenance bup or methadone is not heroin, from that article:

HP: Many people would say that maintenance therapies such as buprenorphine or methadone simply substitute one addiction for another. Why is that beneficial for that person or for the society?

PF: This gets to the definition of the term “addiction.” One might claim that you're substituting one addiction from another, but you're not. Maintenance therapy doesn't have the same compulsive quality. It's not as re-enforcing as short-acting opiate such as heroin. By occupying the receptor with a long-acting agent, we reduce many of the most concerning and harmful compulsive behaviors that go with opiate addiction.

 

[ampaphb]

http://www.salon.com/2013/12/22/the_new_york_times_is_dead_wrong_about_drug_addiction/