Work-disabling back pain in working aged adults.

101N · Dec 2, 2015

lobelsteve · Dec 3, 2015

Garbage in, nonsense out.

Is it burnout?
Is it wine?
Disconnected articles from 1995 to 2013 and a statement of your predetermined melancholia in the field. Just go back to inpatient.

drusso · Dec 3, 2015

See attached. Welcome to the Moo-Shu Circus..."It's all in your head."

"The fundamental reason why I pursue the diagnosis of discogenic pain is that patients have no other valid alternative. Patients with chronic back pain get caught in a circus. They are told that there is nothing wrong with them medically; or they are told something fallacious such as: they once did have nociception; but that has now ceased; and now they have only a “memory” of that pain. Under those conditions, medical treatment will not help; and the only prospect of treatment is behavioural and physical rehabilitation. But that treatment does not work. The patients still have pain. Yet again they are told that there is nothing wrong. They failed rehabilitation, and the only recourse is to repeat it."

Pain Med. 2013 Jun;14(6):813-36. doi: 10.1111/pme.12082. Epub 2013 Apr 8.
Lumbar discogenic pain: state-of-the-art review.
Bogduk N1, Aprill C, Derby R.
Author information

Abstract
OBJECTIVE:
To test the null hypotheses that: lumbar intervertebral discs cannot be a source of pain; discs are not a source of pain; painful lumbar discs cannot be diagnosed; and there is no pathology that causes discogenic pain.

METHODS:
Philosophical essay and discourse with reference to the literature.

RESULTS:
Anatomic and physiologic evidence denies the proposition that disc cannot be a source of pain. In patients with back pain, discs can be source of pain. No studies have refuted the ability of disc stimulation to diagnose discogenic pain. Studies warn only that disc stimulation may have a false-positive rate of 10% or less. Internal disc disruption is the leading cause of discogenic pain. Discogenic pain correlates with altered morphology on computerized tomography scan, with changes on magnetic resonance imaging, and with internal biophysical features of the disc. The morphological and biophysical features of discogenic pain have been produced in biomechanics studies and in laboratory animals.

CONCLUSIONS:
All of the null hypotheses that have been raised against the concept of discogenic pain and its diagnosis have each been refuted by one or more studies. Although studies have raised concerns, none has sustained any null hypothesis. Discogenic pain can occur and can be diagnosed if strict operational criteria are used to reduce the likelihood of false-positive results.

101N · Dec 3, 2015

"The fundamental reason why I pursue the diagnosis of discogenic pain is $.

SSdoc33 · Dec 3, 2015

101N said:
"The fundamental reason why I pursue the diagnosis of discogenic pain is $.

lets call a spade a spade: you are railing against provocation discography. fine. agreed. most on this board arent discography fans.

i dont make crap if i think the patient has discogenic pain. wrong again, 101. cant speak for nic, though

lobelsteve · Dec 3, 2015

101N said:
"The fundamental reason why I pursue the diagnosis of discogenic pain is $.

My treatment is PT/HEP, TENS, no MBB/ESI/disco. Would consider GRC/RF. No surgery. Would allow opiates for FTE.

ampaphb · Dec 3, 2015

Paul can't seem to make the distinction between low back pain of unknown etiology, non-specific low back pain (where no effort has been made to identify a pain generator), and discogenic low back pain.

He then goes on to insult the intelligence of the members of this board by tossing in one 10 year old Eugene Carragee study to somehow discredit discography's ability to identify the disc as a potential pain generator.

I realize 101N thinks he is the smartest guy in the room, but when he has to resort to BS articles written by clearly biased authors as his authority to bolster his argument, he appears to have reached a new low in deception, disingenuousness, and dishonesty.

SSdoc33 · Dec 3, 2015

ampaphb said:
he appears to have reached a new low in deception, disingenuousness, and dishonesty.

thats not fair...... im sure he can sink lower

drusso · Dec 3, 2015

ampaphb said:
I realize 101N thinks he is the smartest guy in the room...

Wait...I thought that *I* was the smartest guy in the room....

ampaphb · Dec 3, 2015

drusso said:
Wait...I thought that *I* was the smartest guy in the room....

Nice to know that when I fire stupid little inane shots across the bow, at least one person actually reads them

drusso · Dec 3, 2015

Maybe everyone needs to attend the SIS Evidence Based Spine Intervention Society Workshop next month and brush up on their science...it could probably settle these debates once and for all. I think that the 9:50AM on Sunday January 17th "Why the literature lies to you" is being given by Roger Chou.

The Evidence-Based Spine Interventions Seminar is only 6 weeks away! This Seminar offers sessions presented exclusively by the Spine Intervention Society’s Board of Directors, many of whom have been instrumental in pioneering the procedures and building the evidence base. The agenda, created by top interventionalists, offers sessions designed to educate our attendees about the latest developments in techniques, advocacy, emerging technology, and more.

Evidence-Based Spine Interventions Seminar AGENDA

Friday, January 15
5:00-6:30 pm Registration Opens
5:30-6:30 pm Poster Presentations
5:30-6:30 pm Networking Reception

Saturday, January 16
7:00 am Registration and Continental Breakfast
8:00 Introductory Comments

8:10 Diagnosis of Spinal Pain
8:10 Value of History and Physical Exam
8:25 Limitations of Imaging
8:45 Philosophy of Diagnostic Blocks and Provocation Testing
10:15 Discussion
10:30 Networking Break
11:00 Provocation Techniques
11:00 Lumbar Disc Stimulation: The Pathophysiology and Diagnosis of Discogenic Pain
11:40 Lumbar Disc Stimulation: Technique, Yield, Utility
12:00 pm Discussion
12:15 Lunch
1:30 Advocacy
2:15 Discussion
2:30 Networking Break
2:45 Therapeutic Procedures - Radiofrequency Neurotomy
2:45 Principles
3:00 Cervical RF – Indications, Technique, Success Rate
3:30 Lumbar RF – Indications, Technique, Success Rate
4:00 Discussion
4:15 Complications Part 1 - Abnormal Flow Patterns and Case Reports
5:15 Discussion
5:30 Adjourn for the Day

Sunday, January 17
7:30 am Continental Breakfast
8:00 Complications Part 2 - Risk Mitigation Techniques
8:30 Discussion
8:40 Emerging Technology
8:40 Neurostimulation - Principles, Basic Science, Current Status
9:25 Discussion
9:35 Evidence-Based Medicine
9:35 How Proper Utilization, Technique, and Research Improve the Spine Care Field
9:50 Why the Literature Lies to You
10:20 Outcomes Measurement - Why It's Essential, How to Do It
10:50 Discussion
11:00 Networking Break
11:15 Therapeutic Procedures - Lumbar Transforaminal Injection
11:15 Definition of Radicular Pain & Indications for Transforaminal Injection
11:25 Imaging Diagnosis of Lesions Causing Radicular Pain, Lumbar Transforaminal Technique / Flow Patterns
11:50 Efficacy and Effectiveness Literature for Lumbar Transforaminal Injections
12:15 pm Discussion
12:30 Conference Adjourns

Book your hotel now, before rates go up Dec. 24!

PainDrain · Dec 3, 2015

For me "discogenic pain" is the patient with a small annular tear who complains of intense back pain that is exacerbated by coughing, car rides, valsalva etc. I have seen these people improve markedly with biaculoplasty/IDET but this is never covered. I typically treat with PT/HEP, lifestyle modification (smoking, weight loss), NSAIDS and muscle relaxants (in extreme cases). I encouraged them that it will get better with time. Most simply choose the quick fix of spinal fusion and in my area (with the absolutely incompetent surgeons) they come back with chronic pain. It's a really fulfilling job.

Dr. Ice · Dec 4, 2015

What about the patient with a small annular tear and radicular pain without actual mechanical compression? Is it a chemical radiculitis? Or is it plausible to be atypical sij pain or "piriformis" syndrome?

drusso · Dec 4, 2015

Dr. Ice said:
What about the patient with a small annular tear and radicular pain without actual mechanical compression? Is it a chemical radiculitis? Or is it plausible to be atypical sij pain or "piriformis" syndrome?

Don't you get it? Patients with discogenic low back pain are either a) Crazy or b) lying. Those are your only choices...

My approach to managing discogenic low back pain is to remember your A, B, C's...

A. Accuse the patient of being crazy or lying
B. Blame the patient for their predicament
C. Condemn the patient to Moo-Shu complementary and alternative treatments or useless psychological treatments.

This approach works particularly well if you're a System's Lackey or just fancy yourself an enlightened population-based health practitioner....

ampaphb · Dec 4, 2015

drusso said:
Don't you get it? Patients with discogenic low back pain are either a) Crazy or b) lying. Those are your only choices

c) crazy and lying. That way, Paul can charge twice as much, while still feeling morally superior and smug.

101N · Dec 4, 2015

SIS membership

Thank you guys for the suggestion

Ducttape · Dec 5, 2015

So drusso, assuming your last post was in jest, what dxactly are you doing for these patients?

I am in line with lobel, being conservative, though i might try a diagnostic MBB, but what treatment are you offering that is better than your self-professed psychology mumbo jumbo? Opioids?

If its IDET, great for your patients, but that isnt covered in what 90% of the US...

drusso · Dec 5, 2015

Ducttape said:
So drusso, assuming your last post was in jest, what exactly are you doing for these patients?

I am in line with lobel, being conservative, though i might try a diagnostic MBB, but what treatment are you offering that is better than your self-professed psychology mumbo jumbo? Opioids?

If its IDET, great for your patients, but that isnt covered in what 90% of the US...

I do what you do...but I work from the assumption that the sinovertebral nerve is a real anatomical structure capable of transducing chemical signals into electrical signals and transmitting those signals to the spinal cord, brain, and ultimately conscious awareness. Once you commit to this kind of thinking and not mystical Moo-shu or characterological explanations for pain you become a more useful therapeutic resource to patients.

J Bone Joint Surg Br. 2007 Sep;89(9):1135-9.
The nerve supply of the lumbar intervertebral disc.
Edgar MA1.
Author information

Erratum in

J Bone Joint Surg Br. 2008 Apr;90(4):543.

Abstract
The anatomical studies, basic to our understanding of lumbar spine innervation through the sinu-vertebral nerves, are reviewed. Research in the 1980s suggested that pain sensation was conducted in part via the sympathetic system. These sensory pathways have now been clarified using sophisticated experimental and histochemical techniques confirming a dual pattern. One route enters the adjacent dorsal root segmentally, whereas the other supply is non-segmental ascending through the paravertebral sympathetic chain with re-entry through the thoracolumbar white rami communicantes. Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission. The nature and mechanism of discogenic pain is still speculative but there is growing evidence to support a 'visceral pain' hypothesis, unique in the muscloskeletal system. This mechanism is open to 'peripheral sensitisation' and possibly 'central sensitisation' as a potential cause of chronic back pain.

101N · Dec 5, 2015

Discogenic pain is a great business model for IPM's lunatic fringe, i.e., those who perform discography and other intradical nonsense, Nick & his SIS cronies/groupies who perpetuate the pseudo-illness & sell classes and books to try to legitimize their lucrative pseudo-illness industry, surgeons who - like IPM hucksters - are paid believers, workers comp/personal injury attorneys, disability attorneys, and pt's with an opioid/settlement/disability agenda.

Note: I'm specifically referring to work-disabling LBP, in working-aged adults with normal - age-appropriate - spinal anatomy. LBP in the elderly is another story.

ampaphb · Dec 5, 2015

So is a grade 5 posterior radial anular fissure, which allows contrast to extend into the epidural space, and causes concordant pain at less than 50 psi over opening pressure "pseudo-illness" if it occurs in a working aged adult with pending personal injury litigation or an open workers' compensation claim? Is it "age-appropriate spinal anatomy"?

Do I qualify as one of "Nik's groupies" &/or "an IPM huckster"? Am I part of the "IPM lunatic fringe" for having the audacity to ask, thus challenging the nihilistic dogma the great and powerful, omniscient and omnipotent 101N espouses?

101N · Dec 5, 2015

Seeing what you look for, and looking for what you know:$

"It is interesting that provocative discography findings had no predictive value in this study. Even subjects with painful disc injections, confirmed anular disruptions and concordant pain responses were not found to have increased adverse outcomes by any of the measures."

drusso · Dec 5, 2015

101N said:
Discogenic pain is a great business model for IPM's lunatic fringe, i.e., those who perform discography and other intradical nonsense, Nick & his SIS cronies/groupies who perpetuate the pseudo-illness & sell classes and books to try to legitimize their lucrative pseudo-illness industry, surgeons who - like IPM hucksters - are paid believers, workers comp/personal injury attorneys, disability attorneys, and pt's with an opioid/settlement/disability agenda.

Note: I'm specifically referring to work-disabling LBP, in working-aged adults with normal - age-appropriate - spinal anatomy. LBP in the elderly is another story.

ampaphb · Dec 5, 2015

101N said:
Seeing what you look for, and looking for what you know:$

"It is interesting that provocative discography findings had no predictive value in this study. Even subjects with painful disc injections, confirmed anular disruptions and concordant pain responses were not found to have increased adverse outcomes by any of the measures."

Wait, Gene Carragee says discography doesn't work? I'm shocked!

ampaphb · Dec 6, 2015

The above represents 101N at his deceptive best. His initial argument was discogenic pain does not exist, and anyone who says it does is (insert your favorite disparaging term here).

When asked to defend his position, he instead changes the argument altogether. In this instance, his new position seems to be OK, so maybe discogenic pain does exist, but even if it does, it has no predictive value.

Of course, predictive value OF WHAT you might ask. The study discusses the predictive value of future episodes of low back pain. But since discography is only appropriately used as a pre-surgucal staging technique, its value is to predict which morphologically abnormal discs on imaging should be included in the surgical construct.

The problem in arguing with someone like this is, he won't stick to one topic.

So why bother? 1) cause to leave his BS unchallenged would be seen by some as a tacit acceptance of his nihilistic drivel. 2) cause in some wackadoo circles, he is seen as an expert, deserving of respect (I personally think they must have sustained a TBI in the past, but hey, what do I know), and 3) this site is frequented by impressionable residents and fellows. I would hate for them to unwittingly take 101N's fringe positions as in anyway reasonable or mainstream.

Stim4me · Dec 6, 2015

For years I believed my axial lbp was facetogenic in nature. After a major flare and an MRI I realized it was primarily discogenic in nature (mild ddd, HIZ, small central HNP, no Radic, clean facets) .The treatment is the same, life style modifications, core strengthening, and occasional NSAIDs.

101N · Dec 6, 2015

I don't question your back pain, or my own for that matter. But you and I are not work-disabled.

Stim4me · Dec 6, 2015

101N said:
I don't question your back pain, or my own for that matter. But you and I are not work-disabled.

Because we like our jobs, which is the most important predictor of returning to work...

ampaphb · Dec 6, 2015

Stim4me said:
Because we like our jobs, which is the most important predictor of returning to work...

While that makes the comp population more difficult to care for, what it doesn't mean is that no comp patient has sustainaned a legitimate injury, nor that such injuries should not be addressed.

ampaphb · Dec 6, 2015

Paul: Suggesting that CRPS, migraine headaches, prostatitis, endometriosis, and dysmenorrhea are all diseases best treated by psychiatry is ludicrous.

drusso · Dec 6, 2015

ampaphb said:
While that makes the comp population more difficult to care for, what it doesn't mean is that no comp patient has sustainaned a legitimate injury, nor that such injuries should not be addressed.

Ampaphb, you must stop abusing yourself with the idea the pain of spinal origin is a bonafide medical problem. It is not. In fact, if spinal pain were to become "de-medicalized" (as argued vociferously in the editorial pages of such esteemed publication as "The Back Letter") http://journals.lww.com/backletter/pages/default.aspx then everything just gets easier...no need to diagnose or spend money on illusory illness.

The first step to de-medicalization is to deny that there is any biological plausibility to a phenomenon. This means that there can be NO biologically based test to diagnose it. Once it ceases to be a biological problem then you simply use shame and stigma to keep people from accessing care or shuttle them off to various cheaper practitioners for Moo-Shu treatments. Since no one expects Moo-Shu treatments to work on real biological problems any, it makes sense that they might work on illusory problems such as discogenic low back pain. Viola!

101N · Dec 6, 2015

Acknowledging the squealing that accompanies the goring ASIPP & SIS's oxen

epidural man · Dec 9, 2015

Stim4me said:
Because we like our jobs, which is the most important predictor of returning to work...

I'm not sure this is true....

I think getting paid NOT to work - regardless of what you where doing - probably does a number on the mind. I suspect if we all got paid an amount that was close to what you got paid while you where working - and it was money paid NOT to work - we may have a hard time returning. Some of us will - yes, but many of us wouldn't.

I hope many of you love your job and would do it for free. That is freakin' awesome if that is true. I like my job. I like what I do. Most jobs I think I would enjoy more involve fantasy (rock star for example) - so I am lucky.

But there isn't a single day at work that I would rather be doing that then playing tennis, or playing craps at a casino, or scalping the market selling vertical spreads and iron condors, or sitting in bed with my wife watching "Curb your Enthusiasm", or rebounding balls for my teenage son giving him pointers.....not a single day....not a single minute. Now PAY ME MONEY to do all that stuff? Sheesh...hard to get better when that happens.

By the way, I have enjoyed this discussion. I think both sides are probably being too simplistic as you all know. Sure some people have pure discogenic pain. Sure some people have non-specific back pain with no real pathology who peg all the screening tools (PHQ-9, ODI, etc). I think most would agree that finding out the "truth" is extremely difficult - even in the best of hands and brightest minds.

Stim4me · Dec 9, 2015

epidural man said:
I'm not sure this is true....

I think getting paid NOT to work - regardless of what you where doing - probably does a number on the mind. I suspect if we all got paid an amount that was close to what you got paid while you where working - and it was money paid NOT to work - we may have a hard time returning. Some of us will - yes, but many of us wouldn't.

I hope many of you love your job and would do it for free. That is freakin' awesome if that is true. I like my job. I like what I do. Most jobs I think I would enjoy more involve fantasy (rock star for example) - so I am lucky.

But there isn't a single day at work that I would rather be doing that then playing tennis, or playing craps at a casino, or scalping the market selling vertical spreads and iron condors, or sitting in bed with my wife watching "Curb your Enthusiasm", or rebounding balls for my teenage son giving him pointers.....not a single day....not a single minute. Now PAY ME MONEY to do all that stuff? Sheesh...hard to get better when that happens.

By the way, I have enjoyed this discussion. I think both sides are probably being too simplistic as you all know. Sure some people have pure discogenic pain. Sure some people have non-specific back pain with no real pathology who peg all the screening tools (PHQ-9, ODI, etc). I think most would agree that finding out the "truth" is extremely difficult - even in the best of hands and brightest minds.

Epidural man you are on the other end of the spectrum... You work very hard and need some ME time.

As for purely WC patients that are injured/disabled, job satisfaction is a critical predictor for return to work status... My guess is that most of our wc patients do not love their jobs and tend to extend their treatment time, sometimes permanently...

epidural man · Dec 10, 2015

Stim4me said:
Epidural man you are on the other end of the spectrum... You work very hard and need some ME time.

As for purely WC patients that are injured/disabled, job satisfaction is a critical predictor for return to work status... My guess is that most of our wc patients do not love their jobs and tend to extend their treatment time, sometimes permanently...

I concede your point - and I see it a lot too - people hate their job - so are looking to me for a way out.

Ducttape · Dec 10, 2015

I love my job.

Or maybe i just love getting out of the house and not have to deal with the trauma of kids and wife... Id go insane if not working...

melancholy · Dec 11, 2015

Stim4me said:
For years I believed my axial lbp was facetogenic in nature. After a major flare and an MRI I realized it was primarily discogenic in nature (mild ddd, HIZ, small central HNP, no Radic, clean facets) .The treatment is the same, life style modifications, core strengthening, and occasional NSAIDs.

did you try some MBB's on yourself with local?

Stim4me · Dec 11, 2015

melancholy said:
did you try some MBB's on yourself with local?

Naproxen 200mg prn is all I needs every now and then. I almost tried neurontin for a cervicogenic headache that lasted 3 months a few year ago...an occipital block knocked it out

ampaphb · Dec 12, 2015

Yes, but did you do your own injections?

Stim4me · Dec 12, 2015

ampaphb said:
Yes, but did you do your own injections?

No way, I'm a whimp....sh@$ I hate getting my influenza and ppd shots

Work-disabling back pain in working aged adults.

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