Pain provocation and disc deterioration by age. A CT/discography study in a low-back pain population

The computed tomography (CT)/discograms and discographic pain provocation reports of 291 clinical patients, 790 discs (mean age, 38; range, 17-79) were collected. The CT/discograms were classified separating anular disruption and degeneration and recording the pain provoked during discography as no pain, dissimilar, similar, or exact reproduction of the patient's clinical pain. Nondegenerated discs usually were found to be painless, and deteriorated discs painful. The proportion of severely degenerated but painless discs increased with age, as did the discs producing dissimilar pain. This may help explain the poor correlation of low-back pain with radiographic degenerative changes reported in previous epidemiologic studies.     

Lumbar discography in normal subjects. A controlled, prospective study

Major advances in the techniques of discography since 1968, in conjunction with major strides in the evaluation of pain in recent years, prompted a study in which Holt's work on the specificity of discography was replicated and extended. For the present study, seven patients who had low-back pain and ten volunteers who had been carefully screened, with a questionnaire and a physical examination, to ensure that they had no history of problems with the back, had an injection at three levels, and all sessions were videotaped. After each injection, the participant was interviewed about the pattern and intensity of the pain, and then the discs were imaged with computed tomography. Five raters, who were blind to the condition of the participant, graded each disc as normal or abnormal on the basis of findings on magnetic resonance images that had been made before the injection and computed tomography (discography) were done. There was only one disagreement between the ratings that were made on the basis of the magnetic resonance images and those that were made on the basis of the discograms. Each participant's pain-related response was evaluated independently by two raters who viewed the videotapes of the discography. Inter-rater reliability was 0.99, 0.93, and 0.88 for the evaluation of intensity of the pain, pain-related behavior, and similarity of the pain to pain that the subject had had before the injection. In the asymptomatic individuals, the discogram was interpreted as abnormal for 17 per cent (five) of the thirty discs and for five of the ten subjects.(ABSTRACT TRUNCATED AT 250 WORDS)     

The relationship of pain provocation to lumbar disc deterioration as seen by CT/discography

The CT/discographic findings from 225 discs in 91 low-back pain patients were compared to the pain provocation during the injection of contrast into the disc. The radiographic appearance of disc deterioration demonstrating disc degeneration and annular disruption of each disc was classified separately using a fourpoint scale: normal, slight, moderate, or severe. Pain reaction to the discogram at each level was recorded as follows: no pain, dissimilar pain, similar pain, or exact reproduction of the patient's clinical pain. This more precise analysis demonstrated a significant relationship between pain and deterioration of discs. The CT/discogram presents an axial view of the disc that allows a subgrouping of disc deterioration that can discriminate between peripheral deterioration (degeneration) and internal deterioration (disruption). The disruption supposedly occurs earlier and is more likely to be the source of exact pain reproduction.     

Thoracic discography in healthy individuals. A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals.

STUDY DESIGN: A prospective case-control investigation. OBJECTIVES: To determine the responses to thoracic discography of asymptomatic individuals. SUMMARY OF BACKGROUND DATA: Literature regarding lumbar and cervical discography reveals that even morphologically abnormal discs often are not painful, whereas painful discs typically exhibit anular or endplate disruption. METHODS: Ten adult lifelong asymptomatic volunteers, ages 23 to 45 years, underwent magnetic resonance imaging of the thoracic spine, followed by four-level discography. Provocative responses were graded on a scale of 0 (no sensation) to 10 (extreme pain or pressure), and filmed discs were graded using a modified Dallas scheme. Concomitantly, 10 nonlitigious adults (6 men and 4 women, ages 31 to 55 years) experiencing chronic thoracic pain were similarly studied as a control group. RESULTS: The mean pain response in the asymptomatic volunteers was 2.4/10. Three discs were intensely painful (scores of 7/10, 8/10, 10/10), with all three exhibiting prominent endplate irregularities and anular tears typical of thoracolumbar Scheuermann's disease. On discography, 27 of 40 discs were abnormal, with endplate irregularities, anular tears, and/or herniations. Ten discs read as normal on magnetic resonance imaging showed anular pathology on discography. In the group with chronic thoracic pain, the average pain response was 6.3/10 (P < 0.05). Of the 48 discs studied, 24 were concordantly painful, with a pain response of 8.5/10 (P < 0.05); 17 had nonconcordant pain/pressure, with an average pain of 4.8/10 (P < 0.05); and 5 had no response. On magnetic resonance imaging 21 of the 48 discs appeared normal. However, on discography, only 10 were judged as normal. CONCLUSIONS: On discography, thoracic discs with prominent Schmorl's nodes may be intensely painful, even in lifelong asymptomatic individuals, but the pain is unfamiliar or nonconcordant. Thoracic discography may-demonstrate disc pathology not seen on magnetic resonance imaging.     

Causes of acute deterioration in patients with a ruptured intracranial aneurysm. A prospective study with serial CT scanning

The authors studied the acute neurological deterioration in 150 patients with aneurysmal hemorrhage. These patients were closely observed for a 4-week period or until death or operation. Forty-six patients suffered a total of 62 episodes of deterioration that developed within 5 minutes after aneurysm rupture; 59 of these episodes consisted of severe impairment of consciousness. Computerized tomography (CT) was performed within a few hours of the event. Serial scans were obtained at least weekly after admission. Rebleeding was diagnosed as the cause of 42 episodes (68%), including six patients who died rapidly without a repeat CT scan. The final diagnosis of the cause in other acute episodes was epilepsy (in six), acute onset of ischemia (in three), and ventricular fibrillation (in one). Ten unexplained events occurred in nine patients. Rebleeding could be excluded with confidence in nine of these events, because the residual clots had disappeared or markedly decreased on CT. It is concluded that a purely clinical diagnosis of rebleeding will be incorrect in about every third patient, even if these patients are under close observation.     

A comparison of CT/discography, pain response and radiographic disc height

CT/discograms of 107 low-back patients were classified by annular degeneration, annular disruption, and pain response. These parameters were compared with the heights of the corresponding discs. Disc height correlated significantly with degenerative annular changes. Comparison of the painless and exact reproduction groups at the L5-S1 level showed a significant increase in exact pain reproduction in narrow discs compared with normal discs. Discs demonstrating slight degenerative changes were often painful but narrowing was detected only when degeneration increased to moderate or severe levels. Some severely degenerated discs were painless and only part of the severe group was narrow. Measuring disc height is a poor method for detecting early, painful degeneration changes.     

Clinical relevance of discography combined with CT scanning. A study of 100 patients

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain.     

CT scanning of lumbar discography. A useful diagnostic adjunct

Twenty-two patients with continued, undiagnosed symptoms of low back and sciatic pain for an average of 14 months were assessed. Patients studied had prior negative evaluations, including EMG, CT scanning, and/or metrizamide myelography. Three-level, posterolateral, extradural discography was performed on the side opposite the sciatica. One to 6-hours after discography, CT scanning was performed on all injected discs: 91% demonstrated abnormal discograms at one/more levels. CT imaging demonstrated contrast tracking to the periphery of the disc in 82%. Discography reproduced the patient's symptoms in 77%. The direction of contrast tracking seen on scanning correlated with clinical symptoms in 73% and with symptoms at discography in 82%. CT scanning was thought to be a useful adjunct to lumbar discography in patients with prior negative evaluations.     

A life-long prospective study on the role of psychosocial factors in neck-shoulder and low-back pain.

The predictive value of psychosocial factors in the development of neck--shoulder and low-back symptoms was investigated in a life-long follow-up study of 154 subjects. Measurements taken in adolescence, such as intelligence, alexithymia (low verbal productivity in projective personality tests), social confidence, hobbies, and the socioeconomic status of the family, showed no consistent associations with neck--shoulder or low-back symptoms in adulthood. Of the variables recorded in adulthood, weak mental resources for promoting health (poor sense of coherence) were consistently associated with neck--shoulder pain, whereas low fundamental education predicted low-back symptoms. The results suggest that psychosocial factors in childhood have a minor role as direct predictors of later symptoms.     

Efficacy of low-dose leflunomide in lupus nephritis: A multi-center prospective study

Objective To investigate the efficacy of leflunomide combined with prednisone in the induction therapy of proliferative lupus nephritis (LN). Methods A prospective, multicenter, randomized controlled clinical trial was conducted in patients with biopsy-proved proliferative lupus nephritis recruited from 15 renal centers from 2013 to 2015. Patients were randomized to two groups. Oral leflunomide or intravenous cyclophosphamide was given to patients in each group. Both groups received a tapering course of oral prednisone therapy. All patients were followed up for 24 weeks. The blood biochemistry, urine index, clinical curative effect and adverse reaction were recorded and analyzed statistically. Results A total of 100 patients were enrolled in this clinical trial, including 48 patients in leflunomide group and 52 patients in cyclophosphamide group. After 24 weeks, the overall response rate was 79% (95%CI 67%-90%) in the leflunomide group and 69% (95%CI 56%-82%) in the cyclophosphamide group. 23% (95%CI 11%-35%) of patients in leflunomide group showed complete remission compared with 27% (95%CI 24%-30%) in cyclophosphamide group (P=0.35). The levels of 24-hr urine protein excretion, SLEDAI and anti-dsDNA antibody titers were decreased in patients treated with leflunomide group after 24-weeks treatment. And the levels of serum albumin and complement 3 after treatment were significantly higher compared with these before treatment. There was also no significant difference in changes of 24-hr urine protein excretion, SLEDAI score, anti-dsDNA antibody titers, serum albumin and complement C3 levels after treatment between two groups. Incidence of adverse events did not differ between the leflunomide and cyclophosphamide group. Conclusions Leflunomide combined with prednisone showed same efficacy compared with cyclophosphamide as induction therapy for lupus nephritis. Leflunomide might be an useful medicine in the induction therapy of lupus nephritis.     

Analysis of female voiding dysfunction: a prospective, multi-center study

Purpose

Female voiding dysfunction lacks clear definitions or objective data even to this day due to the relatively low prevalence and complex etiologies of voiding dysfunction in women compared to men. The prevalence varies widely from 2.7 to 23 % (Nitti et al. in J Urol 161(5):1535–1540, 1999; Rees et al. in Br J Urol 47(7):853–860, 1975; Groutz et al. in Neurourol Urodyn 19(3):213–220, 2000; Farrar et al. in Br J Urol 47(7):815–822, 1975; Massey and Abrams in Br J Urol 61(1):36–39, 1988; Chassagne et al. in Urology 51(3):408–411, 1998). Diagnostic criteria and management of female voiding dysfunction have not yet been established. We performed a prospective, multi-center study at nine hospitals to investigate the characteristics and prevalence of female voiding dysfunction.

Materials and methods

A total of 1,415 women visited urology clinics in nine hospitals from September to December 2005. Among them, 792 patients presented with lower urinary tract symptoms (LUTS). We analyzed their urinary symptoms with an International Prostate Symptom Score (IPSS) and obtained objective data using uroflowmetry, residual urine volume, and urinalysis. The authors hereby define female voiding dysfunction as maximum flow rate (Q _max) of 15 ml/s or less, which may be due to either bladder outlet obstruction (BOO) or bladder dysfunction caused by detrusor underactivity. BOO was defined as Q _max <15 ml/s with detrusor pressure >20 cmH₂O at Q _max, and detrusor underactivity was defined as Q _max <15 ml/s with detrusor pressure <20 cmH₂O at Q _max on pressure flow studies.

Results

Hundred and two patients (12.8 %) from a total of 792 LUTS patients complained of voiding difficulty. Mean total IPSS score, mean IPSS subscores for voiding and storage symptom was 19.5 ± 7.9, 12.0 ± 5.0, and 8.4 ± 3.4, respectively. Among the seven categories of IPSS, incomplete emptying was the most common symptom followed by weak stream. Eighty-nine patients (87.2 %) from a total of 102 voiding dysfunction patients showed BOO, while 13 patients (12.8 %) showed detrusor underactivity. Concomitant diseases observed with voiding dysfunctions were overactive bladder (32 patients), stress urinary incontinence (25), detrusor underactivity (13), previous stress urinary incontinence surgery (12), pelvic organ prolapse (4), and anatomical obstruction (3 patients).

Conclusion

The prevalence of voiding difficulty in female urology patients who visit urologic office clinic was 7.2 and 12.8 % in female LUTS patients. Voiding symptoms were more common than storage symptoms, while functional BOO was more prevalent than detrusor underactivity in female voiding difficulty patients. We may expect alpha blockers to be an effective treatment option in female voiding difficulty due to functional BOO.     

Functional restoration with behavioral support. A one-year prospective study of patients with chronic low-back pain

Patients with chronic disabling low-back pain have poor prospects of returning to work. The authors tested a treatment program of functional restoration with behavioral support through 1 year prospective observation of patients disabled for an average of 19 months without evidence of surgically correctable disease. Ninety patients were studied: 59 program graduates, five program dropouts, 17 patients denied program authorization by their insurance carriers, and six crossover patients. Three patients were admitted but refused to participate in the treatment program. Initial demographic, physical, and self-assessment attributes were similar for all four groups. At year's end, 81% of program graduates, 40% of the dropouts, and 29% of those denied the program had returned to work. All six crossover patients were working 6 months after treatment. Program graduates showed significant improvements in self-assessed pain, disability, and depression, and in physical capacities after 3 weeks of treatment. These improvements were maintained through the year except for partial decreases in frequent lifting, cycling endurance, and isokinetic trunk extension strength. Functional restoration with behavioral support is an effective treatment for patients with chronic, disabling low-back pain, as measured by self-assessments, physical capacities, and return to work.     

A multi-center prospective study for antibiotic prophylaxis to prevent perioperative infections in urologic surgery

In order to assess the ability of our protocol for antibiotic prophylaxis to prevent perioperative infections in urologic surgery, 1,353 operations of open and laparoscopic urologic surgery conducted in 21 hospitals between September 2002 and August 2003 were subjected to analyses. We classified surgical procedures into four categories by invasiveness and contamination levels: Category A; clean less invasive surgery, Category B; clean invasive or clean-contaminated surgery, Category C; surgery with urinary tract diversion using the intestine. Prophylactic antibiotics were administrated intravenously according to our protocol, such as Category A; first or second generation cephems or penicillins on the operative day only, Category B; first and second generation cephems or penicillins for 3 days, and Category C; first, second or third generation cephems or penicillins for 4 days. The wound conditions and general conditions were evaluated in terms of the surgical site infection (SSI) as well as remote infection (RI) up to postoperative day (POD) 30. The SSI rate highest (23.3%) for surgery with intestinal urinary diversion, followed by 10.0% for surgery for lower urinary tract, 8.9% for nephroureterctomy, and 6.0% for radical prostatectomy. The SSI rates in clean surgery including open and laparoscopic nephrectomy/adrenalectomy were 0.7 and 1.4%, respectively. In SSIs, gram-positive cocci such as methicillin-resistant Staphylococcus aureus (58.8%) or Enterobacter faecalis (26.5%) were the most common pathogen. Similarly, the RI rate was the highest (35.2%) for surgery using intestinal urinary diversion, followed by 16.7% for surgery for lower urinary tract, 11.4% for nephroureterctomy, and 7.6% for radical prostatectomy, while RI rates for clean surgery were less than 5%. RIs most frequently reported were urinary tract infections (2.6%) where Pseudomonas aeruginosa (20.3%) and Enterobacter faecalis (15.3%) were the major causative microorganisms. Parameters such as age, obesity, nutritional status (low proteinemia), diabetes mellitus, lung disease, duration of operation, and blood loss volume were recognized as risk factors for SSI or RI in several operative procedures. Postoperative body temperatures, peripheral white blood counts, C reactive protein (CRP) levels in POD 3 were much higher than those in POD 2 in cases suffering from perioperative infections, especially suggesting that CRP could be a predictable marker for perioperative infections.     

A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain

The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct in treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication.     

MRI and discography of annular tears and intervertebral disc degeneration. A prospective clinical comparison.

We attempted to correlate the findings of MRI and discography in patients with low back pain, examining 108 lumbar intervertebral discs in 33 consecutive patients. MRI results were assessed from the intensity and shape of the signal obtained from the central part of the disc. Discography was classified according to the pattern of contrast material, the pressure accepted and the pain reproduced. All discs which were abnormal on MRI had altered patterns on discography, but 18 of the 60 discs with normal MRI had abnormal discograms. Of 39 asymptomatic discs, 33 had normal MRI signals and 24 had normal discograms. None of the 15 discs showing severe degeneration on MRI sustained high levels of intradiscal pressure, but only six of the 60 discs giving normal MRI had low pressure. With current techniques, discography is more accurate than MRI for the detection of annular pathology: a normal MRI does not exclude significant changes in the peripheral structure of the intervertebral disc which can produce low back pain.     

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures

Background

The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting.

Materials and methods

We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento’s criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months.

Results

At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months.

Conclusions

Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion.

Level of evidence

Level-II prognostic.

     

Industrial low-back pain. A prospective evaluation of a standardized diagnostic and treatment protocol

This investigation applied a diagnostic and treatment protocol to two groups of industrial workers: 5,300 employees at Potomac Electric Power Company ( PEPCO ) for two years and 14,000 United States Postal Service workers for one year. An "active" system in which patients were evaluated weekly was implemented at the power company, and a "passive" system in which patients were seen only once was instituted at the U.S. Postal Service. The physicians were unbiased , in that they could not take part in the patients' ongoing care. The results in both groups demonstrated significant and continuous reductions in number of incidents, in days lost from work, in low-back surgery, and in financial costs. The number of low-back pain patients at PEPCO decreased 29% the first year and 44% the second; days lost from work decreased 51% the first year and 89% the second; low-back surgery dropped 88% the first year and 76% the second year. Results for the U.S. Postal Service demonstrated a decrease in the number of low-back pain patients (41%), in days lost from work (60%), and in financial costs (55%). These results, along with our observations about the study, led us to the following conclusions: (1) Good medicine leads to cost savings in treating industrial low-back pain. (2) Use of a standardized medical approach and nomenclature is necessary and practical, for consistent care. (3) A good record keeping system is essential to perform useful medical analyses for identifying scientific problems. (4) Unbiased medical surveillance leads to changes in behavior of both treating physicians and patients. (5) The outcome for most low-back pain patients in industry is not as grim as previously perceived if their medical management is approached in an organized manner.     

The relative value of lumbar roentgenograms, metrizamide myelography, and discography in the assessment of patients with chronic low-back syndrome

This prospective study evaluated the relative value of lumbar roentgenograms, metrizamide myelography, and discography in identifying structural sources for chronic low-back syndrome. One hundred and eight patients with chronic low-back syndrome were evaluated. Patients had not previously had pathology identified which could explain their pain. On discography, 83 patients (78%) had their pain reproduced at least one abnormal level, identifying a structural component to their pain. Only 22 patients (21%) had all levels of pathology identified by roentgenograms and an additional 17 (16%) had pathology appropriately identified by a combination of myelograms and roentgenograms. Using roentgenograms, myelography, and discography, organic pathology was identified which could explain the patient's symptoms in 100 of 108 patients (93%). Based on this study, we think discography is an important diagnostic tool for use in evaluating patients with chronic low-back syndrome. Discography is essential to adequately identify abnormal levels in patients being considered for fusions. Roentgenograms and myelograms are inadequate evaluation in this chronic pain group in that lack of organic pathology cannot be assumed in the presence of normal roentgenograms and myelograms.