Elsevier

World Neurosurgery

Volume 82, Issue 5, November 2014, Pages 872-878
World Neurosurgery

Peer-Review Report
Operative and Nonoperative Treatment Approaches for Lumbar Degenerative Disc Disease Have Similar Long-Term Clinical Outcomes Among Patients with Positive Discography

https://doi.org/10.1016/j.wneu.2013.09.013Get rights and content

Objective

It remains unclear whether fusion for lumbar degenerative disc disease with positive discography produces better outcomes compared with nonoperative treatment. The aim of this study was to compare outcomes of patients with discography-concordant lumbar degenerative disc disease electing for fusion versus nonoperative treatment.

Methods

We retrospectively reviewed consecutive patients with back pain and concordant lumbar discogram who were offered fusion. Follow-up questionnaires included pain score, Oswestry disability index, short form-12, and satisfaction scale. Patients were stratified based on whether they elected for fusion or nonoperative treatment.

Results

Overall follow-up was 48% (96/200). Patients lacking follow-up were slightly older (P = 0.021) and less likely to be smokers (P = 0.013). Between patients with and without follow-up, there were no significant differences in pain score at initial visit, body mass index, or gender (P ≥ 0.40). The 96 patients for whom follow-up was obtained included 53 in the operative and 43 in the nonoperative groups. At baseline, there were no significant differences between these groups based on age, pain score, body mass index, smoking, or gender (P ≥ 0.25). Mean follow-up was 63 months for operative and 58 months for nonoperative patients (P = 0.20). The mean pain score at last follow-up improved significantly for operative and nonoperative patients (P < 0.001). At follow-up, operative and nonoperative groups did not differ significantly with regard to pain scores, Oswestry disability index, short form-12, or satisfaction scale.

Conclusions

Comparison of long-term outcomes for patients with back pain and concordant discography did not demonstrate a significant difference in outcome measures of pain, health status, satisfaction, or disability based on whether the patient elected for fusion or nonoperative treatment.

Introduction

Chronic back pain, with an annual prevalence of 15%–45%, results in enormous health-related expenditure without a consistent improvement in physical, mental, and functional health-related outcomes (32). Chronic low back pain has been attributed to degenerative disc disease (DDD) in a subset of patients, and provocative discography has been proposed as a decision-making guide to better select patients who could potentially benefit from interventional/surgical procedures for relief of back pain thought to be secondary to DDD (31). Discography involves injection of a “contrast” material into the disc space to provide information on disk morphology and to assess whether the injection elicits a “provoked” pain response. Although morphologic alterations may be readily appreciated on discography, their presence alone does not necessarily implicate the disc as a pain generator 1, 31, 33. As a result, considerable importance is given to the provoked pain response, which, when reported by the patient to be similar to their symptomatic pain, is considered as evidence of a symptomatic disk. There is extensive debate in the spine literature with regard to discography, with one of the major concerns being a high false-positive rate of the provoked pain response in asymptomatic and symptomatic individuals 5, 7, 8, 24, 40, 52. However, a recent meta-analysis of false-positive studies using the International Spine Intervention Society standard suggested that discography has a specificity of 0.94, after setting certain patient selection criteria (52).

Multiple studies have tried to determine the correlation between discography results and treatment outcomes 9, 10, 20, 26, 30, 37, 46, 51. The results have been inconsistent, with variable outcomes regarding pain, functionality, and quality of life. The question whether surgery should be performed for back pain relief for those with a positive discogram still remains without a clear answer. Some investigators recommend surgical intervention after a positive discogram only for patients who also have associated abnormal magnetic resonance imaging (MRI) findings 37, 38, 39. The controversy is further compounded by recent translational and clinical evidence documenting damage and progression of disc degeneration as a result of dye injection as part of the discography procedure 6, 21, 22, 25. Interpretation of evidence regarding efficacy of presurgical discography becomes difficult with divergent views among various investigators.

Our objective in the present study was to assess the long-term clinical outcomes of patients with a positive, concordant lumbar discogram who were offered spinal fusion and either accepted or declined this surgical treatment. Our hypothesis was that, compared with the patients electing for nonoperative treatment, the patients treated with lumbar fusion would have better health-related quality of life (HRQOL) and satisfaction scores at long-term follow-up.

Section snippets

Methods

This study was a retrospective review of consecutive patients who were referred for a diagnostic lumbar discography procedure between 2003 and 2009 at a single institution (Thomas Jefferson University, Philadelphia, Pennsylvania, USA). Inclusion criteria for the present study were symptoms of axial low back pain, attempted conservative therapy for a minimum of 6 weeks, and a one level or a two adjacent level positive discogram that was concordant with lumbar DDD based on MRI. All patients

Baseline Comparisons Between the Patient Groups with and without Follow-Up

A total of 200 patients were identified who met baseline inclusion criteria and were offered surgical treatment (lumbar fusion). Of these 200 patients, follow-up was obtained for 96 (48%), including 53 (55%) of the 96 total patients treated with lumbar fusion and 43 (41%) of the total 104 patients in the nonoperative group (based on initial management plan). Compared with patients for whom follow-up could not be obtained, those with follow-up were slightly older (mean age, 47.1 years vs. 43.9

Discussion

Discography was first introduced by Lindblom (28) as an imaging procedure to visualize the herniated nucleus pulposus in the 1940s. At present, discography is used by some physicians as a diagnostic test to help determine whether a patient with back pain with degenerative disk disease may be a candidate for surgical intervention. According to Derby et al. (12), a positive discogram is determined by the following criteria: a pain severity more than 6/10, which is concordant with the patient's

Conclusions

The present study provides comparison of long-term outcomes for patients with low back pain and a positive concordant discography and who either elected for or against lumbar fusion. The results of our study demonstrate significantly improved pain scores at follow-up for the operative and nonoperative treatment groups and do not demonstrate a significant difference for standardized outcome measures of pain, generalized health status, satisfaction, or disability. Collectively, these findings do

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  • Cited by (0)

    Conflict of interest statement: Approval for the present study was obtained through the institutional review board of Thomas Jefferson University. Justin S. Smith is a consultant for Medtronic, Biomet, Globus; received honoraria for teaching: Medtronic, Depuy, Biomet; Research study group support: Depuy. Christopher Shaffrey is a consultant, patent for Biomet; received royalties, patent from Medtronic; is a consultant for Depuy; got grant funding from NIH and DOD. Alexander Vaccaro received Health Care Entity Relationships and Investments from the following companies: Replication Medica / Stock/ Stock Option Ownership Interests; DePuy / Receipt of Royalty Payments; Medtronics / Receipt of Royalty Payments; Stryker Spine / Receipt of Royalty Payments, Institutional/ Educational Grant; Biomet Spine / Receipt of Royalty Payments; Globus / Receipt of Royalty Payments, Stock/ Stock Option Ownership Interests; K-2 Medical / Stock/ Stock Option Ownership Interests; Paradigm Spine / Stock/ Stock Option Ownership Interests; Stout Medical / Consulting/Independent Contractor, Stock/ Stock Option Ownership Interests; Aesculap / Receipt of Royalty Payments; Spine Medica / Stock/ Stock Option Ownership Interests; Computational Biodynamics / Stock/ Stock Option Ownership Interests; Progressive Spinal Technologies / Stock/ Stock Option Ownership Interests; Spinology / Stock/ Stock Option Ownership Interests; Small Bone Innovations / Stock/ Stock Option Ownership Interests; NeuCore / Stock/ Stock Option Ownership Interests; Cross Current / Stock/ Stock Option Ownership Interests; Syndicom / Stock/ Stock Option Ownership Interests; In Vivo / Stock/ Stock Option Ownership Interests; Flagship Surgical / Stock/ Stock Option Ownership Interests; Advanced Spinal Intellectual Properties / Stock/ Stock Option Ownership Interests; Cytonics / Stock/ Stock Option Ownership Interests; Bonovo Orthopaedics / Stock/ Stock Option Ownership Interests; Electrocore Stock/ Stock Option Ownership Interests; Nuvasive / Receipt of Royalty Payments, Institutional/ Educational Grant; Gamma Spine / Stock/ Stock Option Ownership Interests; Location Based Intelligence / Stock/ Stock Option Ownership Interests; FlowPharma / Stock/ Stock Option Ownership Interests; R.S.I. /Stock/ Stock Option Ownership Interests; Gerson Lehrman Group / Consulting/Independent Contractor; Guidepoint Global / Consulting/Independent Contractor; Medacorp / Consulting/Independent Contractor; Cerapedics / Institutional/ Educational Grant; Rothman Institute and Related Properties / Stock/ Stock Option Ownership Interests; AO Spine / Service on Scientific Advisory Board/Board of Directors/Service on Committees; Innovative Surgical Design / Consulting/Independent Contractor, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/ Stock Option Ownership Interests; Association of Collaborative Spine Research / Service on Scientific Advisory Board/Board of Directors/Service on Committees; Spinicity / Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/ Stock Option Ownership Interests. Gursukhman Sidhu, Ken Bode, David Gendelberg, Mitchell Maltenfort, David Ibrahimi have nothing to disclose.

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