"Martha, your chronic low back pain is real after all..."

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drusso

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It's not just psychological: It's embarrassing that doctors ever believed anything different.

http://www.ncbi.nlm.nih.gov/pubmed/26431880

J Pain. 2015 Sep 29. pii: S1526-5900(15)00881-0. doi: 10.1016/j.jpain.2015.08.012. [Epub ahead of print]
Smaller amygdala volumes in patients with chronic low back pain as compared to healthy control subjects.
Mao CP1, Yang HJ2.
Author information

Abstract
Although preclinical and clinical data strongly support an association between amygdala and chronic pain by the presence of mood and cognitive disturbances in affected individuals, little attention has been paid to morphometric measurement of the structure in patients with chronic low back pain (CLBP). In the present study, MR volumetric and surface analysis, using FMRIB's integrated registration and segmentation tool (FIRST), were performed to compare structural MR imaging data obtained from 33 patients with CLBP to those obtained from 33 demographically similar healthy controls. Our results indicated that the normalized volumes of the left and right amygdala were significantly smaller in the CLBP group than in the control group. Detailed surface analyses further localized these differences. The degree of volume reduction was different between the left and right amygdala, with a greater involvement of the left one. Both groups exhibited similar significant hemispheric asymmetry for the amygdala (left greater than right). Similar asymmetry were suggested in the subgroup of 24 un-medicated patients. No significant correlations were found between amygdala volumes and pain characteristics and/or depressive symptoms. Our study provides in vivo imaging evidence of abnormal morphology of the amygdala in patients with CLBP using a fully automated segmentation method.

PERSPECTIVE:
Our study found that patients with CLBP had statistically significantly smaller normalized volumes of the bilateral amygdala, as compared with the healthy controls, with a greater involvement of the left side. These results may help to characterize the impaired affective-cognitive dimension in patients with chronic pain.

Copyright © 2015 American Pain Society. Published by Elsevier Inc. All rights reserved.

KEYWORDS:
FSL-FIRST; amygdala; chronic low back pain; morphology

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i dont understand your conclusion. isnt the amygdala part of the limbic system, responsible for emotional response?

does this article not suggest that there is a problem with a patient's emotional response to chronic pain? doesnt that imply that psychology either contributes or is affected by chronic pain?

I take this article to state that, if CLBP were not psychological in part or as a result, then the amygdala would not change at all in size...
 
Central does on equal psychological.
 
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i dont understand your conclusion. isnt the amygdala part of the limbic system, responsible for emotional response?

does this article not suggest that there is a problem with a patient's emotional response to chronic pain? doesnt that imply that psychology either contributes or is affected by chronic pain?

I take this article to state that, if CLBP were not psychological in part or as a result, then the amygdala would not change at all in size...

Well, I guess that's why people with strokes to their amygdala get better with psychotherapy and there is no data for psychotherapy fixing chronic pain...
 
Ironically, cannabis use shrinks the amygdala in a similar way as does the lived experience of chronic pain. But misguided policymakers wrongly believe that by increasing access to cannabis they are really "keeping people safe." Evidence-based pain specialists should never promote cannabis as a "safe" treatment for chronic, non-malignant pain.

Dev Cogn Neurosci. 2015 Aug 28. pii: S1878-9293(15)00085-7. doi: 10.1016/j.dcn.2015.08.007. [Epub ahead of print]
Cannabis use in early adolescence: Evidence of amygdala hypersensitivity to signals of threat.
Spechler PA1, Orr CA2, Chaarani B3, Kan KJ3, Mackey S3, Morton A3, Snowe MP3, Hudson KE3, Althoff RR3, Higgins ST3, Cattrell A4, Flor H5, Nees F6,Banaschewski T5, Bokde AL6, Whelan R6, Büchel C7, Bromberg U8, Conrod P9, Frouin V10, Papadopoulos D11, Gallinat J11, Heinz A12, Walter H13, Ittermann B13, Gowland P14, Paus T15, Poustka L6, Martinot JL16, Artiges E15, Smolka MN17, Schumann G4, Garavan H3; IMAGEN Consortium.
Author information

Abstract
Cannabis use in adolescence may be characterized by differences in the neural basis of affective processing. In this study, we used an fMRI affective face processing task to compare a large group (n=70) of 14-year olds with a history of cannabis use to a group (n=70) of never-using controls matched on numerous characteristics including IQ, SES, alcohol and cigarette use. The task contained short movies displaying angry and neutral faces. Results indicated that cannabis users had greater reactivity in the bilateral amygdalae to angry faces than neutral faces, an effect that was not observed in their abstinent peers. In contrast, activity levels in the cannabis users in cortical areas including the right temporal-parietal junction and bilateral dorsolateral prefrontal cortex did not discriminate between the two face conditions, but did differ in controls. Results did not change after excluding subjects with any psychiatric symptomology. Given the high density of cannabinoid receptors in the amygdala, our findings suggestcannabis use in early adolescence is associated with hypersensitivity to signals of threat. Hypersensitivity to negative affect in adolescence may place the subject at-risk for mood disorders in adulthood.

Copyright © 2015. Published by Elsevier Ltd.

Br J Psychiatry. 2015 Jan;206(1):77-8. doi: 10.1192/bjp.bp.114.151407. Epub 2014 Nov 27.
Gross morphological brain changes with chronic, heavy cannabis use.
Lorenzetti V1, Solowij N1, Whittle S1, Fornito A1, Lubman DI1, Pantelis C1, Yücel M1.
Author information

Abstract
We investigated the morphology of multiple brain regions in a rare sample of 15 very heavy cannabis users with minimal psychiatric comorbidity or significant exposure to other substances (compared with 15 age- and IQ-matched non-cannabis-using controls) using manual techniques. Heavy cannabis users demonstrated smaller hippocampus and amygdala volumes, but no alterations of the orbitofrontal and anterior- and paracingulate cortices, or the pituitary gland. These findings indicate that chronic cannabis use has a selective and detrimental impact on the morphology of the mediotemporal lobe.

J Neurosci. 2014 Apr 16;34(16):5529-38. doi: 10.1523/JNEUROSCI.4745-13.2014.
Cannabis use is quantitatively associated with nucleus accumbens and amygdala abnormalities in young adult recreational users.
Gilman JM1, Kuster JK, Lee S, Lee MJ, Kim BW, Makris N, van der Kouwe A, Blood AJ, Breiter HC.

Marijuana is the most commonly used illicit drug in the United States, but little is known about its effects on the human brain, particularly on reward/aversion regions implicated in addiction, such as the nucleus accumbens and amygdala. Animal studies show structural changes in brain regions such as the nucleus accumbens after exposure to Δ9-tetrahydrocannabinol, but less is known about cannabis use and brain morphometry in these regions in humans. We collected high-resolution MRI scans on young adult recreational marijuana users and nonusing controls and conducted three independent analyses of morphometry in these structures: (1) gray matter density using voxel-based morphometry, (2) volume (total brain and regional volumes), and (3) shape (surface morphometry). Gray matter density analyses revealed greater gray matter density in marijuana users than in control participants in the left nucleus accumbens extending to subcallosal cortex, hypothalamus, sublenticular extended amygdala, and leftamygdala, even after controlling for age, sex, alcohol use, and cigarette smoking. Trend-level effects were observed for a volume increase in the left nucleus accumbens only. Significant shape differences were detected in the left nucleus accumbens and right amygdala. The left nucleus accumbens showed salient exposure-dependent alterations across all three measures and an altered multimodal relationship across measures in the marijuana group. These data suggest that marijuana exposure, even in young recreational users, is associated with exposure-dependent alterations of the neural matrix of core reward structures and is consistent with animal studies of changes in dendritic arborization.
 
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As much as we try to separate central from psychological, and psychological from "brain matter" and brain/psychological from peripheral/physical, ultimately and unfortunately, they're all inexorably intertwined. This is why are jobs are so hard, and why a multimodal approach is needed to treat our patients.
 
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"Disk degeneration, anular fissures, small protrusions, and facet arthritis are commonly found in individuals with little or no back pain. Furthermore, many studies have shown that serious disability in this group is associated with abnormal psychological profiles, multiple chronic pain processes, and compensation issues.Conversely,longitudinal studies have found that the severity of chronic pain illness in this group appears to correlate much less well with presence or extent of degenerative findings than with these psychosocial or generalized neurophysiological comorbid conditions. (1-5) Not surprisingly, the surgical treatment of this poorly defined discogenic pain illness has been somewhat disappointing."

Carragee, E. JAMA November 22/29, 2006-Vol 296, no 20 pp 2485

1. Spine (Phila Pa 1976). 2006 Dec 1;31(25):2942-9. Does minor trauma cause serious low back illness?
Carragee E1, Alamin T, Cheng I, Franklin T, Hurwitz E.

2. Spine (Phila Pa 1976). 2005 Jul 1;30(13):1541-8; discussion 1549. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Jarvik JG1, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA.

3. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:E109-20.

4. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010;303:1295-302.

5. Spine (Phila Pa 1976). 2007 Jan 15;32(2):269-74. Emotional distress as a predictor for low back disability: a prospective 12-year population-based study. Brage S1, Sandanger I, Nygård JF.

6. J Womens Health (Larchmt). 2015 Aug;24(8):629-35. doi: 10.1089/jwh.2015.5222. Epub 2015 Jul 8. Sex and Age Differences in Global Pain Status Among Patients Using Opioids Long Term for Chronic Noncancer Pain.
 
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"Disk degeneration, anular fissures, small protrusions, and facet arthritis are commonly found in individuals with little or no back pain. Furthermore, many studies have shown that serious disability in this group is associated with abnormal psychological profiles, multiple chronic pain processes, and compensation issues.Conversely,longitudinal studies have found that the severity of chronic pain illness in this group appears to correlate much less well with presence or extent of degenerative findings than with these psychosocial or generalized neurophysiological comorbid conditions. (1-5) Not surprisingly, the surgical treatment of this poorly defined discogenic pain illness has been somewhat disappointing."

Carragee, E. JAMA November 22/29, 2006-Vol 296, no 20 pp 2485

1. Spine (Phila Pa 1976). 2006 Dec 1;31(25):2942-9. Does minor trauma cause serious low back illness?
Carragee E1, Alamin T, Cheng I, Franklin T, Hurwitz E.

2. Spine (Phila Pa 1976). 2005 Jul 1;30(13):1541-8; discussion 1549. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Jarvik JG1, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA.

3. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:E109-20.

4. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010;303:1295-302.

5. Spine (Phila Pa 1976). 2007 Jan 15;32(2):269-74. Emotional distress as a predictor for low back disability: a prospective 12-year population-based study. Brage S1, Sandanger I, Nygård JF.

True: "Disk degeneration, anular fissures, small protrusions, and facet arthritis are commonly found in individuals with little or no back pain."

True: "Many studies have shown that serious disability in this group is associated with abnormal psychological profiles, multiple chronic pain processes, and compensation issues."

Unrelated: "Not surprisingly, the surgical treatment of this poorly defined discogenic pain illness has been somewhat disappointing."

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Raise you hand if you support referring patients with normal spine exams and symptoms of central sensitization syndrome to spine surgeons--especially if their loved ones or caregivers request it?
 

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"Raise you hand if you support referring patients with normal spine exams and symptoms of central sensitization syndrome to spine surgeons--especially if their loved ones or caregivers request it?"

The problem isn't us referring patients with serious psychological issues and complaints of chronic pain to spine surgeons. We see them 6-12 months after the butchers have gotten to them; typically after referral from a PCP for "bulging disc". I practice in a very shady area and three local spine surgeons will fuse anyone, especially workers comp. I had a patient offered fusion for SI joint pain who was about 150lbs overweight, on antidepressant meds, a smoker, type II DM, workers comp and already on chronic narcs. She didn't like it when I told her that if she had fusion she would never work again and be in worse pain with a near 100% fusion failure rate. When will we get real about the failure of spine surgery for typical pathology?
 
There is a huge cohort of ethical spine surgeons that the OP just hasn't been exposed to: Gene Carragee, Sohail Mirza, Jim Weinsten, Hans Bueff, Alf Nachemson, Gordon Waddell, Josef Gorek, Kirk VanPegeghm, Chris Noonan. These guys taught many of us about the spine and they are the standard bearers for conservative spine care. I would send my mom to any of them.

For every story you give about 'unethical spine surgeons' I swear I can give you 5 similar stories about unethical 'pain practitioners' addicting patients, performing unnecessary procedures, putting in pumps, etc.
People who live in glass houses - us - shouldn't be throwing stones.

"The problem" is all of us.
 
I am not letting pain docs off the hook and I agree we bear a huge level of responsibility for our current state. Some in this field who are esteemed vocal "experts" are nothing but drug dealers. We also have a terrible bag of tools to treat true chronic pain. But the fact remains that spinal surgery rates have sky rocketed and it's largely profit driven and the results are mixed at best. We then have very little to offer patients.
 
There is a huge cohort of ethical spine surgeons that the OP just hasn't been exposed to: Gene Carragee, Sohail Mirza, Jim Weinsten, Hans Bueff, Alf Nachemson, Gordon Waddell, Josef Gorek, Kirk VanPegeghm, Chris Noonan. These guys taught many of us about the spine and they are the standard bearers for conservative spine care. I would send my mom to any of them.

For every story you give about 'unethical spine surgeons' I swear I can give you 5 similar stories about unethical 'pain practitioners' addicting patients, performing unnecessary procedures, putting in pumps, etc.
People who live in glass houses - us - shouldn't be throwing stones.

"The problem" is all of us.

waddell's been dead 3 years. and when i inject a FMS patient, they may not get better. but they dont get irreversibly worse.
 
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And Nachemson even longer, so what.

The truth is the VAST MAJORITY FMS'ers don't after surgery either. They go in a catastrophizer and they come out that way.
Scar's and hardware don't hurt and I won't validate the notion that they do. I've sent plenty of normal scoli patients for
huge fusions, 12hr operations, 30L of fluid, and guess what, they do just fine. The 'Look I've got a scar, I'm ruined!" crap
is just that.
 
And Nachemson even longer, so what.

The truth is the VAST MAJORITY FMS'ers don't after surgery either. They go in a catastrophizer and they come out that way.
Scar's and hardware don't hurt and I won't validate the notion that they do. I've sent plenty of normal scoli patients for
huge fusions, 12hr operations, 30L of fluid, and guess what, they do just fine. The 'Look I've got a scar, I'm ruined!" crap
is just that.

so, you are sending your mom to corpses who are unaware of the fusion-for-money greed that exists today. great, they are wonderful conservative spine surgeons. fine.

scars dont hurt. cutting though muscle thats supposed to be attached to bone does. altered biomechanics does. adjacent level disease does.

you are not going to get any argument from anyone that operating on a crazy central-sensitized patient will lead to poor outcomes. however, injecting them will cause much less problems.

you are quickly going from devil's advocate to devil
 
No I'm calling BS on the notion that all spine surgeons are greedy hacks.
 
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