Bio

Clinical Focus


  • Orthopaedic Surgery

Academic Appointments


Administrative Appointments


  • Chief, Spinal Surgery Division (2004 - Present)
  • Medical Director, Service Quality, Stanford Univeristy Hospital and Clinics (2009 - Present)
  • Director, Orthopaedic Spine Center at Stanford, Stanford Hospital and Clinics (1990 - Present)
  • Director, Medical Student Education; Department of Orthopaedic Surgery, Stanford University School of Medicine (1990 - Present)
  • Spine Consultant for Varsity and NCAA Teams, Stanford University (1993 - Present)

Honors & Awards


  • Various awards and Commendations, U.S. Army (to present)
  • Leon Wiltse Award, North American Spine Society (2008)
  • Volvo Clinical Research Award, International Society for the Study of the Lumbar Spine (2000)
  • Clinical Research Award, International Society for the Study of the Lumbar Spine (2009 and 2006)
  • Excellence in Teaching Award, Stanford University School of Medicine (1996, 1997, 2004)
  • Outstanding Paper Award, North American Spine Society (2008 - 03, 01, 00, 1999-97)
  • Best Paper Award, International Society for the Study of the Lumbar Spine (2005)
  • Outstanding Research Award, International Society for the Study of the Lumbar Spine (2003)
  • Summa Cum Laude, State University of New York at Albany (1977)

Professional Education


  • Residency:Stanford University School of Medicine (1988) CA
  • Residency:Stanford University School of Medicine (1984) CA
  • Medical Education:Stanford University School of Medicine (1982) CA
  • Internship:Stanford University School of Medicine (1983) CA
  • Board Certification: Orthopaedic Surgery, American Board of Orthopaedic Surgery (1994)
  • Fellowship:University Of Hong Kong (1990) China
  • M.D., Stanford Univ. School of Med. (1982)
  • B.S., State Univ. of New York, Albany, Biology (1977)

Community and International Work


  • Editor in Chief, The Spine Journal, Stanford and NASS

    Topic

    Spinal Disorders

    Partnering Organization(s)

    North American Spine Society

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

  • VA Neck Pain and Back Pain Guidelines

    Topic

    Spinal Disorders

    Partnering Organization(s)

    Veterans Affairs Department, New York Univeristy

    Location

    US

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • Command Surgeon, 351 Civil Affairs Command

    Topic

    Public Health and Medical Support to US Army CA soldier

    Partnering Organization(s)

    US Armed Forces, Operation Iraqi Freedom

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

  • Low Back Pain Guidelines Panel

    Partnering Organization(s)

    American Pain Society, American College of Physicians

    Location

    US

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • Neck Pain Task Force, Toronto, Canada

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • Medical Officer, US Army Reserve

    Topic

    1980th Forward Surgical Team

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Health Volunteers International, Ho Chi Minh City, Viet Nam

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Viet Nam Rehabilitation Project, Workshop Director, Hanoi, Ho Chi Minh City, Viet Nam

    Topic

    Spinal Cord Injury

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Arbor Free Medical Clinic, Faculty Consultant

    Location

    Bay Area

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Project Leader, Health Volunteer International, Viet Nam

    Partnering Organization(s)

    Orthopaedic Overseas

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • UN Medical Corps/Refugee Volunteer, Hong Kong

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Hong Kong Refugee Camp Volunteer, Hong Kong

    Partnering Organization(s)

    UNHCR

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Research & Scholarship

Current Research and Scholarly Interests


Dr. Carragee's research interests lie in outcomes assessment of surgical and rehabilitative treatment for cervical and lumbar intervertebral disk herniation; diagnosis and treatment of spine infections, instrumentation of the degenerative spine and spinal deformities and low back pain syndromes, pain and pain management.

Teaching

2013-14 Courses


Graduate and Fellowship Programs


Publications

Journal Articles


  • Magnetic resonance imaging predictors of surgical outcome in patients with lumbar intervertebral disc herniation. Spine Lurie, J. D., Moses, R. A., Tosteson, A. N., Tosteson, T. D., Carragee, E. J., Carrino, J. A., Kaiser, J. A., Herzog, R. J. 2013; 38 (14): 1216-1225

    Abstract

    Study Design: A retrospective cohort designObjective: To determine if baseline MRI findings including central/foraminal stenosis, Modic change, disc morphology, facet arthropathy, disc degeneration, nerve root impingement, and thecal sac compression are associated with differential surgical treatment effect.Summary of Background Data: Intervertebral Disc Herniation (IDH) remains the most common source of lumbar radiculopathy treated either with discectomy or non-operative intervention. Although MRI remains the reliable gold standard for diagnosis, uncertainty surrounds the relationship between MRI findings and treatment outcomes.Methods: Three-hundred-and-seven "complete" images from patients enrolled in a previous trial were de-identified and evaluated by one of 4 independent readers. Findings were compared to outcome measures including the Oswestry Disability Index. Differences in surgery and non-operative treatment outcomes were evaluated between image characteristic subgroups and TE determined by the difference in ODI scores.Results: The cohort was comprised of 40% females with an average age of 41.5 (±11.6), 61% of which underwent discectomy for IDH. Patients undergoing surgery with Modic type I endplate changes had worse outcomes (-26.4 versus -39.7 for none and -39.2 for type 2, p = 0.002) and smaller treatment effect (-3.5 versus -19.3 for none and -15.7 for type 2, p = 0.003). Those with compression > = 1/3 showed the greatest improvement within the surgical group (-41.9 for > = 1/3 versus -31.6 for none and -38.1 for <1/3, p = 0.007), and the highest TE (-23 compared to -11.7 for none and -15.2 for <1/3, p = 0.015). Furthermore, patients with minimal nerve root impingement demonstrated worse surgical outcomes (-26.5 versus -41.1 for "displaced" and -38.9 for "compressed", p = 0.016).Conclusion: Among patients with IDH, those with thecal sac compression > = 1/3 had greater surgical treatment effect than those with small disc herniations and Modic type I changes. Additionally, patients with nerve root "compression" and "displacement" benefit more from surgery than those with minimal nerve-root impingement.

    View details for DOI 10.1097/BRS.0b013e31828ce66d

    View details for PubMedID 23429684

  • Does a Fibronectin and Aggrecan Complex Play a Role in Painful Vertebral Disks? PM&R Cuellar, J. M., Golish, S. R., Leroux, E. J., Reuter, M. W., Carragee, E. J., Hanna, L. S., Scuderi, G. J. 2013; 5 (4): 297-302

    Abstract

    To determine the presence of a fibronectin-aggrecan complex (FAC) in the disk space of persons with chronic low back pain as relates to provocative diskography.A single-center prospective consecutive case series.A single private practice setting.Thirty-seven patients with symptomatic degenerative disk disease of the cervical, thoracic, or lumbar spine undergoing provocative diskography to identify a source of pain.Diskographic lavage for analysis was simultaneously performed at each disk level injected during diskography.Visual analog scale (VAS) pain scores, Pfirrmann magnetic resonance imaging grade, and biochemical analysis of disk material were statistically analyzed.A total of 105 levels in 37 patients had a complete set of data (mean age 43.2 ± 11.9 years; 15 male/22 female). The FAC was present in 43 of 108 levels and in at least one level in 25 of 37 patients. The Pfirrmann magnetic resonance imaging grade did not differ between complex-positive and negative levels (P = .125), nor did the intraoperative VAS (IO-VAS) score for pain by level (P = .206). A significant but loose correlation was found between Pfirrmann grade and IO-VAS (R(2) = 0.4, P < .001), but no significant correlation was found between VAS or IO-VAS and complex concentration (R(2) = 0.08, P = .11 and R(2) = 0.003, P = .5).The FAC was identified in some painful disks by diskography. There was no significant correlation between the Pfirrmann grade or pre/intraoperative pain scores during diskography and complex concentrations within the disk measured by disk lavage.

    View details for DOI 10.1016/j.pmrj.2013.01.002

    View details for Web of Science ID 000318465900005

    View details for PubMedID 23490723

  • Thoracolumbar fracture dislocation sustained during childbirth in a patient with ankylosing spondylitis SPINE JOURNAL Mayle, R. E., Cheng, I., Carragee, E. J. 2012; 12 (11): E5-E8

    Abstract

    Ankylosing spondylitis (AS) is a major subtype of the spondyloarthropathies. Uncoupling of bone formation and resorption along with ectopic ossification of paraspinal soft-tissue structures alters the biomechanics of the spine and leads to an increased susceptibility to fracture.To report on a thoracolumbar fracture dislocation sustained in a 33-year-old Gravida 2/Para 2 woman, which occurred during labor. Although there are several reports in the literature of thoracolumbar fracture dislocations sustained in patients with AS, none have been reported during childbirth.Case report.An elevated suspicion for injury should be maintained when patients with AS present with back or neck pain even without a history of significant trauma.

    View details for DOI 10.1016/j.spinee.2012.10.012

    View details for Web of Science ID 000311807300002

    View details for PubMedID 23199410

  • Functional assessment of the acute local and distal transplantation of human neural stem cells after spinal cord injury SPINE JOURNAL Cheng, I., Mayle, R. E., Cox, C. A., Park, D. Y., Smith, R. L., Corcoran-Schwartz, I., Ponnusamy, K. E., Oshtory, R., Smuck, M. W., Mitra, R., Kharazi, A. I., Carragee, E. J. 2012; 12 (11): 1040-1044

    Abstract

    Spinal cord injury can lead to severe functional impairments secondary to axonal damage, neuronal loss, and demyelination. The injured spinal cord has limited regrowth of damaged axons. Treatment remains controversial, given inconsistent functional improvement. Previous studies demonstrated functional recovery of rats with spinal cord contusion after transplantation of rat fetal neural stem cells.We hypothesized that acute transplantation of human fetal neural stem cells (hNSCs) both locally at the injury site as well as distally via intrathecal injection would lead to improved functional recovery compared with controls.Twenty-four adult female Long-Evans hooded rats were randomized into four groups with six animals in each group: two experimental and two control. Functional assessment was measured after injury and then weekly for 6 weeks using the Basso, Beattie, and Bresnahan Locomotor Rating Score. Data were analyzed using two-sample t test and linear mixed-effects model analysis.Posterior exposure and laminectomy at T10 level was used. Moderate spinal cord contusion was induced by the Multicenter Animal Spinal Cord Injury Study Impactor with 10-g weight dropped from a height of 25 mm. Experimental subjects received either a subdural injection of hNSCs locally at the injury site or intrathecal injection of hNSCs through a separate distal laminotomy. Controls received control media injection either locally or distally.Statistically significant functional improvement was observed in local or distal hNSCs subjects versus controls (p=.034 and 0.016, respectively). No significant difference was seen between local or distal hNSC subjects (p=.66).Acute local and distal transplantation of hNSCs into the contused spinal cord led to significant functional recovery in the rat model. No statistical difference was found between the two techniques.

    View details for DOI 10.1016/j.spinee.2012.09.005

    View details for Web of Science ID 000311807300013

    View details for PubMedID 23063425

  • Retrograde ejaculation after anterior lumbar interbody fusion with and without bone morphogenetic protein-2 augmentation: a 10-year cohort controlled study SPINE JOURNAL Comer, G. C., Smith, M. W., Hurwitz, E. L., Mitsunaga, K. A., Kessler, R., Carragee, E. J. 2012; 12 (10): 881-890

    Abstract

    Retrograde ejaculation (RE) is a complication of anterior lumbar interbody fusion (ALIF) techniques. Most commonly, this results from mechanical or inflammatory injury to the superior hypogastric plexus near the aortic bifurcation. Bone morphogenetic protein-2 (BMP-2) has been used in spinal fusions and has been associated with inflammatory and neuroinflammatory adverse reactions, which may contribute to RE development after anterior lumbar surgery.While controlling for anterior approach technique, we compared the incidence of RE with and without rhBMP-2 exposure, in large, matched cohorts of patients after ALIF.Retrospective analysis of 10 years of prospectively gathered outcomes data on consecutive-patient cohorts having the same anterior exposure technique for ALIF with and without rhBMP-2 use.All male patients without baseline sexual incapacity and having ALIF for lumbar spondylosis or spondylolisthesis of the lowest one or two lumbar levels with and without rhBMP-2, from 2002 through 2011.Diagnosis of RE as a new finding after ALIF compared against BMP-2 exposure, comorbid conditions, and other urological complications after ALIF surgery.From the comprehensive surgical database at a high volume, university practice, male subjects having ALIF at one (L5/S1) or two levels (L4/5, L5/S1) from 2002 to 2011 were identified. Baseline comorbid factors, postoperative urinary catheter/retention events, and RE events were recorded and comparative incidence compared.There were four consecutive-patient cohorts identified: one before rhBMP-2 use was adopted (n=174), two cohorts in which BMP-2 use was routine (n=88 and n=151), and one final cohort after BMP-2 use was discontinued from routine use (n=59). The cohorts with and without BMP-2 exposure were closely comparable for age, approach, levels of surgery, comorbid factors affecting RE. Of 239 patients with ALIF and exposure to BMP-2, RE was diagnosed in 15 subjects (6.3%), compared with an RE diagnosis rate of two of 233 control patients without BMP-2 exposure (0.9%; p=.0012). Urinary retention after bladder catheter removal was also more frequently observed in patients exposed to BMP-2 (9.7%) compared with control patients (4.6%; p=.043). Of the baseline comorbid factors, medical or surgical treatment for prostatic hypertrophy disease was associated with an increased risk of RE in the BMP-2 patients (p=.034).This study confirms previous reports of a higher rate of RE in ALIF procedures using rhBMP-2 and an open anterior approach to the spine. This effect may be associated with an increased risk of postoperative urinary retention after BMP-2 exposure. The magnitude of the RE effect may be increased with concomitant prostatic disease treatments.

    View details for DOI 10.1016/j.spinee.2012.09.040

    View details for Web of Science ID 000311684600005

    View details for PubMedID 23098617

  • A biologic without guidelines: the YODA project and the future of bone morphogenetic protein-2 research SPINE JOURNAL Carragee, E. J., Baker, R. M., Benzel, E. C., Bigos, S. J., Cheng, I., Corbin, T. P., Deyo, R. A., Hurwitz, E. L., Jarvik, J. G., Kang, J. D., Lurie, J. D., Mroz, T. E., Oener, F. C., Peul, W. C., Rainville, J., Ratliff, J. K., Rihn, J. A., Rothman, D. J., Schoene, M. L., Spengler, D. M., Weiner, B. K. 2012; 12 (10): 877-880

    View details for DOI 10.1016/j.spinee.2012.11.002

    View details for Web of Science ID 000311684600004

    View details for PubMedID 23199819

  • Commentary: Penetrating neck injury: George Orwell is "Struck by Lighting" SPINE JOURNAL Carragee, E. J. 2012; 12 (9): 769-770

    View details for DOI 10.1016/j.spinee.2012.09.016

    View details for Web of Science ID 000309527900008

    View details for PubMedID 23036144

  • Commentary: Battle injuries: Jessica Lynch sets the record straight SPINE JOURNAL Carragee, E. J. 2012; 12 (9): 830-832

    View details for DOI 10.1016/j.spinee.2012.09.015

    View details for Web of Science ID 000309527900018

    View details for PubMedID 23036146

  • Marching home, again: spine casualties, combat exposure, and the long wars SPINE JOURNAL Carragee, E. J. 2012; 12 (9): 723-726

    View details for DOI 10.1016/j.spinee.2012.09.013

    View details for Web of Science ID 000309527900001

    View details for PubMedID 23036141

  • Commentary: The veteran: "A need to talk but no one wanted to hear about it" SPINE JOURNAL Carragee, E. J. 2012; 12 (9): 804-805

    View details for DOI 10.1016/j.spinee.2012.09.014

    View details for Web of Science ID 000309527900014

    View details for PubMedID 23036145

  • Morbidity and Mortality of C2 Fractures in the Elderly: Surgery and Conservative Treatment NEUROSURGERY Chen, Y., Boakye, M., Arrigo, R. T., Kalanithi, P. S., Cheng, I., Alamin, T., Carragee, E. J., Mindea, S. A., Park, J. 2012; 70 (5): 1055-1059

    Abstract

    Closed C2 fractures commonly occur after falls or other trauma in the elderly and are associated with significant morbidity and mortality. Controversy exists as to best treatment practices for these patients.To compare outcomes for elderly patients with closed C2 fractures by treatment modality.We retrospectively reviewed 28 surgically and 28 nonsurgically treated cases of closed C2 fractures without spinal cord injury in patients aged 65 years of age or older treated at Stanford Hospital between January 2000 and July 2010. Comorbidities, fracture characteristics, and treatment details were recorded; primary outcomes were 30-day mortality and complication rates; secondary outcomes were length of hospital stay and long-term survival.Surgically treated patients tended to have more severe fractures with larger displacement. Charlson comorbidity scores were similar in both groups. Thirty-day mortality was 3.6% in the surgical group and 7.1% in the nonsurgical group, and the 30-day complication rates were 17.9% and 25.0%, respectively; these differences were not statistically significant. Surgical patients had significantly longer lengths of hospital stay than nonsurgical patients (11.8 days vs 4.4 days). Long-term median survival was not significantly different between groups.The 30-day mortality and complication rates in surgically and nonsurgically treated patients were comparable. Elderly patients faced relatively high morbidity and mortality regardless of treatment modality; thus, age alone does not appear to be a contraindication to surgical fixation of C2 fractures.

    View details for DOI 10.1227/NEU.0b013e3182446742

    View details for Web of Science ID 000303390400013

    View details for PubMedID 22157549

  • Commentary: Revision lumbar surgery and revisiting the role of preoperative depression screening SPINE JOURNAL Carragee, E. J., Telles, C. J. 2012; 12 (3): 186-188

    Abstract

    COMMENTARY ON: Adogwa O, Parker SL, Shau DN, et al. Preoperative Zung Depression Scale predicts outcome after revision lumbar surgery for adjacent segment disease, recurrent stenosis, and pseudarthrosis. Spine J 2012;12:179-85 (in this issue).

    View details for DOI 10.1016/j.spinee.2012.03.008

    View details for Web of Science ID 000302355600002

    View details for PubMedID 22469301

  • Overview of Axial Skeleton Injuries: Burden of Disease JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Carragee, E. J. 2012; 20: S18-S22

    Abstract

    Axial skeletal injury and related illness is a major cause of medical disability and force attrition in deployed service members. Predeployment identification of at-risk personnel is unreliable. Risk of axial skeletal injury or illness during deployment is heterogeneous. Major spinal trauma casualties are uncommon, accounting for 1% of casualties, and are usually related to battle injuries. These major spinal injuries are often associated with multiple system/anatomic injuries. Spinal cord injuries account for 18% of major spinal injuries in persons with battle-related spinal injury. Non-battle spine pain, that is, back or neck area pain not associated with major trauma, is a significant force attrition problem, accounting for 40% of all combat casualty evacuation in some years. Personnel attrition due to neck and back pain not associated with major trauma is highly variable by unit and exposure, including psychological exposure. Return-to-duty rates for both traumatic and atraumatic spine injuries is poor (?15%); this rate is predicted by psychological comorbidities.

    View details for DOI 10.5435/JAAOS-20-08-S18

    View details for Web of Science ID 000307199000006

    View details for PubMedID 22865130

  • Managing Nonspecific Low Back Pain Do Nonclinical Patient Characteristics Matter? SPINE Weiner, S. S., Weiser, S. R., Carragee, E. J., Nordin, M. 2011; 36 (23): 1987-1994

    Abstract

    A fully blocked experimental design using clinical vignettes to query primary care physicians on prescription for management of acute nonspecific low back pain.To identify how nonclinical patient factors, specifically sex, patient presentation, and socioeconomic status, influence physician treatment recommendations for assessing and treating acute nonspecific low back pain.Adherence to evidence-based practice guidelines for nonspecific low back pain remains inconsistent. Therefore, it is important to understand what factors guide physician management of these cases.One vignette and questionnaire was distributed to primary care and emergency department clinical physicians during meetings at five teaching hospitals. The questionnaire asked for diagnostic and treatment recommendations including specific tests, medications, therapeutic procedures, activity, referral to other services, and patient education for the case represented in the vignette.Subjects included 284 physicians and approximately 75% had less than 5 years of clinical practice experience. Multivariate logistic regression showed seven significant associations of patient factors with treatment recommendations for acute nonspecific low back pain (one sex, two socioeconomic status, and four patient presentation; P < 0.05).All three assessed nonclinical factors influenced physician decisions regarding diagnostic and treatment recommendations for acute nonspecific low back pain. Patient presentation, suggestive of a patient's emotional state, was shown to be the most influential.

    View details for DOI 10.1097/BRS.0b013e3181fee8ef

    View details for Web of Science ID 000296553000019

    View details for PubMedID 21289556

  • Commentary: One small step SPINE JOURNAL Smuck, M., Carragee, E. J. 2011; 11 (9): 824-825

    View details for DOI 10.1016/j.spinee.2011.08.432

    View details for Web of Science ID 000296276100004

    View details for PubMedID 21951609

  • Charlson Score is a Robust Predictor of 30-Day Complications Following Spinal Metastasis Surgery SPINE Arrigo, R. T., Kalanithi, P., Cheng, I., Alamin, T., Carragee, E. J., Mindea, S. A., Boakye, M., Park, J. 2011; 36 (19): E1274-E1280

    Abstract

    Retrospective chart review.To identify predictors of 30-day complications after the surgical treatment of spinal metastasis.Surgical treatment of spinal metastasis is considered palliative with the aim of reducing or delaying neurologic deficit. Postoperative complication rates as high as 39% have been reported in the literature. Complications may impact patient quality of life and increase costs; therefore, an understanding of which preoperative variables best predict 30-day complications will help risk-stratify patients and guide therapeutic decision making and informed consent.We retrospectively reviewed 200 cases of spinal metastasis surgically treated at Stanford Hospital between 1999 and 2009. Multiple logistic regression was performed to determine which preoperative variables were independent predictors of 30-day complications.Sixty-eight patients (34%) experienced one or more complications within 30 days of surgery. The most common complications were respiratory failure, venous thromboembolism, and pneumonia. On multivariate analysis, Charlson Comorbidity Index score was the most significant predictor of 30-day complications. Patients with a Charlson score of two or greater had over five times the odds of a 30-day complication as patients with a score of zero or one.After adjusting for demographic, oncologic, neurologic, operative, and health factors, Charlson score was the most robust predictor of 30-day complications. A Charlson score of two or greater should be considered a surgical risk factor for 30-day complications, and should be used to risk-stratify surgical candidates. If complications are anticipated, medical staff can prepare in advance, for instance, scheduling aggressive ICU care to monitor for and treat complications. Finally, Charlson score should be controlled for in future spinal metastasis outcomes studies and compared to other comorbidity assessment tools.

    View details for DOI 10.1097/BRS.0b013e318206cda3

    View details for Web of Science ID 000294207500005

    View details for PubMedID 21358481

  • Outcome of Lumbar Epidural Steroid Injection Is Predicted by Assay of a Complex of Fibronectin and Aggrecan From Epidural Lavage SPINE Golish, S. R., Hanna, L. S., Bowser, R. P., Montesano, P. X., Carragee, E. J., Scuderi, G. J. 2011; 36 (18): 1464-1469

    Abstract

    A single-center, prospective, consecutive case series of patients undergoing epidural lavage before the treatment of radiculopathy due to lumbar disc herniation.To determine whether a novel complex of fibronectin and aggrecan predicts clinical response to epidural steroid injection (ESI) for the indication of radiculopathy from lumbar herniated nucleus pulposus (HNP).ESI for lumbar radiculopathy due to HNP is widely used despite variable effectiveness for this indication. With increased attention aimed at cost containment, it would be beneficial to identify those in whom ESI may be helpful. There are currently no accurate diagnostic tests to predict response to ESI in back pain and sciatica syndromes. We have previously investigated biomarkers of disc degeneration associated with radiculopathy.We embarked to determine whether a molecular complex of fibronectin and aggrecan predicts clinical response to ESI for the indication of radiculopathy from HNP. This prospective study was conducted at a single center and included 26 patients with radiculopathic pain and magnetic resonance imaging positive for HNP, who elected ESI. Epidural lavage with physiologic saline was performed immediately before ESI. The lavage fluid was assayed for the fibronectin-aggrecan complex (FAC) by using a heterogeneous sandwich enzyme-linked immunosorbent assay. The results were compared with the interval improvement in the physical component summary (PCS) score of the Medical Outcomes Study Short Form-36 instrument (SF-36) after injection compared with baseline.The mean improvement from baseline PCS in patients with the FAC was 22.9 (SD, 12.4) and without the complex was 0.64 (SD, 3.97; P < 0.001). Differences in total SF-36 improvement were also highly significant (P < 0.001). The presence of the FAC predicts a clinically significant increase in PCS after lumbar ESI by receiver-operating-characteristic analysis (area under the curve = 0.97; P < 0.001). There was no significant difference in age (P = 0.25), sex (P = 0.84), laterality (P = 0.06), lumbar spinal level (P = 0.75), or payer type (worker's compensation vs. private insurance; P = 0.90) between groups with and without the marker.A molecular complex of fibronectin and aggrecan predicts response to lumbar ESI for radiculopathy with HNP. The biomarker is accurate, objective, and not affected by demographic or psychosocial variables in this series.

    View details for DOI 10.1097/BRS.0b013e3181f40e88

    View details for Web of Science ID 000293579300016

    View details for PubMedID 21224775

  • Future directions for The Spine Journal: managing and reporting conflict of interest issues SPINE JOURNAL Carragee, E. J., Hurwitz, E. L., Weiner, B. K., Bono, C. M., Rothman, D. J. 2011; 11 (8): 695-697

    View details for DOI 10.1016/j.spinee.2011.08.418

    View details for Web of Science ID 000295772900004

    View details for PubMedID 21925411

  • Local bone graft harvesting and volumes in posterolateral lumbar fusion: a technical report SPINE JOURNAL Carragee, E. J., Comer, G. C., Smith, M. W. 2011; 11 (6): 540-544

    Abstract

    In lumbar surgery, local bone graft is often harvested and used in posterolateral fusion procedures. The volume of local bone graft available for posterolateral fusion has not been determined in North American patients. Some authors have described this as minimal, but others have suggested the volume was sufficient to be reliably used as a stand-alone bone graft substitute for single-level fusion.To describe the technique used and determine the volume of local bone graft available in a cohort of patients undergoing single-level primary posterolateral fusion by the authors harvesting technique.Technical description and cohort report.Consecutive patients undergoing lumbar posterolateral fusion with or without instrumentation for degenerative processes.Local bone graft volume.Consecutive patients undergoing lumbar posterolateral fusion with or without instrumentation for degenerative processes of were studied. Local bone graft was harvested by a standard method in each patient and the volume measured by a standard procedure.Twenty-five patients were studied, and of these 11 (44%) had a previous decompression. The mean volume of local bone graft harvested was measured to be 25 cc (range, 12-36 cc). Local bone graft was augmented by iliac crest bone in six of 25 patients (24%) if the posterolateral fusion bed was not well packed with local bone alone. There was a trend to greater local bone graft volumes in men and in patients without previous decompression.Large volumes of local bone can be harvested during posterolateral lumbar fusion surgery. Even in patients with previous decompression the volume harvested is similar to that reported harvested from the posterior iliac crest for single-level fusion.

    View details for DOI 10.1016/j.spinee.2011.02.014

    View details for Web of Science ID 000292320100016

    View details for PubMedID 21729803

  • Retrograde ejaculation after anterior lumbar interbody fusion using rhBMP-2: a cohort controlled study SPINE JOURNAL Carragee, E. J., Mitsunaga, K. A., Hurwitz, E. L., Scuderi, G. J. 2011; 11 (6): 511-516

    Abstract

    The commercially available growth factor recombinant bone morphogenic protein-2 (rhBMP-2) used in spinal fusion has been associated with numerous adverse reactions, including inflammatory reactions in soft tissue, heterotopic bone formation, radiculitis, osteolysis, and cage or graft subsidence. The original Food and Drug Administration Summary of anterior lumbar interbody fusion (ALIF) reported 12 retrograde ejaculation (RE) events (8%) in the rhBMP-2 groups compared with (1.4%) in the control group. It had been debated whether this finding was related to rhBMP-2 use.To compare the incidence of RE after ALIF in patients with and without rhBMP-2 use.Retrospective analysis of prospectively gathered outcomes data on consecutive subjects having ALIF with and without rhBMP-2 use.Male patients with lumbar spondylosis or spondylolisthesis having ALIF of the lowest one or two lumbar levels with and without rhBMP-2.Report of RE as a new finding after ALIF.From the comprehensive outcome database at a high-volume university practice, male subjects having ALIF for one- (L5/S1) or two-level (L4/L5, L5/S1) lumbar fusion were identified. Retrograde ejaculation events were recorded and comparative incidence compared.The two groups were comparable for age and additional procedures performed. There were 69 L5/S1 ALIFs performed with rhBMP-2 and 174 ALIFs performed without rhBMP-2 during the study period. Of those, 24 and 64 were two-level ALIFs performed with and without rhBMP-2, respectively. There were five RE events (7.2%) reported in the rhBMP-2 group and 1 (0.6%) in the control group. Comparing single-level L5/S1 ALIF, there was a 6.7% and 0% rate of RE in the rhBMP-2 versus control groups, respectively. At 1 year after surgery, three of six affected subjects reported resolution of the RE.This study confirms previous reports of a higher rate of RE in ALIF procedures using rhBMP-2. This may be an important consideration in subjects concerned with sterility after surgery.

    View details for DOI 10.1016/j.spinee.2011.02.013

    View details for Web of Science ID 000292320100009

    View details for PubMedID 21612985

  • A challenge to integrity in spine publications: years of living dangerously with the promotion of bone growth factors SPINE JOURNAL Carragee, E. J., Ghanayem, A. J., Weiner, B. K., Rothman, D. J., Bono, C. M. 2011; 11 (6): 463-468

    View details for DOI 10.1016/j.spinee.2011.06.001

    View details for Web of Science ID 000292320100001

    View details for PubMedID 21729794

  • A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned SPINE JOURNAL Carragee, E. J., Hurwitz, E. L., Weiner, B. K. 2011; 11 (6): 471-491

    Abstract

    Increasingly, reports of frequent and occasionally catastrophic complications associated with use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in spinal fusion surgeries are being published. In the original peer review, industry-sponsored publications describing the use of rhBMP-2 in spinal fusion, adverse events of these types and frequency were either not reported at all or not reported to be associated with rhBMP-2 use. Some authors and investigators have suggested that these discrepancies were related to inadequate peer review and editorial oversight.To compare the conclusions regarding the safety and related efficacy published in the original rhBMP-2 industry-sponsored trials with subsequently available Food and Drug Administration (FDA) data summaries, follow-up publications, and administrative and organizational databases.Systematic review.Results and conclusions from original industry-sponsored rhBMP-2 publications regarding safety and related efficacy were compared with available FDA data summaries, follow-up publications, and administrative and organizational database analyses.There were 13 original industry-sponsored rhBMP-2 publications regarding safety and efficacy, including reports and analyses of 780 patients receiving rhBMP-2 within prospective controlled study protocols. No rhBMP-2-associated adverse events (0%) were reported in any of these studies (99% confidence interval of adverse event rate <0.5%). The study designs of the industry-sponsored rhBMP-2 trials for use in posterolateral fusions and posterior lateral interbody fusion were found to have potential methodological bias against the control group. The reported morbidity of iliac crest donor site pain was also found to have serious potential design bias. Comparative review of FDA documents and subsequent publications revealed originally unpublished adverse events and internal inconsistencies. From this review, we suggest an estimate of adverse events associated with rhBMP-2 use in spine fusion ranging from 10% to 50% depending on approach. Anterior cervical fusion with rhBMP-2 has an estimated 40% greater risk of adverse events with rhBMP-2 in the early postoperative period, including life-threatening events. After anterior interbody lumbar fusion rates of implant displacement, subsidence, infection, urogenital events, and retrograde ejaculation were higher after using rhBMP-2 than controls. Posterior lumbar interbody fusion use was associated with radiculitis, ectopic bone formation, osteolysis, and poorer global outcomes. In posterolateral fusions, the risk of adverse effects associated with rhBMP-2 use was equivalent to or greater than that of iliac crest bone graft harvesting, and 15% to 20% of subjects reported early back pain and leg pain adverse events; higher doses of rhBMP-2 were also associated with a greater apparent risk of new malignancy.Level I and Level II evidence from original FDA summaries, original published data, and subsequent studies suggest possible study design bias in the original trials, as well as a clear increased risk of complications and adverse events to patients receiving rhBMP-2 in spinal fusion. This risk of adverse events associated with rhBMP-2 is 10 to 50 times the original estimates reported in the industry-sponsored peer-reviewed publications.

    View details for DOI 10.1016/j.spinee.2011.04.023

    View details for Web of Science ID 000292320100003

    View details for PubMedID 21729796

  • Are Persistently Symptomatic Vertebral Compression Fractures Associated With Abnormal Inflammatory Profiles? A Prospective Study JOURNAL OF SPINAL DISORDERS & TECHNIQUES Golish, S. R., Hanna, L. S., Cuellar, J. M., Fernyhough, J. C., Campbell, D. R., Carragee, E. J., Scuderi, G. J. 2011; 24 (2): 121-125

    Abstract

    A case-control study with prospectively collected samples for laboratory analysis in a series of patients with spinal fragility fractures and a series of patients without fracture who underwent fusion for LBP.Was an exploratory data analysis for candidate cytokine biomarkers present in the fracture milieu of patients with persistent back pain associated with vertebral compression fracture.Lumbar and thoracic compression fractures are common. Little is known about the presence of inflammatory mediators within fractured vertebra in the clinical setting.Thirty patients diagnosed with a single thoracic or lumbar compression fracture were treated with single level vertebroplasty. At the time of intervention, needle aspiration was carried out at the fractured level. A multiplexed bead assay was used to assess the presence of 27 different cytokines and inflammatory mediators. A control group consisted of needle aspiration samples of 30 lumbar vertebra from 13 patients with chronic pain but no fracture undergoing open instrumented fusion.Thirty patients with 30 fractures consisted of 23 female and 7 male with a mean age of 77.5 years (SD 13.6; range 42 to 97) and a mean of 3.9 weeks of pain (SD 3.1; range 1 to 12). The highest levels of inflammatory mediators were (in order): IL-1 receptor antagonist, PDGF, RANTES, IP-10, IL-8, and eotaxin. These mediators were present at concentrations>200 pg/mL. Compared with controls with chronic pain, significant differences were present for 4 mediators: TNF, MIP-1b, IL-9, and IL-12. The panel of these 4 markers was 93.3% specific and 66.7% sensitive for fracture compared with the control group.Inflammatory mediators are present in needle aspirates of symptomatic vertebral compression fractures. Some of these mediators show different levels than in patients with chronic pain but no fracture.Diagnostic level of evidence II.

    View details for DOI 10.1097/BSD.0b013e3181dc1e70

    View details for Web of Science ID 000288740200009

    View details for PubMedID 21445026

  • Predictors of Survival After Surgical Treatment of Spinal Metastasis NEUROSURGERY Arrigo, R. T., Kalanithi, P., Cheng, I., Alamin, T., Carragee, E. J., Mindea, S. A., Park, J., Boakye, M. 2011; 68 (3): 674-681

    Abstract

    Surgery for spinal metastasis is a palliative treatment aimed at improving patient quality of life by alleviating pain and reversing or delaying neurologic dysfunction, but with a mean survival time of less than 1 year and significant complication rates, appropriate patient selection is crucial.To identify the most significant prognostic variables of survival after surgery for spinal metastasis.Chart review was performed on 200 surgically treated spinal metastasis patients at Stanford Hospital between 1999 and 2009. Survival analysis was performed and variables entered into a Cox proportional hazards model to determine their significance.Median overall survival was 8.0 months, with a 30-day mortality rate of 3.0% and a 30-day complication rate of 34.0%. A Cox proportional hazards model showed radiosensitivity of the tumor (hazard ratio: 2.557, P<.001), preoperative ambulatory status (hazard ratio: 2.355, P=.0001), and Charlson Comorbidity Index (hazard ratio: 2.955, P<.01) to be significant predictors of survival. Breast cancer had the best prognosis (median survival, 27.1 months), whereas gastrointestinal tumors had the worst (median survival, 2.66 months).We identified the Charlson Comorbidity Index score as one of the strongest predictors of survival after surgery for spinal metastasis. We confirmed previous findings that radiosensitivity of the tumor and ambulatory status are significant predictors of survival.

    View details for DOI 10.1227/NEU.0b013e318207780c

    View details for Web of Science ID 000287242300036

    View details for PubMedID 21311295

  • Intradiscal treatment of back pain SPINE JOURNAL Carragee, E. J. 2011; 11 (2): 97-99

    View details for DOI 10.1016/j.spinee.2011.01.015

    View details for Web of Science ID 000286980400007

    View details for PubMedID 21296291

  • A case of late epidural hematoma in a patient on clopidogrel therapy postoperatively: when is it safe to resume antiplatelet agents? SPINE JOURNAL Carragee, E. J., Golish, S. R., Scuderi, G. J. 2011; 11 (1): E1-E4

    Abstract

    The use of antiplatelet agents after coronary artery stent placement is currently recommended to prevent coronary stent obstruction. These patients may have concurrent disabling spinal stenosis and require spinal decompression. Resuming antiplatelet agents as soon as possible after spinal surgery is recommended.To describe a unique case of late postoperative epidural hematoma occurring with the use of clopidogrel.A case report and review of the literature.The hospital chart, history, physical examination, and imaging of a single patient were reviewed.A 59-year-old man underwent spinal decompression and fusion for neurogenic claudication with lumbar spinal stenosis and spondylolisthesis while managed on clopidogrel for prevention of thrombosis after cardiac stent placement. He developed a symptomatic epidural hematoma 12 days postoperatively, well outside the usual time frame for this complication. The patient was closely monitored, and lumbar radiculopathy resolved over the ensuing days.After spinal surgery and resumption of antiplatelet therapy, the physician needs to maintain vigilance in observing patients for late postoperative complications such as epidural hematoma, which could have catastrophic consequences if not recognized in a timely manner.

    View details for DOI 10.1016/j.spinee.2010.10.013

    View details for Web of Science ID 000285414600001

    View details for PubMedID 21095164

  • Accelerated Degeneration After Failed Cervical and Lumbar Nucleoplasty JOURNAL OF SPINAL DISORDERS & TECHNIQUES Cuellar, V. G., Cuellar, J. M., Vaccaro, A. R., Carragee, E. J., Scuderi, G. J. 2010; 23 (8): 521-524

    Abstract

    Observational cohort study.Studies evaluating the treatment of presumed discogenic spine pain using nucleoplasty have reported variable success rates. It has been suggested that these procedures lower the intradiscal pressure, reduce disk protrusion, improve disk hydration, and restore disk height. It is proposed that such structural changes in treated disks correspond to the clinical improvement in patients. Radiographic and clinical evidence showing the efficacy of nucleoplasty remains inadequate.To document the comparative changes in magnetic resonance imaging (MRI) the appearance of disk morphology as reflected by Pfirrmann classification scores before and after the nucleoplasty treatment in patients with continued symptoms.Twenty-eight consecutive patients with persistent symptoms after nucleoplasty within 1 year of treatment were evaluated. Prenucleoplasty and postnucleoplasty MRIs were evaluated and Pfirrmann scores of the symptomatic level were determined.In all the treated patients, comparison between the prenucleoplasty and the postnucleoplasty MRI of the targeted disks failed to show increased signal hydration, disk space height improvement, or shrinkage of the preoperative disk bulge at a mean time of 6 months after the procedure. Of the 17 cervical levels treated in 12 patients, 5 seemed to show progressive degeneration at treated levels (42% of the patients). Of the 17 lumbar procedures in 16 patients, 4 seemed to show progressive degeneration (25% of the patients) and 1 developed a new spondylolisthesis (6.3%). Thus, 32% of the patients in our cohort showed progressive degeneration at the treated level. The median Pfirrmann score in both prenucleoplasty and postnucleoplasty was 2, and the mean Pfirrmann classification prenucleoplasty and postnucleoplasty was 1.8 and 2.1, respectively (P<0.05, 2-tailed t test).This study failed to detect any morphologic improvement of disk abnormalities by MRI evaluation in patients with persistent pain, who then underwent nucleoplasty. Thirty-two percent showed progressive degeneration in less than 1 year after nucleoplasty, a rate greater than expected by natural progression during the interval of examination.

    View details for DOI 10.1097/BSD.0b013e3181cc90dd

    View details for Web of Science ID 000284942700013

    View details for PubMedID 21131800

  • Identification of a complex between fibronectin and aggrecan G3 domain in synovial fluid of patients with painful meniscal pathology CLINICAL BIOCHEMISTRY Scuderi, G. J., Woolf, N., Dent, K., Golish, S. R., Cuellar, J. M., Cuellar, V. G., Yeomans, D. C., Carragee, E. J., Angst, M. S., Bowser, R., Hanna, L. S. 2010; 43 (10-11): 808-814

    Abstract

    We previously described a panel of four cytokines biomarkers in knee synovial fluid for acute knee pain associated with meniscal pathology. The cytokine biomarkers included interferon gamma (IFN-gamma), interleukin 6 (IL-6), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein-1 beta (MIP-1beta). Validation studies using other immunologic techniques confirmed the presence of IL-6, MCP-1 and MIP-1beta, but not IFN-gamma. Therefore we sought the identity of the IFN-gamma signal in synovial fluid.Knee synovial fluid was collected from patients with an acute, painful meniscal injury, as well as asymptomatic volunteers. A combination of high-pressure chromatography, mass spectrometry and immunological techniques were used to enrich and identify the protein components representing the IFN-gamma signal.A protein complex of fibronectin and the aggrecan G3 domain was identified in the synovial fluid of patients with a meniscal tear and pain that was absent in asymptomatic controls. This protein complex correlated to the IFN-gamma signal. A novel enzyme-linked immunosorbent assay (ELISA) was developed to specifically identify the complex in synovial fluid.We have identified a protein complex of fibronectin and aggrecan G3 domain that is a candidate biomarker for pain associated with meniscal injury.

    View details for DOI 10.1016/j.clinbiochem.2010.04.069

    View details for Web of Science ID 000279133100003

    View details for PubMedID 20460120

  • Minimum acceptable outcomes after lumbar spinal fusion SPINE JOURNAL Carragee, E. J., Cheng, I. 2010; 10 (4): 313-320

    Abstract

    Defining success after spinal surgery remains problematic. The minimal clinically important difference (MCID) in pain or functional outcomes is a common metric often calculated independent of perceived risk and morbidity, which is an important consideration in large procedures such as spinal fusion and instrumentation.The purpose of this study was to describe a method of assessing treatment success based on prospective, patient-reported "minimum acceptable" outcome for which they would undergo a procedure. These goals can then be compared at follow-up to gauge how frequently patient goals are met and determine correlation with patient satisfaction.This is a clinical descriptive study of the patient-reported minimum acceptable outcomes for spinal fusion surgery.Minimum acceptable outcomes were determined by patients on preoperatively administered standard questionnaires regarding ultimate pain intensity, functional outcome (Oswestry Disability Index [ODI]), medication usage, and work status. Satisfaction with outcomes was assessed at 2-year follow-up.One hundred sixty-five consecutive patients undergoing lumbar fusion for either isthmic spondylolisthesis or disc degeneration were asked to preoperatively define on standard questionnaires their minimum acceptable outcomes after surgery. Two-year outcomes and satisfaction were subsequently reported and compared with the preoperatively determined minimum acceptable outcomes.Both the spondylolisthesis and the degenerative disc disease (DDD) groups reported that a high degree of improvement was the minimum acceptable threshold for considering spinal fusion. A large majority indicated that the minimum acceptable outcomes included at least a decrease in pain intensity to 3/10 or less, an improvement in ODI of 20 or more, discontinuing opioid medications, and return to some occupational activity. Achieving the minimum acceptable outcome was strongly associated with satisfaction at 2 years after surgery. Patients with compensation claims, psychological distress, and other psychosocial stressors were more likely to report satisfaction in the absence of achieving their minimum acceptable outcome.Patients with spondylolisthesis and DDD both have relatively high minimum acceptable outcomes for spinal fusion. In these cohorts, few subjects considered more commonly proposed MCIDs for pain and function as an acceptable outcome and report that they would not have surgery if they did not expect to achieve more than those marginal improvements. Although there was good concordance between achieving the minimum acceptable outcomes and ultimate satisfaction, patients with significant psychosocial factors (compensation claims, psychological distress, and others) are less likely to associate satisfaction with outcomes with actually achieving these improvements.

    View details for DOI 10.1016/j.spinee.2010.02.001

    View details for Web of Science ID 000276971600006

    View details for PubMedID 20362247

  • The vertebroplasty affair: the mysterious case of the disappearing effect size SPINE JOURNAL Carragee, E. J. 2010; 10 (3): 191-192

    View details for DOI 10.1016/j.spinee.2010.01.002

    View details for Web of Science ID 000208284600002

    View details for PubMedID 20207329

  • Cytokine evaluation in individuals with low back pain using discographic lavage SPINE JOURNAL Cuellar, J. M., Golish, S. R., Reuter, M. W., Cuellar, V. G., Angst, M. S., Carragee, E. J., Yeomans, D. C., Scuderi, G. J. 2010; 10 (3): 212-218

    Abstract

    The pathophysiology underlying degenerative disc disease and its implication in painful syndromes remain unclear. However, spine magnetic resonance imaging (MRI) can demonstrate changes in disc water content and the annulus; provocative discography purportedly identifies degenerate discs causing serious low back pain; and biochemical assays have identified local inflammatory markers. No study to date has correlated pain on disc injection during discography evaluation with relevant MRI findings and biochemical markers.The purpose of this study was to correlate concordant pain on during discography to biochemical markers obtained by disc lavage and MRI findings.This is a Phase 1 Diagnostic Test Assessment Cohort Study (Sackett and Haynes).The patient sample included 21 symptomatic patients with suspected discogenic pain and three Phase 1 control subjects.The outcome measures included discography pain scores, MRI degenerative grades, and immunoreactivity to various inflammatory cytokine concentrations present in disc lavage samples.Twenty-one symptomatic patients with lumbar degenerative disc disease and three control subjects underwent discography, MRI, and biochemical analysis of disc lavage fluid. Lumbar MRI was scored for Pfirrmann grading of the lumbar discs, and annular disruption was identified by nuclear disc lavage. Disc lavage samples were analyzed for biochemical markers by high-sensitivity immunoassay.Eighty-three discs from 24 patients were studied: 67 discs from 21 patients with axial back pain (suspected discogenic pain group) and 16 discs from 3 scoliosis patients without back pain (Phase 1 control subjects). Among the biochemical markers surveyed, interferon gamma (IFN-gamma) immunoreactivity was most consistently identified in patients with axial back pain. Discs with annular disruption and concordant pain reproduction at a visual analog scale of 7 to 10/10 had greater IFN-gamma immunoreactivity than those without this finding (p=.003); however, at least some IFN-gamma immunoreactivity was found in all but one disc in the symptomatic group.Among the potential inflammatory markers tested in this Phase 1 study, IFN-gamma immunoreactivity was most commonly elevated in discogram "positive" discs but absent in asymptomatic controls. However, this marker was also frequently elevated in degenerative but "negative" discography discs. From these findings, Phase 2 and Phase 3 validity studies are reasonable to pursue. Phase 4 utility studies may be performed concurrently to assess this method's predictive value in outcome studies.

    View details for DOI 10.1016/j.spinee.2009.12.007

    View details for Web of Science ID 000208284600006

    View details for PubMedID 20207331

  • Pseudomorbidity in iliac crest bone graft harvesting: the rise of rhBMP-2 in short-segment posterior lumbar fusion SPINE JOURNAL Carragee, E. J., Bono, C. M., Scuderi, G. J. 2009; 9 (11): 873-879

    View details for DOI 10.1016/j.spinee.2009.09.001

    View details for Web of Science ID 000271754400001

    View details for PubMedID 19850231

  • Epidural Interferon Gamma-Immunoreactivity A Biomarker for Lumbar Nerve Root Irritation SPINE Scuderi, G. J., Cuellar, J. M., Cuellar, V. G., Yeomans, D. C., Carragee, E. J., Angst, M. S. 2009; 34 (21): 2311-2317

    Abstract

    Prospective observational cohort.Correlate epidural inflammatory cytokines with the clinical response to epidural steroid injection in patients with lumbar nerve root irritation.Some back pain syndromes are thought to be associated with activation of inflammatory pathways and others may be associated with primary mechanical derangements. Human studies providing detailed evidence for the primary inflammatory causation, which may be best treated with anti-inflammatory strategies, are lacking. There are currently no accurate diagnostic tests to predict the response to epidural steroid injection or surgical intervention in back pain and sciatica syndromes. METHODS.: Forty-seven consecutive patients with lumbar degenerative changes and low back and/or leg pain were prospectively enrolled. An epidural lavage was performed, followed by injection of marcaine/depo-medrol. Subjects scored their pain before and 3 months after the procedure. The immunoreactivity of an array of cytokines was measured in lavage samples and compared with clinical response to the therapeutic injection. Ten subjects underwent repeat epidural lavage sampling 3 months after the steroid injection.Interferon gamma (IFNgamma) was the most consistently detected cytokine. IFNgamma-immunoreactivity also highly correlated with reported reduction of pain 3-months after the epidural steroid injection. In subjects reporting significant pain relief (>50%) from the injection, mean [IFNgamma] was significantly greater compared with patients experiencing no significant relief. The IFNgamma-immunoreactivity in repeat lavage samples decreased to trace residual concentrations in patients who reported pain relief from the steroid injection.The presence of epidural IFNgamma-immunoreactivity corresponding to >10 pg/mL predicted significant pain relief after epidural steroid injection with >95% accuracy. These results suggest that IFNgamma may be part of a biochemical cascade triggering pain in sciatica; IFNgamma-immunoreactivity may aid as a biomarker for predicting the response to steroid therapy and/or surgical intervention, and may serve as a future therapeutic target.

    View details for DOI 10.1097/BRS.0b013e3181af06b6

    View details for Web of Science ID 000270382600011

    View details for PubMedID 19934811

  • 2009 ISSLS Prize Winner: Does Discography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disc A Ten-Year Matched Cohort Study SPINE Carragee, E. J., Don, A. S., Hurwitz, E. L., Cuellar, J. M., Carrino, J., Herzog, R. 2009; 34 (21): 2338-2345

    Abstract

    Prospective, match-cohort study of disc degeneration progression over 10 years with and without baseline discography. Objectives. To compare progression of common degenerative findings between lumbar discs injected 10 years earlier with those same disc levels in matched subjects not exposed to discography. Summary of Background Data. Experimental disc puncture in animal and in vivo studies have demonstrated accelerated disc degeneration. Whether intradiscal diagnostic or treatment procedures used in clinical practice causes any damage to the punctured discs over time is currently unknown.Seventy-five subjects without serious low back pain illness underwent a protocol MRI and an L3/4, L4/5, and L5/S1 discography examination in 1997. A matched group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for 10 years. At 7 to 10 years after baseline assessment, eligible discography and controlled subjects underwent another protocol MRI examination. MRI graders, blind to group designation, scored both groups for qualitative findings (Pfirrmann grade, herniations, endplate changes, and high intensity zone). Loss of disc height and loss of disc signal were measured by quantitative methods.Well matched cohorts, including 50 discography subjects and 52 control subjects, were contacted and met eligibility criteria for follow-up evaluation. In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (noninjected) discs: progression of disc degeneration, 54 discs (35%) in the discography group compared to 21 (14%) in the control group (P = 0.03); 55 new disc herniations in the discography group compared to 22 in the control group (P = 0.0003). New disc herniations were disproportionately found on the side of the anular puncture (P = 0.0006). The quantitative measures of disc height and disc signal also showed significantly greater loss of disc height (P = 0.05) and signal intensity (P = 0.001) in the discography disc compared to the control disc.Modern discography techniques using small gauge needle and limited pressurization resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and the development of reactive endplate changes compared to match-controls. Careful consideration of risk and benefit should be used in recommending procedures involving disc injection.

    View details for DOI 10.1097/BRS.0b013e3181ab5432

    View details for Web of Science ID 000270382600014

    View details for PubMedID 19755936

  • Continuing debate: validity and utility of magnetic resonance imaging of the upper cervical spine after whiplash exposure SPINE JOURNAL Carragee, E. J. 2009; 9 (9): 778-779

    View details for DOI 10.1016/j.spinee.2009.06.003

    View details for Web of Science ID 000269771300013

    View details for PubMedID 19699466

  • Changes in posterior lumbar disk contour abnormality with flexion-extension movement in subjects with low back pain and degenerative disk disease. PM & R : the journal of injury, function, and rehabilitation Lee, S., Lee, J., Butts, K., Carragee, E., Fredericson, M. 2009; 1 (6): 541-546

    Abstract

    To determine whether posterior lumbar disk contour dimensions differ in the flexed seated, upright seated, and extended seated positions.Two subgroups of subjects with degenerative disk disease were compared: those with central posterior disk bulge (at L4-5 or L5-S1 levels) and those with a dark nucleus pulposus without posterior disk bulge (L3-4, L4-5, and/or L5-S1 levels).Academic medical center.Eight subjects with a central disk bulge and 9 subjects with a dark nucleus pulposus on magnetic resonance imaging.Not applicable.Quantitative comparisons of posterior disk contour between neutral, flexed, and extended sitting positions.Of 8 subjects with central disk bulge, spinal flexion (from the neutral position) produced a decreased disk contour in all subjects, whereas spinal extension (from the neutral position) produced an increased disk contour in 6 subjects, a decreased disk contour in 1 subject, and no measurable change in 1 subject. Changes in posterior disk contour in subjects with a dark nucleus pulposus were variable. Approximately half increased and half decreased, but no relation to position was determined.The results of this pilot study suggest a consistent pattern of decreased posterior disk contour with spinal flexion and increased posterior disk contour with spinal extension in subjects with central disk bulge, but not in those with a dark nucleus pulposus.

    View details for DOI 10.1016/j.pmrj.2009.03.014

    View details for PubMedID 19627944

  • Surgery for Low Back Pain A Review of the Evidence for an American Pain Society Clinical Practice Guideline SPINE Chou, R., Baisden, J., Carragee, E. J., Resnick, D. K., Shaffer, W. O., Loeser, J. D. 2009; 34 (10): 1094-1109

    Abstract

    Systematic review.To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis.Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions.Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms.Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

    View details for DOI 10.1097/BRS.0b013e3181a105fc

    View details for Web of Science ID 000265677900015

    View details for PubMedID 19363455

  • Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain An Evidence-Based Clinical Practice Guideline From the American Pain Society SPINE Chou, R., Loeser, J. D., Owens, D. K., Rosenquist, R. W., Atlas, S. J., Baisden, J., Carragee, E. J., Grabois, M., Murphy, D. R., Resnick, D. K., Stanos, S. P., Shaffer, W. O., Wall, E. M. 2009; 34 (10): 1066-1077

    Abstract

    Clinical practice guideline.To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain.A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group.Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations.Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

    View details for DOI 10.1097/BRS.0b013e3181a1390d

    View details for Web of Science ID 000265677900013

    View details for PubMedID 19363457

  • Lifetime Asymptomatic for Back Pain The Validity of Self-report Measures in Soldiers SPINE Carragee, E. J., Cohen, S. P. 2009; 34 (9): 978-983

    Abstract

    A 5-year prospective observational study in US Army Reserve soldiers.The aims of this study were 2-fold: to evaluate the prevalence of soldiers reporting no previous back pain (BP) on 3 consecutive annual assessments, and to compare these findings to those obtained from a subsequent monthly detailed BP assessment.BP history is a risk factor for future BP and disability. Conversely, subjects reporting a negative history of back troubles are thought to be at low risk for future BP events. Reporting of previous BP is assumed to have high validity. Few studies have critically evaluated the validity of the self-reported "lifetime asymptomatic" status in civilian or military populations.Two hundred eighty-five special operations reserve soldiers were queried annually using standardized US Army Medical Questionnaires, among whom 154 (54%) reported no BP or history thereof over 3 consecutive years. Over the next 18 months these soldiers completed annual US Army Medical Questionnaires, as well as monthly numerical rating scale pain scores, Oswestry Disability Indexes, and questions regarding back injuries. At the study's conclusion, soldiers again completed the annual medical certificate, and the results of this final BP assessment were compared with those from monthly surveillance reports.During monthly surveillance of purported "lifetime asymptomatic" soldiers, the 18-month cumulative percentages reporting BP scores > or = 2, > or = 4, and > or = 6 were 84%, 64%, and 14%, respectively. For Oswestry Disability Index scores, these percentages were 25% for scores > or = 10, and 12% for scores > or = 20. Yet, at the conclusion of the 5-year study, 97% soldiers still described themselves as being "asymptomatic for BP problems."In physically active soldiers self-identified as without back problems, the report of BP using frequent surveillance tools is extremely common. The overwhelming majority of these soldiers appeared to have high resilience to common BP episodes (i.e., returned to usual duties). Episodic BP should be considered a normative rather than exceptional occurrence. Similar to other conditions, long-interval surveys of BP history may underestimate the true prevalence of BP.

    View details for DOI 10.1097/BRS.0b013e318198d517

    View details for Web of Science ID 000265677800018

    View details for PubMedID 19532006

  • Clinical Research Is the Spine Field a Mine Field? SPINE Carragee, E. J., Deyo, R. A., Kovacs, F. M., Peul, W. C., Lurie, J. D., Urrutia, G., Corbin, T. P., Schoene, M. L. 2009; 34 (5): 423-430

    View details for DOI 10.1097/BRS.0b013e318198c962

    View details for Web of Science ID 000265673900001

    View details for PubMedID 19212275

  • TREATMENT OF NECK PAIN Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Reprinted from Spine, vol 33, pg S153-S169, 2008) JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS Carragee, E. J., Hurwitz, E. L., Cheng, I., Carroll, L. J., Nordin, M., Guzman, J., Peloso, P., Holm, L. W., Cote, P., Hogg-Johnson, S., van der Velde, G., Cassidy, J. D., Haldeman, S. 2009; 32 (2): S176-S193

    Abstract

    Best evidence synthesis.To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease.There have been no comprehensive systematic literature or evidence-based reviews published on this topic.We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis.Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients.Surgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, seems to lack scientific support.

    View details for DOI 10.1016/j.jmpt.2008.11.018

    View details for Web of Science ID 000264208500018

    View details for PubMedID 19251063

  • Lumbar Spine: Reliability of MR Imaging Findings RADIOLOGY Carrino, J. A., Lurie, J. D., Tosteson, A. N., Tosteson, T. D., Carragee, E. J., Kaiser, J., Grove, M. R., Blood, E., Pearson, L. H., Weinstein, J. N., Herzog, R. 2009; 250 (1): 161-170

    Abstract

    To characterize the inter- and intraobserver variability of qualitative, non-disk contour degenerative findings of the lumbar spine at magnetic resonance (MR) imaging.The case accrual method used to perform this institutional review board-approved, HIPAA-compliant retrospective study was the random selection of 111 interpretable MR examination cases of subjects from the Spine Patient Outcomes Research Trial. The subjects were aged 18-87 years (mean, 53 years +/- 16 [standard deviation]). Four independent readers rated the cases according to defined criteria. A subsample of 40 MR examination cases was selected for reevaluation at least 1 month later. The following findings were assessed: spondylolisthesis, disk degeneration, marrow endplate abnormality (Modic changes), posterior anular hyperintense zone (HIZ), and facet arthropathy. Inter- and intraobserver agreement in rating the data was summarized by using weighted kappa statistics.Interobserver agreement was good (kappa = 0.66) in rating disk degeneration and moderate in rating spondylolisthesis (kappa = 0.55), Modic changes (kappa = 0.59), facet arthropathy (kappa = 0.54), and posterior HIZ (kappa = 0.44). Interobserver agreement in rating the extent of Modic changes was moderate: kappa Values were 0.43 for determining superior anteroposterior extent, 0.47 for determining superior craniocaudal extent, 0.57 for determining inferior anteroposterior extent, and 0.48 for determining inferior craniocaudal extent. Intraobserver agreement was good in rating spondylolisthesis (kappa = 0.66), disk degeneration (kappa = 0.74), Modic changes (kappa = 0.64), facet arthropathy (kappa = 0.69), and posterior HIZ (kappa = 0.67). Intraobserver agreement in rating the extent of Modic changes was moderate, with kappa values of 0.54 for superior anteroposterior, 0.60 for inferior anteroposterior, 0.50 for superior craniocaudal, and 0.60 for inferior craniocaudal extent determinations.The interpretation of general lumbar spine MR characteristics has sufficient reliability to warrant the further evaluation of these features as potential prognostic indicators.

    View details for DOI 10.1148/radiol.2493071999

    View details for Web of Science ID 000265642700021

    View details for PubMedID 18955509

  • Is the self-reported history accurate in patients with persistent axial pain after a motor vehicle accident? SPINE JOURNAL Don, A. S., Carragee, E. J. 2009; 9 (1): 4-12

    Abstract

    A patient's self-reported history has, in general, assumed to be accurate. Clinical management of individuals with persistent axial pain after a motor vehicle accident (MVA) and measures to prevent future MVA, spinal cord injury, and traffic deaths often depend on a presumed accurate report of preexisting axial pain, drug, alcohol, and psychological problems to initiate intervention. In addition, research efforts to determine the effects of MVA on subsequent health are often predicated on a presumed accurate history from the patient of past medical and psychosocial problems. Despite so many clinical, public health, and research efforts being dependent on an accurate assessment of pre-injury health, the validity of the self-reported history after MVA has not been systematically investigated.To determine the validity of self-reported history in subjects with axial neck or back pain attributed to a recent MVA.A prospective, multiclinic validation study examining the critical elements of a patient's self-reported history after an MVA judged against an audit of his or her medical records.A cohort of consecutive patients with persistent axial pain after an MVA was prospectively identified from five spine-specialist's outpatient clinics. Of 702 patients, 335 subjects were randomly selected for auditing of their medical records.Self-reported demographic and clinical features were recorded by standardized questionnaires and clinical interviews. Audits compared these responses to an extensive medical record search.The self-reported prevalence of preexisting axial pain, at-risk comorbidities (psychological distress, alcohol, and drug abuse), and control conditions (hypertension and diabetes) was recorded. The medical records of a random sample of 50% of the enrolled cohort underwent auditing of their medical records in a wide search of network paper and electronic and archived records, and compared with the self-reported history of pre-accident health.Overall, approximately 50% of the subjects were found to have previous axial pain problems at audit when none was reported to the spine-specialist after an MVA. Similarly, approximately 75% of the subjects were found to have one or more preexisting comorbid conditions at audit that were not reported during the evaluation after the MVA (alcohol abuse, illicit drug use, and psychological diagnosis). For those who perceived that the accident was the fault of another, as opposed to their own or no one's fault, the documented previous back and neck pain troubles in the medical records was more than twice the self-reported rate of these problems (p<.01). The rate of previously documented psychological problems was more than seven times that of the self-reported rate (p = 0.001). In those subjects who perceived that the accident was their own or no one's fault, a lesser degree of under-reporting of axial pain and comorbid conditions was found.The validity of the patient's self-reported history when presenting with persistent axial pain after an MVA appears poor in this large multiclinic random sample.The self-reported rates of alcohol abuse, illicit drug use, and psychological diagnosis, as well as prior axial pain were significantly lower than that seen in the medical records, especially in thosewho perceive that the MVA was another's fault. The failure to recognize this under-reporting may seriously compromise clinical care, public health efforts at injury prevention, and research protocols dependent on accurate pre-accident morbidity assessments.

    View details for DOI 10.1016/j.spinee.2008.11.002

    View details for Web of Science ID 000262378500002

    View details for PubMedID 19111258

  • Does acute placement of instrumentation in the treatment of vertebral osteomyelitis predispose to recurrent infection - Long-term follow-up in immune-suppressed patients SPINE Carragee, E., Iezza, A. 2008; 33 (19): 2089-2093

    Abstract

    Single institution, prospective observation study.To determine the long-term clinical outcomes of immune-suppressed patients with pyogenic vertebral osteomyelitis (PVO) treated with spinal instrumentation in the setting of active infection.The mainstay of treatment for PVO remains nonoperative. Surgical indications include neurologic compromise, deformity, abscess and failure of medical management. Some authors have been concerned regarding risk of local infection reoccurrence when spinal instrumentation has been placed in the setting of active infection. To our knowledge no long-term follow-up has been reported for this condition.Thirty-two consecutive immune compromised patients with PVO were treated with debridement and spinal instrumentation in the setting of acute infection at a single institution. Patients were observed by a set protocol and evaluated for reoccurrence of infection at regular intervals for up to 10 years.The 32 patients in our study group had significant medical comorbidities and were immune compromised. All patients were treated with single stage debridement and instrumented fusion during active infection. Twenty-two patients had a full 10 years follow-up without clinical recurrence of the local infection. Four patients died during the observation period, and none had clinic or autopsy evidence of recurrence. One patient developed recurrent infection after 14 months and was successfully treated with repeat debridement and retention of the instrumentation. Although this patient had a chronically infected vascular shunt, he was disease free at final follow-up of 10 years. Four patients had their implants removed for pain, suspected nonunion or suspected recurrent infection. None of these patients had histologic or microbacteriological evidence of injection.The use of spinal instrumentation in immune-compromised patients with PVO is associated with a low risk of long-term recurrent infection.

    View details for Web of Science ID 000258928800012

    View details for PubMedID 18758365

  • Reliability of readings of magnetic resonance imaging features of lumbar spinal stenosis SPINE Lurie, J. D., Tosteson, A. N., Tosteson, T. D., Carragee, E., Carrino, J., Kaiser, J., Sequeiros, R. T., Lecomte, A. R., Grove, M. R., Blood, E. A., Pearson, L. H., Weinstein, J. N., Herzog, R. 2008; 33 (14): 1605-1610

    Abstract

    A reliability assessment of standardized magnetic resonance imaging (MRI) interpretations and measurements.To determine the intra- and inter-reader reliability of MRI features of lumbar spinal stenosis (SPS), including severity of central, subarticular, and foraminal stenoses, grading of nerve root impingement, and measurements of cross-sectional area of the spinal canal and thecal sac.MRI is commonly used to assess patients with spinal stenosis. Although a number of studies have evaluated the reliability of certain MRI characteristics, comprehensive evaluation of the reliability of MRI readings in spinal stenosis is lacking.Fifty-eight randomly selected MR images from patients with SPS enrolled in the Spine Patient Outcomes Research Trial were evaluated. Qualitative ratings of imaging features were performed according to defined criteria by 4 independent readers (3 radiologists and 1 orthopedic surgeon). A sample of 20 MRIs was reevaluated by each reader at least 1 month later. Weighted kappa statistics were used to characterize intra- and inter-reader reliability for qualitative rating data. Separate quantitative measurements were performed by 2 other radiologists. Intraclass correlation coefficients and summaries of measurement error were used to characterize reliability for quantitative measurements.Intra-reader reliability was higher than inter-reader reliability for all features. Inter-reader reliability in assessing central stenosis was substantial, with an overall kappa of 0.73 (95% CI 0.69-0.77). Foraminal stenosis and nerve root impingement showed moderate to substantial agreement with overall kappa of 0.58 (95% CI 0.53-0.63) and 0.51 (95% CI 0.42-0.59), respectively. Subarticular zone stenosis yielded the poorest agreement (overall kappa 0.49; 95% CI 0.42-0.55) and showed marked variability in agreement between reader pairs. Quantitative measures showed inter-reader intraclass correlation coefficients ranging from 0.58 to 0.90. The mean absolute difference between readers in measured thecal sac area was 128 mm (13%).The imaging characteristics of spinal stenosis assessed in this study showed moderate to substantial reliability; future studies should assess whether these findings have prognostic significance in SPS patients.

    View details for Web of Science ID 000256837500016

    View details for PubMedID 18552677

  • Reliability of magnetic resonance imaging readings for lumbar disc herniation in the Spine Patient Outcomes Research Trial (SPORT) SPINE Lurie, J. D., Tosteson, A. N., Tosteson, T. D., Carragee, E., Carrino, J., Kaiser, J., Sequeiros, R. T., Lecomte, A. R., Grove, M. R., Blood, E. A., Pearson, L. H., Herzog, R., Weinstein, J. N. 2008; 33 (9): 991-998

    Abstract

    Assessment of the reliability of standardized magnetic resonance imaging (MRI) interpretations and measurements.To determine the intra- and inter-reader reliability of MRI parameters relevant to patients with intervertebral disc herniation (IDH), including disc morphology classification, degree of thecal sac compromise, grading of nerve root impingement, and measurements of cross-sectional area of the spinal canal, thecal sac, and disc fragment.MRI is increasingly used to assess patients with sciatica and IDH, but the relationship between specific imaging characteristics and patient outcomes remains uncertain. Although other studies have evaluated the reliability of certain MRI characteristics, comprehensive evaluation of the reliability of readings of herniated disc features on MRI is lacking.Sixty randomly selected MR images from patients with IDH enrolled in the Spine Patient Outcomes Research Trial were each rated according to defined criteria by 4 independent readers (3 radiologists and 1 orthopedic surgeon). Quantitative measurements were performed separately by 2 other radiologists. A sample of 20 MRIs was re-evaluated by each reader at least 1 month later. Agreement for rating data were assessed with kappa statistics using linear weights. Reliability of the quantitative measurements was assessed using intraclass correlation coefficients (ICCs) and summaries of measurement error.Inter-reader reliability was substantial for disc morphology [overall kappa 0.81 (95% confidence interval (CI): 0.78, 0.85)], moderate for thecal sac compression [overall kappa 0.54 (95% CI: 0.37, 0.68)], and moderate for grading nerve root impingement [overall kappa 0.47 (95% CI: 0.36, 0.56)]. Quantitative measures showed high ICCs of 0.87 to 0.96 for spinal canal and thecal sac cross-sectional areas. Measures of disc fragment area had moderate ICCs of 0.65 to 0.83. Mean absolute differences between measurements ranged from approximately 15% to 20%.Classification of disc morphology showed substantial intra- and inter-reader agreement, whereas thecal sac and nerve root compression showed more moderate reader reliability. Quantitative measures of canal and thecal sac area showed good reliability, whereas measurement of disc fragment area showed more modest reliability.

    View details for Web of Science ID 000255290300010

    View details for PubMedID 18427321

  • Assessment of neck pain and its associated disorders - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Nordin, M., Carragee, E. J., Hogg-Johnson, S., Weine, S. S., Hurwitz, E. L., Peloso, P. M., Guzman, J., van der Velde, G., Carroll, L. J., Holm, L. W., Cote, P., Cassidy, J. D., Haldeman, S. 2008; 17: S101-S122
  • Treatment of neck pain: Noninvasive interventions - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Hurwitz, E. L., Carragee, E. J., van der Velde, G., Carroll, L. J., Nordin, M., Guzman, J., Peloso, P. M., Holm, L. W., Cote, P., Hogg-Johnson, S., Cassidy, J. D., Haldeman, S. 2008; 17: S123-S152
  • The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Holm, L. W., Carroll, L. J., Cassidy, J. D., Hogg-Johnson, S., Cote, P., Guzman, J., Peloso, P., Nordin, M., Hurwitz, E., van der Velde, G., Carragee, E., Haldeman, S. 2008; 17: S52-S59
  • Course and prognostic factors for neck pain in whiplash-associated disorders (WAD) - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Carroll, L. J., Holm, L. W., Hogg-Johnson, S., Cote, P., Cassidy, J. D., Haldeman, S., Nordin, M., Hurwitz, E. L., Carragee, E. J., van der Velde, G., Peloso, P. M., Guzman, J. 2008; 17: S83-S92
  • The burden and determinants of neck pain in the general population - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Hogg-Johnson, S., van der Velde, G., Carroll, L. J., Holm, L. W., Cassidy, J. D., Guzman, J., Cote, P., Haldeman, S., Ammendolia, C., Carragee, E., Hurwitz, E., Nordin, M., Peloso, P. 2008; 17: S39-S51
  • Course and prognostic factors for neck pain in workers - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Carroll, L. J., Hogg-Johnson, S., Cote, P., van der Velde, G., Holm, L. W., Carragee, E. J., Hurwitz, E. L., Peloso, P. M., Cassidy, J. D., Guzman, J., Nordin, M., Haldeman, S. 2008; 17: S93-S100
  • Research priorities and methodological implications - The bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Carroll, L. J., Hurwitz, E. L., Cote, P., Hogg-Johnson, S., Carragee, E. J., Nordin, M., Holm, L. W., van der Velde, G., Cassidy, J. D., Guzman, J., Peloso, P. M., Haldeman, S. 2008; 17: S214-S220
  • Clinical practice implications of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders - From concepts and findings to recommendations EUROPEAN SPINE JOURNAL Guzman, J., Haldeman, S., Carroll, L. J., Carragee, E. J., Hurwitz, E. L., Peloso, P., Nordin, M., Cassidy, J. D., Holm, L. W., Cote, P., van der Velde, G., Hogg-Johnson, S. 2008; 17: S199-S213
  • Methods for the best evidence synthesis on neck pain and its associated disorders - The bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Carroll, L. J., Cassidy, J. D., Peloso, P. M., Giles-Smith, L., Cheng, C. S., Greenhalgh, S. W., Haldeman, S., van der Velde, G., Hurwitz, E. L., Cote, P., Nordin, M., Hogg-Johnson, S., Holm, L. W., Guzman, J., Carragee, E. J. 2008; 17: S33-S38
  • Course and prognostic factors for neck pain in the general population - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Carroll, L. J., Hogg-Johnson, S., van der Velde, G., Haldeman, S., Holm, L. W., Carragee, E. J., Hurwitz, E. L., Cote, P., Nordin, M., Peloso, P. M., Guzman, J., Cassidy, J. D. 2008; 17: S75-S82
  • A new conceptual model of neck pain - Linking onset, course, and care: The bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Guzman, J., Hurwitz, E. L., Carroll, L. J., Haldeman, S., Cote, P., Carragee, E. J., Peloso, P. M., van der Velde, G., Holm, L. W., Hogg-Johnson, S., Nordin, M., Cassidy, J. D. 2008; 17: S14-S23
  • Treatment of neck pain - Injections and surgical interventions: Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Carragee, E. J., Hurwitz, E. L., Cheng, I., Carroll, L. J., Nordin, M., Guzman, J., Peloso, P., Holm, L. W., Cote, P., Hogg-Johnson, S., van der Velde, G., Cassidy, J. D., Haldeman, S. 2008; 17: S153-S169

    Abstract

    Best evidence synthesis.To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease.There have been no comprehensive systematic literature or evidence-based reviews published on this topic.We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis.Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients.Surgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, seems to lack scientific support.

    View details for DOI 10.1007/s00586-008-0632-y

    View details for Web of Science ID 000255167500017

  • The burden and determinants of neck pain in workers - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders EUROPEAN SPINE JOURNAL Cote, P., van der Velde, G., Cassidy, J. D., Carroll, L. J., Hogg-Johnson, S., Holm, L. W., Carragee, E. J., Haldeman, S., Nordin, M., Hurwitz, E. L., Guzman, J., Peloso, P. M. 2008; 17: S60-S74
  • Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents SPINE JOURNAL Carragee, E. J. 2008; 8 (2): 311-319

    Abstract

    Determining the presence of comorbid conditions in patients with persistent axial pain after motor vehicle accident (MVA) is important to direct appropriate care and as a public health measure against future traffic injuries. In the clinical care of patients after MVA, they are usually asked about previous axial pain problems and relevant comorbid conditions (psychological distress and drug and alcohol abuse). The accuracy of self-reported previous axial pain history and comorbid conditions after MVA has not been systematically evaluated but has been assumed to be high.To establish the validity of certain elements of the self-reported history in patients with back or neck pain attributed to an MVA.A validation study of crucial elements of the patient history obtained after MVA using internal (chart audit) and external (age- and sex-matched population data) as gold standard references.Medium-sized (n>400) clinical cohort of patients without fracture or dislocation seen within 3 months after an MVA in a university spine clinic.Responses to standardized questionnaires included previous back or neck pain, previous psychological distress, previous illicit drug usage, previous alcohol abuse, other chronic pain conditions, perceived fault of the MVA, and whether a compensation claim has been filed.A consecutive cohort of patients seen from 1998 to 2004 for evaluation of back or neck/shoulder pain reportedly caused by an MVA was enrolled. All clinic patients completed standardized questionnaires. The prevalence of self-reported pre-MVA axial pain and at-risk conditions (drug, alcohol, and psychological problems) and control conditions (hypertension and diabetes) were compared against the age- and sex-matched prevalence determined by the 2005 US Department of Health and Human Services National Surveys on Drug Use and Health (external gold standard). Randomly selected previous medical records were also audited (internal gold standard) and compared with post-MVA description of preaccident health.Four hundred twenty-two subjects were enrolled, and random audits of 100 subjects were completed. In 68% of the random audits, comorbid conditions denied in the postaccident history (previous axial pain, drug or alcohol abuse, and psychological diagnoses) were documented. In subjects perceiving the MVA to be another's fault (but not their own), the reported prevalence of previous axial pain was markedly below matched data for population prevalence and audited data. Similar findings were observed for psychological problems, illicit drug use, and alcohol abuse. In subjects pursuing compensation claims and retaining an attorney, 80% had significant past axial pain history or serious comorbidities in their records not disclosed in the spine clinic evaluation. In subjects reporting that the MVA was either one's "own fault" or "no one's fault," this effect was seen but was smaller in all dimensions.In patients being seen for continued pain related to an MVA, the validity of self-reported previous axial pain and comorbid conditions appeared poor. The self-reported prevalence of previous axial pain and drug, alcohol, and psychological problems is much less than the documented prevalence in prior medical records. These rates were also markedly below the expected prevalence in age- and sex-matched populations. This effect was seen most prominently in patients perceiving the accident to be another party's fault and in those filing compensation claims. The failure to appreciate previous axial pain problems and drug, alcohol, and psychological problems may compromise patient care and public health opportunities.

    View details for DOI 10.1016/j.spinee.2007.04.008

    View details for Web of Science ID 000254240800007

    View details for PubMedID 17662666

  • Course and prognostic factors for neck pain in workers - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Carroll, L. J., Hogg-Johnson, S., Cote, P., van der Velde, G., Holm, L. W., Carragee, E. J., Hurwitz, E. L., Peloso, P. M., Cassidy, J. D., Guzman, J., Nordin, M., Haldeman, S. 2008; 33 (4): S93-S100

    Abstract

    Best-evidence synthesis.To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in workers.Knowledge of the course of neck pain in workers guides expectations for recovery. Identifying prognostic factors assists in planning effective workplace policies, formulating interventions and promoting lifestyle changes to decrease the frequency and burden of neck pain in the workplace.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 14 of these studies related to course and prognostic factors in working populations. Between 60% and 80% of workers with neck pain reported neck pain 1 year later. Few workplace or physical job demands were identified as being linked to recovery from neck pain. However, workers with little influence on their own work situation had a slightly poorer prognosis, and white-collar workers had a better prognosis than blue-collar workers. General exercise was associated with better prognosis; prior neck pain and prior sick leave were associated with poorer prognosis.The Neck Pain Task Force presents a report of current best evidence on course and prognosis for neck pain. Few modifiable prognostic factors were identified; however, having some influence over one's own job and being physically active seem to hold promise as prognostic factors.

    View details for Web of Science ID 000253739500014

    View details for PubMedID 18204406

  • The burden and determinants of neck pain in workers - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Cote, P., van der Velde, G., Cassidy, J. D., Carroll, L. J., Hogg-Johnson, S., Holm, L. W., Carragee, E. J., Haldeman, S., Nordin, M., Hurwitz, E. L., Guzman, J., Peloso, P. M. 2008; 33 (4): S60-S74

    Abstract

    Systematic review and best evidence synthesis.To describe the prevalence and incidence of neck pain and disability in workers; to identify risk factors for neck pain in workers; to propose an etiological diagram; and to make recommendations for future research.Previous reviews of the etiology of neck pain in workers relied on cross-sectional evidence. Recently published cohorts and randomized trials warrant a re-analysis of this body of research.We systematically searched Medline for literature published from 1980-2006. Retrieved articles were reviewed for relevance. Relevant articles were critically appraised. Articles judged to have adequate internal validity were included in our best evidence synthesis.One hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible. The annual prevalence of neck pain varied from 27.1% in Norway to 47.8% in Québec, Canada. Each year, between 11% and 14.1% of workers were limited in their activities because of neck pain. Risk factors associated with neck pain in workers include age, previous musculoskeletal pain, high quantitative job demands, low social support at work, job insecurity, low physical capacity, poor computer workstation design and work posture, sedentary work position, repetitive work and precision work. We found preliminary evidence that gender, occupation, headaches, emotional problems, smoking, poor job satisfaction, awkward work postures, poor physical work environment, and workers' ethnicity may be associated with neck pain. There is evidence that interventions aimed at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers.Neck disorders are a significant source of pain and activity limitations in workers. Most neck pain results from complex relationships between individual and workplace risk factors. No prevention strategies have been shown to reduce the incidence of neck pain in workers.

    View details for Web of Science ID 000253739500011

    View details for PubMedID 18204402

  • Methods for the best evidence synthesis on neck pain and its associated disorders - The bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Carroll, L. J., Cassidy, J. D., Peloso, P. M., Giles-Smith, L., Cheng, C. S., Greenhalgh, S. W., Haldeman, S., van der Velde, G., Hurwitz, E. L., Cote, P., Nordin, M., Hogg-Johnson, S., Holm, L. W., Guzman, J., Carragee, E. J. 2008; 33 (4): S33-S38

    Abstract

    Best evidence synthesis.To provide a detailed description of the methods undertaken in a systematic search and perform a best evidence synthesis on the frequency, determinants, assessment, interventions, course and prognosis of neck pain, and its associated disorders.Neck pain is an important cause of health burden; however, the published information is vast, and stakeholders would benefit from a summary of the best evidence.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders conducted a systematic search and critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain. Citations were screened for relevance to the Neck Pain Task Force mandate, using a priori criteria, and relevant studies were critically reviewed for their internal scientific validity. Findings from studies meeting criteria for scientific validity were synthesized into a best evidence synthesis.We found 31,878 citations, of which 1203 were relevant to the mandate of the Neck Pain Task Force. After critical review, 552 studies (46%) were judged scientifically admissible and were compiled into the best evidence synthesis.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders undertook a best evidence synthesis to establish a baseline of the current best evidence on the epidemiology, assessment and classification of neck pain, as well as interventions and prognosis for this symptom. This article reports the methods used and the outcomes from the review. We found that 46% of the research literature was of acceptable scientific quality to inform clinical practice, policy-making, and future research.

    View details for Web of Science ID 000253739500008

    View details for PubMedID 18204397

  • The burden and determinants of neck pain in the general population - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Hogg-Johnson, S., van der Velde, G., Carroll, L. J., Holm, L. W., Cassidy, J. D., Guzman, J., Cote, P., Haldeman, S., Ammendolia, C., Carragee, E., Hurwitz, E., Nordin, M., Peloso, P. 2008; 33 (4): S39-S51

    Abstract

    Best evidence synthesis.To undertake a best evidence synthesis of the published evidence on the burden and determinants of neck pain and its associated disorders in the general population.The evidence on burden and determinants of neck has not previously been summarized.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Studies meeting criteria for scientific validity were included in a best evidence synthesis.We identified 469 studies on burden and determinants of neck pain, and judged 249 to be scientifically admissible; 101 articles related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person years (disc herniation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30% and 50%; the 12-month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing.Neck pain is common. Nonmodifiable risk factors for neck pain included age, gender, and genetics. Modifiable factors included smoking, exposure to tobacco, and psychological health. Disc degeneration was not identified as a risk factor. Future research should concentrate on longitudinal designs exploring preventive strategies and modifiable risk factors for neck pain.

    View details for Web of Science ID 000253739500009

    View details for PubMedID 18204398

  • Research priorities and methodological implications - The bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Carroll, L. J., Hurwitz, E. L., Cote, P., Hogg-Johnson, S., Carragee, E. J., Nordin, M., Holm, L. W., van der Velde, G., Cassidy, J. D., Guzman, J., Peloso, P. M., Haldeman, S. 2008; 33 (4): S214-S220

    Abstract

    Best evidence synthesis.To report on gaps in the literature and make methodologic recommendations based on our review of the literature on frequency and risk factors, assessment, intervention, and course and prognostic factors for neck pain and its associated disorders.The scientific literature on neck pain is large and of variable quality. We reviewed 1203 studies and judged 46% to be of sufficient scientific validity to be included in the best evidence synthesis. Scientific quality varied across study topics, and fundamental questions remain about important issues.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.We outline a large number of gaps in the current literature. For example, we found important gaps in our knowledge about neck pain in children (risk factors, screening criteria to rule out serious injury, management, course and prognosis); and in the prevention of neck pain-related activity limitations. Few studies addressed the impact of culture or social policies (such as governmental health policies or insurance compensation policies) on neck pain. A number of important questions remain about the effectiveness of commonly used interventions for neck pain.The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for whiplash-associated disorders. We identify a number of gaps in the current knowledge, and provide recommendations for the conduct of future studies.

    View details for Web of Science ID 000253739500023

    View details for PubMedID 18204394

  • Clinical practice implications of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders - From concepts and findings to recommendations SPINE Guzman, J., Haldeman, S., Carroll, L. J., Carragee, E. J., Hurwitz, E. L., Peloso, P., Nordin, M., Cassid, J. D., Holm, L. W., Cote, P., van der Velde, G., Hogg-Johnson, S. 2008; 33 (4): S199-S213

    Abstract

    Best evidence synthesis.To provide evidence-based guidance to primary care clinicians about how to best assess and treat patients with neck pain.There is a need to translate the results of clinical and epidemiologic studies into meaningful and practical information for clinicians.Based on best evidence syntheses of published studies on the risk, prognosis, assessment, and management of people with neck pain and its associated disorders, plus additional research projects and focused literature reviews reported in this supplement, the 12-member multidisciplinary Scientific Secretariat of the Neck Pain Task Force followed a 4-step approach to develop practical guidance for clinicians.The Neck Pain Task Force recommends that people seeking care for neck pain should be triaged into 4 groups: Grade I neck pain with no signs of major pathology and no or little interference with daily activities; Grade II neck pain with no signs of major pathology, but interference with daily activities; Grade III neck pain with neurologic signs of nerve compression; Grade IV neck pain with signs of major pathology. In the emergency room after blunt trauma to the neck, triage should be based on the NEXUS criteria or the Canadian C-spine rule. Those with a high risk of fracture should be further investigated with plain radiographs and/or CT-scan. In ambulatory primary care, triage should be based on history and physical examination alone, including screening for red flags and neurologic examination for signs of radiculopathy. Exercises and mobilization have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain after a motor vehicle collision. Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain without trauma. Those with confirmed Grade III and severe persistent radicular symptoms might benefit from corticosteroid injections or surgery. Those with confirmed Grade IV neck pain require management specific to the diagnosed pathology.The best available evidence suggests initial assessment for neck pain should focus on triage into 4 grades, and those with common neck pain (Grade I and Grade II) might be offered the listed noninvasive treatments if short-term relief is desired.

    View details for Web of Science ID 000253739500022

    View details for PubMedID 18204393

  • Treatment of neck pain: Noninvasive interventions - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Hurwitz, E. L., Carragee, E. J., van der Velde, G., Carroll, L. J., Nordin, M., Guzman, J., Peloso, P. M., Holm, L. W., Cote, P., Hogg-Johnson, S., Cassidy, J. D., Haldeman, S. 2008; 33 (4): S123-S152

    Abstract

    Best evidence synthesis.To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders.No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade.We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis.Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies.

    View details for Web of Science ID 000253739500016

    View details for PubMedID 18204386

  • Course and prognostic factors for neck pain in the general population - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Carroll, L. J., Hogg-Johnson, S., van der Velde, G., Haldeman, S., Holm, L. W., Carragee, E. J., Hurwitz, E. L., Cote, P., Nordin, M., Peloso, P. M., Guzman, J., Cassidy, J. D. 2008; 33 (4): S75-S82

    Abstract

    Best evidence synthesis.To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population.Knowing the course of neck pain guides expectations for recovery. Identifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis.We found 226 articles on the course and prognostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again 1 to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psychosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prognostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies.The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome.

    View details for Web of Science ID 000253739500012

    View details for PubMedID 18204403

  • Assessment of neck pain and its associated disorders - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Nordin, M., Carragee, E. J., Hogg-Johnson, S., Weiner, S. S., Hurwitz, E. L., Peloso, P. M., Guzman, J., van der Velde, G., Carroll, L. J., Holm, L. W., Cote, P., Cassidy, J. D., Haldeman, S. 2008; 33 (4): S101-S122

    Abstract

    Best evidence synthesis.To critically appraise and synthesize the literature on assessment of neck pain.The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.

    View details for Web of Science ID 000253739500015

    View details for PubMedID 18204385

  • Course and prognostic factors for neck pain in whiplash-associated disorders (WAD) - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Carroll, L. J., Holm, L. W., Hogg-Johnson, S., Cote, P., Cassidy, J. D., Haldeman, S., Nordin, M., Hurwitz, E. L., Carragee, E. J., van der Velde, G., Peloso, P. M., Guzman, J. 2008; 33 (4): S83-S92

    Abstract

    Best evidence synthesis.To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades I-III whiplash-associated disorders (WAD).Knowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning management and intervention strategies and effective compensation policies to decrease the burden of WAD.The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for WAD. Recovery of WAD seems to be multifactorial.

    View details for Web of Science ID 000253739500013

    View details for PubMedID 18204405

  • A new conceptual model of neck pain - Linking onset, course, and care: The bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Guzman, J., Hurwitz, E. L., Carroll, L. J., Haldeman, S., Cote, P., Carragee, E. J., Peloso, P. M., van der Velde, G., Holm, L. W., Hogg-Johnson, S., Nordin, M., Cassidy, J. D. 2008; 33 (4): S14-S23

    Abstract

    Iterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence on neck pain and its associated disorders.To provide an integrated model for linking the epidemiology of neck pain with its management and consequences, and to help organize and interpret existing knowledge, and to highlight gaps in the current literature.The wide variability of scientific and clinical approaches to neck pain described in the literature requires a unified conceptual model for appropriate interpretation of the research evidence.The 12-member Scientific Secretariat of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders critically reviewed and eventually accepted as scientifically admissible a total of 552 scientific papers. The group met face-to-face on 18 occasions and had frequent additional telephone conference meetings over a 6-year period to discuss and interpret this literature and to agree on a conceptual model, which would accommodate findings. Models and definitions published in the scientific literature were discussed and repeatedly modified until the model and case definitions presented here were finally approved by the group.Our new conceptual model is centered on the person with neck pain or who is at risk for neck pain. Neck pain is viewed as an episodic occurrence over a lifetime with variable recovery between episodes. The model outlines the options available to individuals who are dealing with neck pain, along with factors that determine options, choices, and consequences. The short- and long-term impacts of neck pain are also considered. Finally, the model includes a 5-axis classification of neck pain studies based on how subjects were recruited into each study.The Scientific Secretariat found the conceptual model helpful in interpreting the available scientific evidence. We believe it can assist people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions.

    View details for Web of Science ID 000253739500006

    View details for PubMedID 18204387

  • The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions - Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders SPINE Holm, L. W., Carroll, L. J., Cassidy, J. D., Hogg-Johnson, S., Cote, P., Guzman, J., Peloso, P., Nordin, M., Hurwitz, E., van der Velde, G., Carragee, E., Haldeman, S. 2008; 33 (4): S52-S59

    Abstract

    Best evidence synthesis.To undertake a best evidence synthesis on the burden and determinants of whiplash-associated disorders (WAD) after traffic collisions.Previous best evidence synthesis on WAD has noted a lack of evidence regarding incidence of and risk factors for WAD. Therefore there was a warrant of a reanalyze of this body of research.A systematic search of Medline was conducted. The reviewers looked for studies on neck pain and its associated disorders published 1980-2006. Each relevant study was independently and critically reviewed by rotating pairs of reviewers. Data from studies judged to have acceptable internal validity (scientifically admissible) were abstracted into evidence tables, and provide the body of the best evidence synthesis.The authors found 32 scientifically admissible studies related to the burden and determinants of WAD. In the Western world, visits to emergency rooms due to WAD have increased over the past 30 years. The annual cumulative incidence of WAD differed substantially between countries. They found that occupant seat position and collision impact direction were associated with WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension during rear-end collisions had a preventive effect on reporting WAD, especially in females.WAD after traffic collisions affects many people. Despite many years of research, the evidence regarding risk factors for WAD is sparse but seems to include personal, societal, and environmental factors. More research including, well-defined studies with accurate denominators for calculating risk, and better consideration of confounding factors, are needed.

    View details for Web of Science ID 000253739500010

    View details for PubMedID 18204401

  • A brief overview of evidence-informed management of chronic low back pain with surgery SPINE JOURNAL Don, A. S., Carragee, E. 2008; 8 (1): 258-265

    Abstract

    The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-informed management of chronic low back pain without surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Although this special focus issue was focused on nonoperative care, it was deemed important to provide an overview of the surgical management of CLBP. This is intended to inform stakeholders of surgical options that are available to them should nonsurgical interventions prove ineffective or contraindicated. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

    View details for DOI 10.1016/j.spinee.2007.10.027

    View details for Web of Science ID 000252601300027

    View details for PubMedID 18164474

  • The pyrite standard: the Midas touch in the diagnosis of axial pain syndromes. spine journal Carragee, E. J., Haldeman, S., Hurwitz, E. 2007; 7 (1): 27-31

    View details for PubMedID 17197329

  • Does minor trauma cause serious low back illness? SPINE Carragee, E., Alamin, T., Cheng, I., Franklin, T., Hurwitz, E. 2006; 31 (25): 2942-2949

    Abstract

    Prospective, 5-year, cohort study of working subjects.To assess whether the occurrence of common minor trauma events affects the risk of developing serious low back pain (LBP) and LBP disability in subjects with and without degenerative changes to the lumbar spine.Although some theories suggest that minor traumatic events in combination with preexisting degenerative changes commonly cause significant structural injury to spinal segments and serious LBP illness, no prospective data exist on the relationship of minor trauma, detailed structural changes, and outcome measures of serious LBP episodes and occupational disability.Two hundred subjects without clinical LBP problems were recruited, and underwent baseline clinical and imaging studies. Every 6 months, subjects completed a scripted, algorithm-based interview assessing interval back pain episodes, severity, medical treatment, occupational disability, and the subject's perceived relation of this LBP episode to any preceding event. If a serious LBP episode clinically required a new magnetic resonance examination, the follow-up imaging was obtained and compared to baseline for interval changes.There was no association of minor trauma to adverse LBP events. For each 6-month study interval, the risk of developing a serious LBP episode was 2.1% unassociated with minor trauma and 2.4% following minor trauma (P = 0.59). Neither the frequency of minor trauma events nor the reported severity of the event correlated with adverse outcomes. Subjects with advanced structural findings were not more likely to become symptomatic with minor trauma events than with spontaneously evolving LBP episodes. Follow-up magnetic resonance imaging evaluating new serious LBP illness rarely revealed new clinically significant findings. Age and sex-adjusted prediction models, including abnormal psychometric testing, smoking, and compensation issues, accurately identified 80% of serious LBP events and 93% of LBP disability events.In this study cohort, minor trauma does not appear to increase the risk of serious LBP episodes or disability. The vast majority of incident-adverse LBP events may be predicted not by structural findings or minor trauma but by a small set of demographic and behavioral variables.

    View details for Web of Science ID 000242576200009

    View details for PubMedID 17139225

  • Are first-time episodes of serious LBP associated with new MRI findings? spine journal Carragee, E., Alamin, T., Cheng, I., Franklin, T., van den Haak, E., Hurwitz, E. 2006; 6 (6): 624-635

    Abstract

    Magnetic resonance (MR) imaging is frequently used to evaluate first-time episodes of serious low back pain (LBP). Common degenerative findings are often interpreted as recent developments and the probable anatomic cause of the new symptoms. To date no prospective study has established a baseline MR status of the lumbar spine in subjects without significant LBP problems and prospectively surveyed these subjects for acute changes shortly after new and serious LBP episodes. This method can identify new versus old MR findings possibly associated with the acute symptomatic episode.To determine if new and serious episodes of LBP are associated with new and relevant findings on MRI.Prospective observational study with baseline and post-LBP MRI monitoring of 200 subjects over 5 years.Clinical outcomes: LBP intensity (visual analogue scale), Oswestry Disability Index, and work loss. MRI outcomes: disc degeneration, herniation, annular fissures, end plate changes, facet arthrosis, canal stenosis, spondylolisthesis, and root impingement.200 subjects with a lifetime history of no significant LBP problems, and a high risk for new LBP episodes were studied at baseline with physical examination, plain radiographs, and MR imaging. Subjects were followed every 6 months for 5 years with a detailed telephone interview. Subjects with a new severe LBP episode (LBP>or=6/10,>1 week) were assessed for new diagnostic tests. New MR imaging, taken within 6 to 12 weeks of the start of a new LBP episode, was compared with baseline (asymptomatic) images. Two independent and blinded readers evaluated each baseline and follow-up study.During the 5-year observation period of 200 subjects, 51 (25%) subjects were evaluated with a lumbar MRI for clinically serious LBP episodes, and 3/51 (6%) had a primary radicular complaint. These 51 subjects had 67 MR scans. Of 51 subjects, 43 (84%) had either unchanged MR or showed regression of baseline changes. The most common progressive findings were disc signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two subjects, both with primary radicular complaints, had new findings of probable clinical significance (4%). Subjects having another MR were more likely to have had chronic pain at baseline (odds ratio [OR]=3.19; 95% confidence interval [CI] 1.61-6.32), to smoke (OR=5.81; 95% CI 1.99-16.45), have baseline psychological distress (OR 2.27; 95% CI 1.15-4.49), and have previous disputed compensation claims (OR=2.35; 95% CI 0.97-5.69). Subjects involved in current compensation claims were also more likely to have an MR scan to evaluate the LBP episode (risk ratio=4.75, p<.001), but were unlikely to have significant new findings. New findings were not more frequent in subjects with LBP episodes developing after minor trauma than when LBP developed spontaneously.Findings on MR imaging within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events. Primary radicular syndromes may have new root compression findings associated with root irritation.

    View details for PubMedID 17088193

  • Surgical treatment for unstable low-grade isthmic spondylolisthesis in adults: a prospective controlled study of posterior instrumented fusion compared with combined anterior-posterior fusion. spine journal Swan, J., Hurwitz, E., Malek, F., van den Haak, E., Cheng, I., Alamin, T., Carragee, E. 2006; 6 (6): 606-614

    Abstract

    The surgical treatment for low-grade isthmic spondylolisthesis in adults with intractable lumbar pain is usually spinal fusion. It has been postulated that anterior column reconstruction may be relatively advantageous in those patients with unstable slips.To compare the early and medium term treatment efficacy of two common fusion techniques in isthmic spondylolisthesis.Prospective controlled trial comparing single-level posterior-lateral instrumented fusion with combined anterior and posterior-lateral instrumented fusion in sequential matched cohorts of patients with radiographically unstable isthmic spondylolisthesis.Primary outcome measure of success was an Oswestry Disability Index (ODI)

    View details for PubMedID 17088191

  • A gold standard evaluation of the "discogenic pain" diagnosis as determined by provocative discography SPINE Carragee, E. J., Lincoln, T., Parmar, V. S., Alamin, T. 2006; 31 (18): 2115-2123

    Abstract

    This is a prospective study of the validity of a positive test result in provocative lumbar discography for the diagnosis of "discogenic pain."To investigate the hypothesis that provocative discography by strict criteria accurately identifies a low back pain illness due to a primary disc lesion.According to the Sackett and Haynes criteria for establishing diagnostic test validity, no test without a gold standard external standard can be meaningfully applied. Provocative discography as a test for determining "discogenic pain" has, to date, not been compared against a gold standard. Absent a gold standard reference, there can be no validity assessment or systematic improvement of test accuracy. This is the first study to apply an external gold standard evaluation of the diagnostic validity of discography in any manner.Over a 5-year period using a strict enrollment protocol, 32 patients with low back pain and a positive single-level low-pressure provocative discogram, underwent spinal fusion. Subjects with known patient selection comorbidities were excluded. Generic surgical limitations/morbidity were controlled by comparison to the clinical outcomes of a strictly-matched cohort of 34 patients having a well-accepted single-level lumbar pathology (unstable spondylolisthesis). Treatment success was compared between groups.In the control-spondylolisthesis group, 23 of 32 patients (72%) met the highly effective success criteria compared with 8 of 30 in the presumed discogenic pain cohort (27%). The proportion of patients who met the "minimal acceptable outcome" was 29 of 32 (91%) in the spondylolisthesis group and 13 of 30 (43%) in the presumed discogenic pain group. Adjusting for surgical morbidity and dropout failure, by either criteria of success, the best-case positive predictive value of discography was calculated to be 50% to 60%.Positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness in this first study comparing discography results to a gold standard.

    View details for Web of Science ID 000239832500017

    View details for PubMedID 16915099

  • A prospective controlled study of limited versus subtotal posterior discectomy: Short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect SPINE Carragee, E. J., Spinnickie, A. O., Alamin, T. F., Paragioudakis, S. 2006; 31 (6): 653-657

    Abstract

    Prospective observational study with historical control. The prospective study population consisted of 30 patients undergoing a posterior lumbar subtotal discectomy for lumbar disc herniation. This group was compared to a historical cohort of 46 patients treated with limited discectomy alone.To compare clinical outcomes after limited versus subtotal discectomy for lumbar disc herniations.Large posterior anular defects found at posterior discectomy have been associated with more frequent reherniation when treated with limited discectomy (i.e., removing only extruded or loose intervertebral fragments). A trial of more aggressive discectomy (subtotal) was undertaken to determine if the rate of reherniation could be decreased with this technique.A total of 30 patients undergoing a posterior lumbar discectomy for lumbar disc herniation were treated with an aggressive (subtotal) resection of intervertebral disc material after removal of the extruded or protruded fragments. This group was compared against a historical cohort of 46 patients treated with limited discectomy alone. Reherniation rates and clinical outcomes were determined by independent evaluation at 6, 12, and 24 months after surgery.The reherniation rate in the limited discectomy group was 18% versus 9% in the subtotal discectomy group at follow-up (P = 0.1). However, the back pain (visual analog scale) (P = 0.02) and Oswestry scores (P = 0.06) were worse in the subtotal discectomy group at 12-month follow-up. Time to return to work was longer, and pain medication usage was higher in the subtotal discectomy group at 12-month follow-up. Despite a trend toward a higher reherniation rate, the patient satisfaction at 2-year follow-up was higher in the limited discectomy group.The more aggressive removal of remaining intervertebral disc material may decrease the risk of reherniation, but the overall outcome was less satisfactory, especially during the first year after surgery.

    View details for Web of Science ID 000236000100008

    View details for PubMedID 16540869

  • Low-pressure positive discography in subjects asymptomatic of significant low back pain illness SPINE Carragee, E. J., Alamin, T. F., Carragee, J. M. 2006; 31 (5): 505-509

    Abstract

    Retrospective data review of positive disc injections at low pressures among subjects without chronic low back pain (LBP) illness compared to patients with chronic LBP undergoing Discography.To test the hypothesis that false-positive injections during Discography can effectively be eliminated by defining the positive injection criteria to include only those discs in which pain is produced with low injection pressure injections.The use of lumbar Discography as a diagnostic tool remains controversial. Studies have shown that disc injections among subjects asymptomatic of clinical LBP will produce painful injections in a significant proportion of subjects, rendering the interpretation of positive diskograms in clinical practice problematic. It has been argued that lumbar disc injections at low pressure may be clinically different from those at higher pressure and that a guideline accepting only of low-pressure injections will effectively eliminate false positives.A total of 69 volunteers with no clinically significant LBP undergoing experimental lumbar Discography were analyzed. There were 4 subgroups of this study cohort: no LBP, no chronic pain (n = 10); no LBP, chronic pain (n = 14); no LBP, previous lumbar discectomy (n = 20); and minor benign "backache" (n = 25). Pressure measurements during injection were made, and the pressure at which a significant pain response was elicited was recorded. This result was compared to the pain response and pressure profiles of 52 patients undergoing Discography for chronic LBP illness in consideration of treatment. Raters who were blinded to the subject's study group scored the studies. Diskogram morphology, pain response, and concordance, as well as magnetic resonance imaging, plain radiographs, psychometric testing (Distress and Risk Assessment Method), and compensation history were documented for each group. A low-pressure positive was defined as significant pain elicited less than 22 psi more than opening pressure.The number and percent of individuals with at least 1 low-pressure positive disc in the experimental group were 17 of 69 (25%) and in the clinical LBP group 14 of 52 (27%). The percentage of subjects with positive pain in the different experimental subgroups was: no LBP, no chronic pain 0/10 (0%); no LBP, chronic pain 5/14 (36%); no LBP, previous lumbar discectomy 5/20 (25%); and minor benign "backache" 7/25 (28%). Positive injections correlated with anular disruption, abnormal psychometric findings, and chronic pain states.The analysis shows that the rate of low-pressure painful injections in subjects without chronic LBP illness is approximately 25%, and correlates with both anatomic and psychosocial factors. In certain subgroups, this may represent an unacceptable risk of false-positive results.

    View details for Web of Science ID 000235657600001

    View details for PubMedID 16508542

  • The surgical treatment of disc degeneration: is the race not to the swift? spine journal Carragee, E. J. 2005; 5 (6): 587-588

    View details for PubMedID 16291096

  • Clinical practice. Persistent low back pain. New England journal of medicine Carragee, E. J. 2005; 352 (18): 1891-1898

    View details for PubMedID 15872204

  • Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. spine journal Carragee, E. J., Alamin, T. F., Miller, J. L., Carragee, J. M. 2005; 5 (1): 24-35

    Abstract

    A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain (LBP) illness. Although the relative contributions of structural and psychosocial variables are intensely debated, the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects. These factors dictate the requirement for large sample sizes, extensive structural imaging and extended longitudinal study. Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline.To establish, using a strict patient sample design, the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness.A prospective, longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics.One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic (non-lumbar) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease, to undergo baseline examination, testing and 5-year follow-up.Observations were made at 6-month intervals over 4 to 6 years (mean, 5.3) for the after primary outcomes measures: episodes of serious back pain (visual analogue scale [VAS] > or =6), episodes of occupational disability less than 1 week, episodes of occupational disability for 1 week, remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment.Lumbar magnetic resonance imaging (MRI), lumbar provocative discography (in psychometrically normal subjects), physical examinations, medical and work histories and psychometric testing were performed at baseline. Imaging and psychometric testing were graded by blinded examiners. A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data. The interview covered interval medical, occupational and accident or injury histories.Psychosocial variables strongly predicted both long- and short-term disability events, duration and health-care visits for LBP problems (p<0.0001-0.004). The likelihood of a sustained remission from the baseline persistent (subclinical) LBP appeared to be linked to occupation factors (leaving a heavy labor occupation; p=0.0001), neurophysiologic variables (chronic nonlumbar pain; p=0.0002) and psychometric profiles at baseline (DRAM and FABQ-PA; p=0.003-0.002). Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome. A positive provocative discogram at baseline did not predict any future adverse event.The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables. Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care.

    View details for PubMedID 15653082

  • Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography SPINE Carragee, E. J., Barcohana, B., Alamin, T., van den Haak, E. 2004; 29 (10): 1112-1117

    Abstract

    A prospective controlled longitudinal study.To determine whether subjects, asymptomatic for lower back problems, who undergo experimental discography, will develop lower back problems during the medium term to the full term.Previous work has shown significant pain on discographic injection in approximately 40% of asymptomatic subjects. It has been suggested that those subjects with painful injections would soon develop lower back pain (LBP) syndromes in the near future: that is, the experimental discography was detecting an imminent "pain generator" before clinically symptomatic. METHODS.: Fifty subjects without low back pain were recruited for clinical and psychometric testing, MRI scanning, and experimental lumbar discography to determine the rate of painful lumbar disc injections in select subjects without LBP history. After determining which subjects had painful injections, all subjects completing the discography protocol were prospectively followed at yearly intervals to determine the occurrence of LBP and LBP disability over time. Statistical methods were then used to determine the correlation, if any, between the asymptomatic subjects' clinical, MRI, and discography findings, and the subsequent LBP measures. Controls, not participating in the lumbar discography study, were also followed. Controls were matched for clinical features, sex, age, and occupational/recreational exposure. Follow-up examinations were performed at yearly intervals by blinded researchers using a scripted interview and completing standard questionnaires.A total of 46 of 50 completed the discogram, and all 46 subjects completed the final 4-year follow-up examination. There was a low incidence of LBP episodes in the experimental groups and control. A painful disc injection, independent of psychological profile, did not predict LBP or any other functional outcome measure at follow-up on multivariate analysis. The presence of an anular fissure seen on discography was weakly associated with the cumulative incidence of LBP episodes after discography (P = 0.08). The presence of high intensity zone on MRI in any disc was also weakly associated with the development of LBP episodes (P = 0.09). Psychometric profiles at the start of the study strongly and independently predicted future back pain (P = 0.01), medication usage (P = 0.002), and work loss (P = 0.01) over the 4-year study. Compared with controls not having undergone discography, there was no significant difference in back pain, function, work loss, doctors visits for back pain, or medication intake in any group. A subset in the injection group with somatization disorder had a higher LBP visual analog score compared with somatization disorder controls at 1 year,but this was not significant at 4 years after testing.Painful disc injections are poor independent predictors of subsequent LBP episodes in subjects initially without active lower back complaints. Anular disruption is a weak predictor of future LBP problems. Psychological distress and preexisting chronic pain processes are stronger predictors of LBP outcomes.

    View details for Web of Science ID 000221519900011

    View details for PubMedID 15131439

  • Diagnostic evaluation of low back pain ORTHOPEDIC CLINICS OF NORTH AMERICA Carragee, E. J., Hannibal, M. 2004; 35 (1): 7-?

    Abstract

    The diagnostic evaluation of chronic LBP is at best a complex and involved undertaking. The most important part of the process lies in the knowledge of the patient and a solid history and physical examination. From there, most of the serious and life-threatening causes of LBP can be elucidated and studies may be used for confirmation. Imaging studies are used most practically as confirmation studies once a working diagnosis is determined. MRI, although excellent at defining tumor, infection, and nerve compression, can be too sensitive with regard to degenerative disease findings and commonly displays pathology that is not responsible for the patient's symptoms. As an example, the high-intensity zones (HIZ) seen on MRI are reliable in determining annular defects in the disc but are not reliable in establishing internal disc disruption as the cause of LBP. Discography is the primary tool used by many physicians to determine the true pain generator when discogenic LBP is suspected. Because the reliability of the patient response is fundamental to discography, interpreting the test in different settings must be considered. In individuals with disc degeneration and annular defects, discography may elicit LBP with injection whether the patient is symptomatic with serious LBP or not. The pain response may be amplified in those subjects with issues of chronic pain, social stressors, such as secondary gain or litigation claims, or psychologic distress disorder. These factors have been shown experimentally to be associated with an increased risk for a false positive injection. The ability of an individual to differentiate the true site of LBP by the quality of sensation with disc injection (concordancy) of pain produced by the injected disc also may not be reliable. In fact, individuals may not have the neural discrimination to differentiate sclerotomal pain originating from different sites in the low back and pelvis. One may realize that chronic LBP illness may not stem from a mechanical spinal disorder alone. In fact, the mechanical pathology may be just a portion of the problem with amplification by neurophysiologic, social, and psychologic issues. Chronic disabling LBP commonly is confounded by chronic pain, emotional troubles, poor job satisfaction, alcohol and narcotic abuse, and compensation issues, just to identify a few. It would follow that expecting to identify a single cause for this symptom complex is impractical and any single test may not be a reasonable approach. Furthermore, surgical correction of the mechanical portion of chronic LBP. even if correctly identified, then can be expected only to relieve a portion of a patient's symptoms as long as the confounding issues continue to be significant or have become life long adaptive mechanisms. In the end, the discogram and other diagnostic tests are tools that have clear limitations. In this field, clinical judgment begins and ends with an understanding of a patient's life and circumstances as much as with their specific spinal pathology.

    View details for DOI 10.1016/S0030-5898(03)00099-3

    View details for Web of Science ID 000188754500003

    View details for PubMedID 15062713

  • Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. journal of bone and joint surgery. American volume Carragee, E. J., Han, M. Y., Suen, P. W., Kim, D. 2003; 85-A (1): 102-108

    Abstract

    The surgical treatment of sciatica with discectomy is ineffective in a sizable percentage of patients, and reherniation occurs after 5% to 15% of such procedures. The purpose of the present study was to determine if competence of the disc anulus and the type of herniation could be used to predict postoperative clinical outcomes following lumbar discectomy.A prospective observational study of 187 consecutive patients undergoing single-level primary lumbar discectomy was conducted. A single surgeon performed all of the procedures, and an independent examiner evaluated 180 of the patients clinically at a minimum of two and a median of six years after surgery. The extent of anular deficiency and the presence of disc fragments were determined. On the basis of these intraoperative findings, disc herniations were classified into four categories: (1) Fragment-Fissure herniations (eighty-nine patients), (2) Fragment-Defect herniations (thirty-three patients), (3) Fragment-Contained herniations (forty-two patients), and (4) No Fragment-Contained herniations (sixteen patients). The effects of disc herniation morphology and preoperative variables on subsequent clinical outcome were determined with the Student t test for continuous variables and chi-square analysis for categorical variables.Patients in the Fragment-Fissure group, who had disc fragments and a small anular defect, had the best overall outcomes and the lowest rates of reherniation (1%) and reoperation (1%). Patients in the Fragment-Contained group had a 10% rate of reherniation and a 5% rate of reoperation. Patients in the Fragment-Defect group, who had extruded fragments and massive posterior anular loss, had a 27% rate of reherniation and a 21% rate of reoperation. Patients in the No Fragment-Contained group did poorly: 38% had recurrent or persistent sciatica, and the standard outcomes scores were less improved compared with those in the other groups (p < 0.001).Intraoperative findings, as described in the present study, were more clearly associated with outcomes than were demographic, socioeconomic, or clinical variables. The degree of anular competence after discectomy and the type of herniation appear to have value for the prediction of the recurrence of sciatica, reoperation, and clinical outcome following lumbar discectomy.Prognostic study, Level I-1 (prospective study). See p. 2 for complete description of levels of evidence.

    View details for PubMedID 12533579

  • Indications for lumbar microdiskectomy. Instructional course lectures Carragee, E. 2002; 51: 223-228

    Abstract

    A very high percentage of patients coming to surgery for large disk extrusions and sciatica do very well with minimally invasive diskectomy. In most patients given relatively early surgical treatment, the primary predictor of outcome is the size of the disk herniation and the remaining competency of the anulus fibrosus. With the passage of time and with prolonged disability before surgery, psychosocial factors become increasingly important in determining outcomes. Factors such as psychological distress, depression, involvement with workers' compensation claims and disability claims, drug and alcohol abuse, and level of education appear to be secondary factors, at least initially, in subjects with large extruded fragments. In subjects with smaller disk herniation or in those with chronic disability, these factors may indicate a higher risk of treatment failure.

    View details for PubMedID 12064106

  • Provocative discography in volunteer subjects with mild persistent low back pain. spine journal Carragee, E. J., Alamin, T. F., Miller, J., Grafe, M. 2002; 2 (1): 25-34

    Abstract

    Whether discographic injections would be positive in subjects with benign persistent "backache" who are not seeking treatment is unknown. This information is important, because benign backache undoubtedly co-exists in patients with chronic low back pain (CLBP) illness that is not discogenicin origin. If these subjects had a high rate of positive discography, the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness. Conversely, if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections, the basic tenet of discographic diagnosis would be strengthened.To compare, using a strict experimental design, the relative pain and concordancy response to provocative discography in subjects with clinically insignificant "backache" and clinical subjects with CLBP illness considering surgical treatment.Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain (CLBP) illness.Twenty-five subjects with mild persistent low back pain (LBP) were recruited for an experimental discography study. Subjects were recruited from a clinical study of patients having had cervical spine surgery. Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP, be taking no medications for backache, have no activity restrictions because of LBP, and have normal psychometric scores. To more closely approximate the pain behavior in CLBP illness, 50% (12) of the "backache" group were recruited with a chronic painful condition (neck/shoulder) unrelated to the low back. CLBP subjects, patients coming to discography for consideration of surgical treatment, were used as control subjects.Results of discography were determined using the criteria of Walsh et al.: pain response of 3 or greater, two or more pain behaviors, a negative "control" discographic injection, and a similar or exact concordancy rating.Discography was performed on experimental subjects and control patients. Experienced raters, who were blinded to control versus experimental status of the subjects, scored the magnetic resonance image, discogram, psychometric tests and discography videotapes of the subjects' pain behavior.Thirteen of 25 volunteer subjects had pain rated as "bad" or worse with disc injection. There were 12 painful and fully concordant disc injections in 9 of these 25 "backache" subjects (36%). These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain. All positive discs had annular disruption to or through the outer annulus. Of the 9 subjects with positive discograms, 3 had no chronic pain states and 6 did. All subjects with positive injections had negative control discs. In comparison, in 52 subjects with CLBP illness 38 (73%) had at least one positive disc injection.In a group of volunteer subjects with persistent "backache," 36% were found to have significant pain on disc injection, which is reported to be concordant with their usual pain. The presence of positive concordant pain responses and negative control discs in 33% of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinically relevant spinal pathology.

    View details for PubMedID 14588285

  • Discography. a review. spine journal Carragee, E. J., Alamin, T. F. 2001; 1 (5): 364-372

    Abstract

    Discography is used today as the basis of the diagnosis of discogenic back and neck pain. As such, it plays a pivotal role in the formulation of treatment plans for patients complaining of chronic axial spine pain.A brief history of discography is described here, followed by a discussion of the current uses of discography, the technique involved, and recent studies questioning its validity.A selective review of discography articles from peer-reviewed literature from 1967 to 2000 is provided. We included articles analyzing the validity of discography as well as those concerning its proper use, technique, and complications.Articles relevant to the subject of discography were systematically reviewed for recommendations regarding technique, the interpretation of results, and conclusions regarding its validity.The specificity of discography is dramatically affected by the characteristics of the patient examined. In a patient with chronic pain states and psychiatric risk factors, the specificity was determined to be at most 20%. In healthy patients with no chronic pain states and a normal psychiatric profile, the specificity was found to be at most 90%. The ability of a patient to determine reliably the concordance of pain provoked during discography is poor. We could find no data addressing the sensitivity of the study.Clinicians who use discography to determine treatment pathways for their patients need to critically examine the validity of the test. Recent studies examining the specificity of discography have led us to proceed much more cautiously in interpreting the results of discography.

    View details for PubMedID 14588317

  • Psychological screening in the surgical treatment of lumbar disc herniation CLINICAL JOURNAL OF PAIN Carragee, E. J. 2001; 17 (3): 215-219

    Abstract

    The specific use of psychological screenings to determine appropriateness for lumbar discectomy surgery and predict outcomes is not well understood. Data from spine surgery as a whole are not likely generalizable to the patient with a significant disc herniation considering surgery. As opposed to most "back pain syndromes," acute and subacute sciatica from disc hemiation has a very high chance of dramatic and lasting improvement with surgery. Recent studies have shown standard psychometric tests used as preoperative screening in this situations fail to predict outcomes in most subgroups. Data from the author's institution suggest severe emotional distress in those patients coming to early surgical intervention does not correlate with adverse outcomes. However, the same psychometric profile in those patients with chronic sciatica pain and disability does predict worse outcomes compared with chronic pain in less emotionally distressed patients. The data suggest that the ability to rapidly relieve pain in the case of disc herniation may limit the morbid effects of psychological distress seen in many back pain syndromes. With prolonged pain and emotional distress, however, adverse and possibly self-perpetuating psychological and social changes may significantly decrease the impact of disc surgery.

    View details for Web of Science ID 000171142600005

    View details for PubMedID 11587111

  • Psychological and functional profiles in select subjects with low back pain. spine journal Carragee, E. J. 2001; 1 (3): 198-204

    Abstract

    Some researchers have found a correlation of poor treatment outcomes in patients with low back pain and abnormal psychological profiles, whereas others have failed to confirm this correlation. A critical feature of this debate has been whether abnormal psychological profiles seen in patients with back pain are the result of the ongoing back pain or whether pre-existing psychological features predispose to a poor clinical outcome.To determine the relationship of psychometric testing scores to the presence and duration of back pain of differing causes.This was a prospective observational study of the psychological profiles of groups of patients with low back pain and controls.Subjects having a variety of painful back conditions (n=310) were compared with a control group of subjects without low back complaints who had undergone cervical spine surgery (n=73).Psychometric testing (Modified Zung and Modified Somatic Pain Questionnaire) was performed along with pain scores (visual analog scale [VAS]), a standardized Low Back Pain Questionnaire, and the Oswestry Low Back Pain Disability Questionnaire in the evaluation of back pain and control subjects.The subjects with painful back conditions included patients with presumed discogenic pain undergoing discography (n=95); patients with symptomatic isthmic spondylolisthesis coming to fusion (n=61); patients with chronic vertebral osteomyelitis before diagnosis and treatment (n=39). There was also a nonpatient group of soldiers with chronic low back pain not seeking medical care (n=115). The control subjects without low back pain consisted of a group who had undergone cervical spine surgery (n=73). Psychometric testing was performed and compared in the evaluation of subjects having these different painful back conditions. Analysis was done comparing pain scores, function scores, and psychological testing scores between the symptomatic and asymptomatic groups.The VAS maximum in last week score for the entire group was 7.1, and scores were not significantly different in all low back pain groups. The Oswestry scores were poorest in the discography group compared to spondylolisthesis and osteomyelitis. Functional scores were similar in the soldiers with low back pain and controls without low back pain. Both Depression and Somatic Pain scores were most abnormal in the discogenic low back pain group. Only 21% of this group had normal scores, compared with 71% of the spondylolisthesis group, 79% of osteomyelitis group, and 88% of the group with chronic low back pain not seeking treatment (p<.001 in all groups). The asymptomatic control group had 85% normal scores.Despite similar pain levels and pain duration, patients with the discographic diagnosis of discogenic back pain have poorer functional scores and very abnormal psychological scores compared with other subjects with chronic low back pain resulting from spondylolisthesis requiring surgery or chronic pyogenic osteomyelitis. Chronic moderately severe mechanical low back pain in healthy subjects was not associated with abnormal psychological scores or functional disability.

    View details for PubMedID 14588348

  • Changes in posterior disc bulging and intervertebral foraminal size associated with flexion-extension movement: a comparison between L4-5 and L5-S1 levels in normal subjects. spine journal Fredericson, M., Lee, S. U., Welsh, J., Butts, K., Norbash, A., Carragee, E. J. 2001; 1 (1): 10-17

    Abstract

    No previous study has used magnetic resonance imaging (MRI) to evaluate changes of posterior disc bulging and intervertebral foraminal size in the normal spine with flexion-extension movement, comparing L4-5 versus L5-S1 intervertebral levels.To determine changes in posterior disc bulging and intervertebral foraminal size with flexion-extension movement, comparing L4-5 versus L5-S1 intervertebral levels.An in vivo study of magnetic resonance kinematics with spine flexion extension.Spines of three volunteers with no history of low back pain were scanned in neutral, flexion, and extension positions in a vertically open MRI system. MRI was repeated after 6 hours of normal activity and an additional 4 hours of heavy activity with a weighted vest. Posterior bulging of the intervertebral disc and the size of intervertebral foramen were measured at the L4-5 and L5-S1 levels.With spine flexion, posterior bulging of the discs increased at L4-5 in eight of nine measurements (three different spine-loading states for each of three subjects) and L5-S1 discs in six of nine measurements. In most cases, posterior bulging decreased with extension. No significant difference was noted in the degree of disc bulge between levels. Foraminal size at L4-5 increased with flexion and decreased with extension, and the extent of these changes was greater at the L4-5 level than at L5-S1.This pilot study demonstrates two distinct behavior characteristics of the normal spine with flexion-extension movement.

    View details for PubMedID 14588361

  • Provocative discography in patients after limited lumbar discectomy - A controlled, randomized study of pain response in symptomatic and asymptomatic subjects SPINE Carragee, E. J., Chen, Y., Tanner, C. M., Truong, T., Lau, E., BRITO, J. L. 2000; 25 (23): 3065-3071

    Abstract

    This was a prospective observational study of patients with low back pain and those without after laminotomy and discectomy.To determine, using a strict experimental design, the relative pain intensity response to provocative discography in symptomatic and asymptomatic subjects after lumbar discectomy for intervertebral disc herniation.Provocative discography frequently is used to evaluate persistent or recurrent low back pain syndromes in patients who have undergone posterior discectomy. The validity of interpreting painful injections during this procedure has not been critically assessed. The prevalence of significantly painful disc injections in a group with good outcomes after surgery is not known. Knowing the rates of significantly painful injections in asymptomatic patients after lumbar discectomy may clarify the meaning of painful injections in symptomatic patients.From a cohort of 240 patients who had undergone single-level limited discectomy for sciatica, 20 asymptomatic volunteers were recruited for experimental three-level lumbar discography. Inclusion criteria required nearly perfect scores on standardized back pain rating instruments, no other spinal pathology, and normal psychometric screening. A control group of 27 symptomatic patients, after single-level discectomy with intractable low back pain syndrome, and without other spinal pathology, underwent discography. Seven patients in the control group had normal psychometric tests. Experienced raters who were blinded to control versus experimental status of the subjects scored the magnetic resonance imaging, discogram, psychometric tests, and discography videotapes of the subjects' pain behavior.There were 8 of 20 (40%) positive injections of discs that had previous surgery in the asymptomatic group and 17 of 27 (63%) positive injections in the symptomatic group. Specifically with regard to the symptomatic group, there were 3 of 7 (43%) positive injections (all concordant) in patients with normal psychometric scores, as compared with 14 of 20 (70%) positive injections (12 concordant) in patients with abnormal psychometric scores. Injections of discs that had previous surgery resulted in a mean pain score of 2.1 of 5 in the asymptomatic group, 2.1 in the symptomatic group with normal psychometric scores, and 3.4 in the symptomatic group with abnormal psychometric scores. Of the discs not treated with surgery, 2 were positive in the asymptomatic group (10%), 3 in 2 symptomatic subjects with normal psychological testing (29), and 18 in 13 symptomatic subjects with abnormal psychometric testing (76%).A high percentage of asymptomatic patients with normal psychometric testing who previously have undergone lumbar discectomy will have significant pain on injection of their discs that had previous surgery (40%). This is not significantly different from the experience of symptomatic patients with normal psychometric testing undergoing discography on discs that had previous surgery. Patients with abnormal psychological profiles have significantly higher rates of positive disc injections than either asymptomatic volunteers or symptomatic subjects with normal psychological screening.

    View details for Web of Science ID 000165706400013

    View details for PubMedID 11145818

  • 2000 Volvo Award Winner in Clinical Studies - Lumbar high-intensity zone and discography in subjects without low back problems SPINE Carragee, E. J., Paragioudakis, S. J., Khurana, S. 2000; 25 (23): 2987-2992

    Abstract

    A prospective observational study of patients with low back pain and those without was performed.To investigate the prevalence and significance of a high-intensity zone in a group of patients asymptomatic for low back pain, but who had known risk factors for lumbar disc degeneration. This asymptomatic group was compared with a symptomatic group of patients with respect to the presence of anular high-intensity zone and the pain response with discography.Some authors have estimated the prevalence of a high-intensity zone in a group of symptomatic patients to be 86%. They have reported a strong correlation between a high-intensity zone and positive discography in patients with low back pain. Other investigators have reported evidence either supporting or discounting these findings.Patients with low back pain and those without underwent physical examination, psychometric testing, plain radiograph, magnetic resonance imaging, and discography. The presence of a high-intensity zone, anular disruption, and positive discographic pain then were compared between the two groups. There were strict inclusion criteria for both groups. A total of 109 discs in 42 patients were evaluated in the symptomatic group and compared with 143 discs in 54 patients in the asymptomatic group. The presence of a high-intensity zone was determined by a standardized criteria on T2-weighted magnetic resonance images. Psychometric testing also was administered to each patient before discography. Standard discography was performed on all the patients, and the pain response was recorded using a visual analog scale according to the Walsh et al criteria.The prevalence of a high-intensity zone in the patient populations was 59% in the symptomatic group and 24% in the asymptomatic group. In the symptomatic group, 33 (30.2%) of 109 discs were found to have a high-intensity zone. In the asymptomatic group, 13 of 143 discs were found to have a high-intensity zone. In the symptomatic group, 72.7% of the discs with a high-intensity zone were positive on discography, whereas 38.2% of the discs without a high-intensity zone were positive. In the asymptomatic group, 69.2% of the discs with a high-intensity zone were positive on discography, whereas 10% of the discs without a high-intensity zone were positive. In the patients with normal psychometric testing, 50% of the discs with a high-intensity zone were positive on discography, as compared with 100% positive discography results in patients with abnormal psychometric testing or chronic pain.The presence of a high-intensity zone does not reliably indicate the presence of symptomatic internal disc disruption. Although higher in symptomatic patients, the prevalence of a high-intensity zone in asymptomatic individuals with degenerative disc disease (25%) is too high for meaningful clinical use. When injected during discography, the same percentage of asymptomatic and symptomatic discs with a high-intensity zone were shown to be painful.

    View details for Web of Science ID 000165706400004

    View details for PubMedID 11145809

  • Can discography cause long-term back symptoms in previously asymptomatic subjects? SPINE Carragee, E. J., Chen, Y., Tanner, C. M., Hayward, C., Rossi, M., Hagle, C. 2000; 25 (14): 1803-1808

    Abstract

    A prospective controlled study of patients without low back pain observed after experimental lumbar discography.To determine whether discography may cause long-term low back symptoms in selected patients.Lumbar discography is generally considered safe, although controversial, with few complications. There is little information on long-term follow-up of asymptomatic patients after experimental discography.Twenty-six patients without pre-existing low back pain were observed for 1 year after lumbar discography to determine the effects of lumbar discography in three experimental groups: 10 patients who had remote cervical spine surgery with excellent results (pain-free group); 10 patients who had the same surgery with poor results (chronic pain group); and 6 patients who had primary somatization disorders. Two control groups were also observed: a group of patients with somatization disorder who were similarly evaluated but without discography, a group of patients with low back pain observed for 1 year after discography without surgery.In the three experimental groups (no back pain before discography) no subject with normal psychometric testing had persistent pain after discography (0/11), whereas 6 (40%) of 15 with abnormal psychometric test results reported significant new low back pain. None of the pain-free group (0/10), 20% of the chronic neck pain group (2/10), and 66% of the somatization group (4/6) continued to have significant back pain 1 year after injection. Psychological testing and occupational disability strongly predicted continued pain after discography. The control groups had no significant change in low back symptomatology during the year of observation.Discography in a subject group without low back pain but with significant emotional and chronic pain problems may result in reports of significant back pain for at least 1 year after injection. Subjects with normal psychometric test results had no reports of significant long-term back pain after discography.

    View details for Web of Science ID 000088211900013

    View details for PubMedID 10888949

  • The rates of false-positive lumbar discography in select patients without low back symptoms SPINE Carragee, E. J., Tanner, C. M., Khurana, S., Hayward, C., Welsh, J., Date, E., Truong, T., Rossi, M., Hagle, C. 2000; 25 (11): 1373-1380

    Abstract

    Experimental disc injections in subjects with no history of low back symptoms.To determine in an experimental setting the relative pain response and pain-related behavior in selected subjects without a history of low back pain undergoing lumbar discography. This study aimed to select a study population that more closely represented patients undergoing discography in clinical practice.Previous work has shown that in young, healthy men with little degenerative disc disease and no history of low back problems, discographic injections usually did not cause significant pain. This group differed from the patients who usually undergo discographic evaluation in clinical practice. Most clinical patients are older, have significant degenerative disc disease, have behavioral changes associated with chronic pain, and often have confounding psychosocial troubles. The authors undertook to study discography in subjects without low back pain but with clinical profiles similar to patients undergoing discography in clinical practice.Twenty-six individuals, mean age 43 years, with no history of low back pain had lumber discography according to the strict protocol of Walsh et al. Of these, 10 were pain-free; 10 had chronic neck and arm pain, but no low back symptoms; and 6 had primary somatization disorders without low back symptoms.-Significant positive pain response and pain-related behavior with discography were found in 10% of the pain-free group, in 40% of the chronic cervical pain group, and in 83% of the somatization disorder group completing the injections. Twenty-four subjects had negative control discs. Discs with annular disruption were more likely to be painful on injection, particularly in those individuals with ongoing compensation issues, chronic pain, or abnormal psychological testing.-If strict criteria are applied, the rate of false-positive discography may be low in subjects with normal psychometric profiles and without chronic pain. Significantly painful injections were very common in subjects with annular disruption and chronic pain or abnormal psychometric testing.

    View details for Web of Science ID 000087435200010

    View details for PubMedID 10828919

  • Is lumbar discography a determinate of discogenic low back pain: provocative discography reconsidered. Current review of pain Carragee, E. J. 2000; 4 (4): 301-308

    Abstract

    Provocative lumbar discography was investigated in a series of clinical studies at the Stanford University of Medicine, Stanford, CA. This work demonstrated that pain intensity during disc injection is strongly influenced by the subject's emotional and psychological profiles, chronic pain behavior, and ongoing compensation claims whether the patient has any back pain illness or not. Pain reproduction was also primarily related to penetration of the dye through the outer annulus and could not reliably be used to confirm the location of the pain source.

    View details for PubMedID 10953278

  • False-positive findings on lumbar discography - Reliability of subjective concordance assessment during provocative disc injection SPINE Carragee, E. J., Tanner, C. M., Yang, B., BRITO, J. L., Truong, T. 1999; 24 (23): 2542-2547

    Abstract

    Experimental disc injections in subjects with no history of low back symptoms.To determine in an experimental model the reliability of patients' subjective interpretation of pain concordancy during provocative disc injection.Discography in the evaluation of low back pain relies on a patient's subjective assessment of pain magnitude and quality during disc injection. Reproduction of significant pain on disc injection, which is similar to patients' usual pain, is believed to prove that the disc injected is the source of the patient's low back pain. In the current study, this hypothesis was tested in a controlled setting on patients with known nonspinal pain in a common referral area of discogenic pain.Patients with no history of low back pain were recruited to participate in a study of discography. Patients scheduled to undergo posterior iliac crest bone graft harvesting for nonthoracolumbar procedures were evaluated with lumbar radiography, magnetic resonance imaging, and psychometric testing. Two to 4 months after bone graft harvesting, patients underwent lumbar discography by strict blinded protocol. Patients were asked to compare the sensations elicited at discography to their usual back/buttock pain since bone graft harvesting. Pain was rated as 0-5 on a pain thermometer and concordancy was rated as none, dissimilar, similar, or exact.Eight subjects completed the study, and 24 discs were injected. Of the 14 disc injections causing some pain response, 5 were believed to be "different" (nonconcordant) pains (35.7%); 7 were "similar" (50.0%), and 2 were "exact" pain reproductions (14.3%). The presence of anular disruption predicted concordant pain reproduction (P < 0.05). Of 10 discs with anular tears, injection of 5 elicited pain that was similar to or an exact reproduction of pain at the iliac crest bone graft harvest sites. By the usual criteria for positive discography, 4 of the 8 patients (50%) would have been classified as positive. In these patients, the pain on a single disc injection was very painful, and the pain quality was noted to be exact or similar to the usual discomfort. All subjects had a negative control disc.The findings of this study demonstrate that patients with no history of low back pain who had undergone posterior iliac bone graft harvesting for nonlumbar procedures often experienced a concordant painful sensation on lumbar discography with their usual gluteal area pain. Thus, the ability of a patient to separate spinal from nonspinal sources of pain on discography is questioned, and a response of concordant pain on discography may be less meaningful than often assumed.

    View details for Web of Science ID 000084169700016

    View details for PubMedID 10626318

  • Activity restrictions after posterior lumbar discectomy - A prospective study of outcomes in 152 cases with no postoperative restrictions SPINE Carragee, E. J., Han, M. Y., Yang, B., Kim, D. H., Kraemer, H., Billys, J. 1999; 24 (22): 2346-2351

    Abstract

    A prospective clinical trial was conducted.To determine the feasibility of removing activity restrictions after surgery and encouraging early return to work; to ascertain the clinical and behavioral response to such a strategy; and to identify factors predictive of early return to work, preparatory to possible randomized clinical trials.Current practice usually entails several weeks to several months of restricted activities after lumbar discectomy to avoid disc "reinjury." Earlier work has suggested these restrictions may not be necessary.One hundred fifty-two consecutive working patients undergoing limited open discectomy for herniated lumbar intervertebral disc were treated postoperatively with no activity restrictions. Patients were encouraged to return to full activities as soon as possible. The patients were followed for a minimum of 2 years (average follow-up time = 4.8 years). At follow-up, an independent examiner evaluated each patient and collected further postoperative data.One hundred forty-nine of the 152 patients (98%) returned to work. The average work loss was 1.2 weeks and 148 of 149 patients had returned to full duty by 8 weeks. Approximately one-third of the group returned to work within 1 week of surgery (32%), many the next day. Statistical analysis demonstrated very early return to work did not correlate with either recurrent sciatica, reoperation for reherniation, or ultimate clinical outcome. Seventeen patients (11.2%) had possible reherniations (recurrent sciatica) and eight underwent reoperation (5.3%).Lifting of postoperative activity restrictions after limited discectomy allowed shortened time to return to work relative to the 4 to 16 weeks commonly recommended. Complication rates appear comparable to those reported in the literature for patients under postoperative restrictions. Postoperative restrictions may not be necessary in most patients.

    View details for Web of Science ID 000083688100010

    View details for PubMedID 10586459

  • Pain control and cultural norms and expectations after closed femoral shaft fractures. American journal of orthopedics (Belle Mead, N.J.) Carragee, E. J., VITTUM, D., Truong, T. P., Burton, D. 1999; 28 (2): 97-102

    Abstract

    The purpose of this observation-cohort survey study was to compare the analgesia given and satisfaction with analgesia after a uniform orthopedic injury and operation in culturally disparate settings. Twenty-five patients with isolated closed femoral shaft fractures treated with intramedullary rod fixation within 1 week of injury were retrospectively evaluated at two urban hospitals in the United States. They were compared with a matched group from three urban hospitals in Vietnam (two in Hanoi and one in Ho Chi Minh City [Saigon]). Ages and sex did not differ significantly between the two groups. The mean weight of the Vietnamese group was significantly less than that of the US group (58 vs. 81 kg). During the 14 days following injury, the Vietnamese and American groups were given a mean of 0.9 mg/kg per day versus 30.2 mg/kg per day of morphine equivalent units, respectively. Two (8%) of the Vietnamese group felt their pain control had been inadequate, versus 20 (80%) of the US group. Similarly, 2 (8%) of the US group and 7 (28%) of the Vietnamese group felt they had received "too much" pain medication. Mean heart rates during the first 5 days after surgery were not significantly different in the two groups. Only 4% of the US group felt they had had an accurate impression of how much a femur fracture would hurt prior to the injury, whereas 76% of Vietnamese patients responded that they imagined such an injury would be approximately as painful as it was. Results were similar for preconceptions of pain as a result of surgery and during the postoperative period. More than 50% of patients from the US group felt there must be some explanation other than the femur fracture to explain the severity of their pain, such as infection, missed injury, hardware failure, or inappropriate medical care. Despite much higher administration of narcotic analgesia, American patients with femoral shaft fractures were much more dissatisfied with their analgesic results. In assessing the recommended dosing for "adequate analgesia" and "analgesic requirements," determinations may depend less upon tissue injury than upon cultural norms and patient expectations.

    View details for PubMedID 10067712

  • The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis SPINE Carragee, E. J., Kim, D., VANDERVLUGT, T., VITTUM, D. 1997; 22 (18): 2089-2093

    Abstract

    Retrospective chart review of 44 cases.To describe the clinical usage of the erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis.The erythrocyte sedimentation rate is often used to determine the efficacy and duration of treatment in pyogenic vertebral osteomyelitis. Although consensus and anecdotal reports support this notion, no detailed review of the erythrocyte sedimentation rate response in conservative treatment of pyogenic vertebral osteomyelitis has been made, to date.For 44 patients with pyogenic vertebral osteomyelitis who had erythrocyte sedimentation rate testing at or before the time of diagnosis and at least twice during the next month, the clinical findings and results of the erythrocyte sedimentation rate testing were reviewed.Of 18 cases with no significant fall in the erythrocyte sedimentation rate during the first month, 9 (50%) failed conservative treatment. Conversely, of the 26 cases with a good erythrocyte sedimentation rate response during the first month, three (12%) were clinical failures. However, a rapid decline of the erythrocyte sedimentation rate (> 50% in the first month) is rarely seen in treatment failure. In addition, approximately 2 weeks after antibiotic treatment, 19 of 32 were actually higher than at the time of diagnosis, but went on to clinical cure without surgery. The erythrocyte sedimentation rate, in combination with the patient's age and immune status, predicted the success of antibiotic treatment, in most cases. The erythrocyte sedimentation rate response alone during the first month was not a clear predictor of success.Although the erythrocyte sedimentation rate does correlate well with response to treatment as a general rule, care must be taken in interpretation of a persistently elevated or even rising erythrocyte sedimentation rate as an isolated clinical finding.

    View details for Web of Science ID A1997XX08300005

    View details for PubMedID 9322319

  • Single-level posterolateral arthrodesis, with or without posterior decompression, for the treatment of isthmic spondylolisthesis in adults. A prospective, randomized study. journal of bone and joint surgery. American volume Carragee, E. J. 1997; 79 (8): 1175-1180

    Abstract

    Forty-two neurologically intact adults in whom non-operative treatment of grade-I or grade-II isthmic spondylolisthesis of the most caudad lumbar segment had failed were entered into a prospective study of the results of operative treatment. Twenty patients who smoked were managed with a posterolateral arthrodesis with instrumentation (transpedicular fixation), and twenty-two patients who did not smoke were managed with a posterolateral arthrodesis without instrumentation. Of the patients who were managed with instrumentation, eight were randomized to treatment with a decompressive laminectomy and twelve, to treatment without it; in the group that was managed without instrumentation, the distribution was ten and twelve patients, respectively. The patients were followed clinically for a mean of 4.5 years (range, 3.5 to six years). Of the eighteen patients who had been managed with decompression, four had a pseudarthrosis and six had an unsatisfactory result compared with none and one of the twenty-four who had been managed without decompression (p = 0.02 and p = 0.01, respectively). In the group of twenty patients (smokers) who had been managed with instrumentation, none of the twelve managed without decompression had a pseudarthrosis compared with one of the eight managed with decompression (p = 0.2). In the group of twenty-two patients (non-smokers) who had been managed without instrumentation, none of the twelve managed without decompression had a pseudarthrosis compared with three of the ten managed with decompression (p = 0.04). In the group managed with instrumentation, two of the eight who had had decompression had an unsatisfactory result compared with none of the twelve who had not had decompression. In the group managed without instrumentation, four of the ten who had had decompression had an unsatisfactory result compared with one of the twelve who had not had decompression. The addition of decompression to arthrodesis, performed with or without instrumentation, for the treatment of low-grade isthmic spondylolisthesis in patients who do not have a serious neurological deficit does not appear to improve the result and may significantly increase the rates of pseudarthrosis and unsatisfactory results.

    View details for PubMedID 9278077

  • Instrumentation of the infected and unstable spine: A review of 17 cases from the thoracic and lumbar spine with pyogenic infections JOURNAL OF SPINAL DISORDERS Carragee, E. J. 1997; 10 (4): 317-324

    Abstract

    A retrospective review of 17 consecutive cases of spinal instrumentation for pyogenic vertebral osteomyelitis (PVO) with follow-up of > 2 years was undertaken, to describe the clinical course and outcomes in patients with instrumentation of actively infected spines. In 17 patients with PVO, instrumentation of the spine was performed during the period of clinical infection. Twelve of 17 patients were immunocompromised because of systemic or iatrogenic factors. Five patients had a history of malignancy and four had had spinal irradiation. In all 17 cases, the infection appeared to clinically be controlled after instrumentation. All patients were mobilized directly after instrumentation. The erythrocyte sedimentation rate returned to normal in 15 patients without rheumatic disease and decreased by more than half in two patients with inflammatory arthritis. Four patients had died at follow-up, and none of these had signs of persistent infection. Eight cases had significant postoperative complications (47%), including two instrumentation failures and one wound dehiscence. Spinal instrumentation in selected cases of PVO allows early mobilization and did not seem to compromise the ability to clear infection. In certain recalcitrant cases, stabilization seemed to promote clinical resolution of the infection.

    View details for Web of Science ID A1997XR48100008

    View details for PubMedID 9278917

  • A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation - Correlation of outcomes with disc fragment and canal morphology SPINE Carragee, E. J., Kim, D. H. 1997; 22 (14): 1650-1660

    Abstract

    A two-part observational study. In Part 1, consecutive lumbar magnetic resonance imaging scans in patients with sciatica meeting enrollment criteria were prospectively and blindly analyzed by a set protocol. In Part 2, further clinical findings at the time of the magnetic resonance imaging were obtained by retrospective chart review and outcome assessment done at follow-up of more than 2 years.To determine the quantitative magnetic resonance findings of disc and canal measures in patients with sciatica and to analyze the predictive values of these magnetic resonance imaging and clinical variables on outcomes.Part 1: Consecutive patients with a primary diagnosis of sciatica who came to lumbar magnetic resonance imaging were enrolled, and magnetic resonance imaging dimensions of discs and canal at the herniated level were collected. Part 2: Of 186 patients in Part 1, 135 were followed for more than 2 years; 87 were treated conservatively, and 48 were treated surgically. Outcomes were judged on satisfaction, activity level, medication intake, and reported pain at follow-up (mean, 2.6 years).Part 1: Wide ranges of disc and canal measurements were seen in all parameters. Significant differences in all magnetic resonance parameters were noted between male and female patients. Men had proportionately greater canal compromise by the affected disc than women. Positive sciatic tension signs and short duration of symptoms correlated with large disc herniation. Right-sided symptomatic herniations were usually larger than left. Part 2: At follow-up, predictors of outcome were determined independently for the surgery and the nonoperative groups. In the nonoperative group, a shorter duration of sciatica was the most significant predictor of a good outcome (P = 0.0018). Moreover, a duration of symptoms less than 6 months, no involvement with litigation, and younger age were also correlated with a favorable outcome. The only magnetic resonance parameter associated with good outcome was a small ratio of disc hemiarea to remaining canal hemiarea (P = 0.045). For the surgical group, a larger anteroposterior disc length was the most significant independent predictor of a positive outcome (P < 0.0001). Larger ratios of disc area to canal area are also significantly associated with good outcomes (P < 0.0001), as are large disc areas and small remaining canal areas. Large right-left canal widths and small disc widths are also identified as predictors of a favorable outcome. Of the clinical parameters, concurrent medical illness, workers' compensation involvement, and female gender appear to be the most significantly correlated with poor outcome. All fair or poor surgical outcomes were in patients with smaller (< 6 mm) disc herniations.Quantitative measurements by magnetic resonance imaging of disc and canal morphology of 188 patients with sciatica indicate a wide range of herniation and canal sizes, with significant differences between men and women. In a cohort of 135 patients followed for more than 2 years, demographic and clinical features appeared to predict outcomes of nonoperative treatment, whereas morphometric features of disc herniation and the spinal canal seen on magnetic resonance imaging were much more powerful predictors of surgical outcomes.

    View details for Web of Science ID A1997XM75400025

    View details for PubMedID 9253102

  • Pyogenic vertebral osteomyelitis. journal of bone and joint surgery. American volume Carragee, E. J. 1997; 79 (6): 874-880

    Abstract

    I retrospectively reviewed the records of 111 patients who had pyogenic vertebral osteomyelitis unrelated to an open procedure on the spine. The mean age at the time of the diagnosis was sixty years (range, eighteen to eighty-four years); sixty-one patients (55 per cent) were sixty years old or more. Forty-four patients (40 per cent) had an impaired immune system secondary to diabetes mellitus, the use of corticosteroids, chemotherapy for cancer, rheumatic or immunological disease, renal or hepatic failure, malnutrition, or myelodysplasia. Magnetic resonance imaging, critical for the determination of an early diagnosis, was performed for 103 patients (93 per cent). The infection in sixty-eight patients (61 per cent) was diagnosed within one month after the onset of symptoms. The most frequent infecting organism was Staphylococcus aureus (forty patients; 36 per cent). The infection in forty-one patients (37 per cent) was caused by organisms, such as Staphylococcus epidermidis, Propionibacterium acnes, and diphtheroid species, that are traditionally considered to be of low virulence. The urinary tract was the most frequent source of infection (confirmed in thirteen patients and suspected in twenty-one). The success of non-operative treatment was predicted by four independent variables: an age of less than sixty years, the immune status, infection with Staphylococcus aureus, and a decreasing erythrocyte sedimentation rate. Forty-two patients were managed with debridement and arthrodesis. Fourteen of these patients also had instrumentation of the spine, in the presence of infection, without compromise of the outcome. Eighteen patients died by the time of the latest follow-up evaluation at a mean of four years (range, two years and two months to six years and six months): seven who had been managed non-operatively died in the first month after the diagnosis was made, three died in the acute postoperative period, three died of late complications of paraplegia, and five died of unrelated causes. None of the eighty-nine patients who were seen at a minimum of two years postoperatively had had late recurrence of infection. Chronic, severe back pain was noted in only seven patients.

    View details for PubMedID 9199385

  • The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis SPINE Carragee, E. J. 1997; 22 (7): 780-785

    Abstract

    Retrospective chart review of 103 cases.To describe the clinical use of magnetic resonance imaging in a pyogenic vertebral osteomyelitis.Long delays in diagnosing pyogenic vertebral osteomyelitis of the spine have been shown in many reports. Magnetic resonance imaging has been advocated as the imaging method of choice in suspected spinal infections. The use, accuracy, and timing of magnetic resonance imaging in pyogenic vertebral osteomyelitis have not been reported in a large series.In 103 patients with pyogenic vertebral osteomyelitis who underwent magnetic resonance imaging at or before the time of diagnosis, the author reviewed the clinical findings and results of the magnetic resonance imaging, timing with respect to symptom duration and diagnosis, and accuracy of readings in detecting spinal infection. Follow-up magnetic resonance imaging reports also were reviewed.Magnetic resonance imaging appeared to give the correct diagnosis or suggest pyogenic vertebral osteomyelitis as a possible diagnosis in 55% and 36% of cases, respectively, with less than 2 weeks of symptoms. After 2 weeks, the percentages of correct and possible diagnoses of pyogenic vertebral osteomyelitis increased to 76% and 20%, respectively. Magnetic resonance imaging was obtained within 1 month of the start of symptoms in 73% of cases. The diagnosis was made within 1 month in the most cases as well, compared with a 2- to 6-month delay in most series. Follow-up magnetic resonance images often gave impressions of progressive disease, where the clinical picture appeared to improve.Magnetic resonance imaging is valuable in suggesting the diagnosis even very early in the clinical course of pyogenic vertebral osteomyelitis. Its use may eliminate significant delays in diagnosis. The use of magnetic resonance imaging in following the therapeutic response remains to be defined.

    View details for Web of Science ID A1997WT38800015

    View details for PubMedID 9106320

  • Wound care after posterior spinal surgery - Does early bathing affect the rate of wound complications? SPINE Carragee, E. J., VITTUM, D. W. 1996; 21 (18): 2160-2162

    Abstract

    The study was a prospective clinical trial with historic control.To determine if early bathing after posterior spinal surgery resulted in increased wound problems.Little is known about the time needed for wound healing before patients may get the wound wet. Traditional teaching usually calls for the wound to be kept clean and dry for 10-14 days or until shortly after the sutures are removed. Studies have shown wound closure with skin staples to be resistant to external contamination.One hundred consecutive patients undergoing posterior spinal surgery with skin closure using steel skin staples were prospectively allowed to shower and wet the surgical wound 2-5 days after surgery. These results were compared with a historic control of 100 consecutive patients done in the previous year by the same surgeon with a similar patient profile, albeit with fewer patients who underwent revision surgery and instrumentation in the control group. Follow-up evaluation was done by an independent reviewer. Certain high risk patients were excluded from the trial and control groups.Ninety-five patients in the historic control group were available for follow-up evaluation, and 97 of the experimental (early bathing group) were available. There was one deep infection in the control group and none in the experimental group. There were three superficial wound problems in the control group, and two in the early bathing group. All superficial wound troubles healed without sequelae. Operating time, complexity, and revision rates were slightly higher in the experimental group.Prohibition of showering of patients after uncomplicated posterior spinal surgery and wound closure with skin staples may be unnecessary beyond the first few days.

    View details for Web of Science ID A1996VK47700020

    View details for PubMedID 8893443

  • Are postoperative activity restrictions necessary after posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases SPINE Carragee, E. J., Helms, E., OSULLIVAN, G. S. 1996; 21 (16): 1893-1897

    Abstract

    A prospective clinical trial was conducted.To determine if removing activity restrictions after surgery and encouraging early return to work would affect clinical outcomes after lumbar discectomy.Current practice usually recommends several weeks to months of restricted activities after lumbar discectomy. No formal studies have been done to determine the optimal period of restriction, if any, after surgery.Fifty consecutive patients undergoing limited open discectomy for herniated lumbar intervertebral disc were prospectively treated with no restrictions at all after surgery and were urged to return to full activities as soon as possible. The patients were followed for a minimum of 2 years. At follow-up evaluation, an independent examiner evaluated each patient.The mean time from surgery to return to work was 1,7 weeks. Eleven of 44 (25%) patients returned to work on the next work day. Ninety-seven percent of patients who were working before surgery returned to their previous work. Forty-three of 44 (97%) patients had returned to full duty by 8 weeks after surgery. At follow-up evaluation (3.8 years), five patients had changed work; three patients increased their work level, and two decreased their work level. No patient changed employment because of back or leg pain. There were three reherniations at the operative level (6%), all occurring more than 1 year after surgery. One patient required reoperation. Back and leg pain scores at follow-up evaluation were very low.Lifting of postoperative restrictions after limited discectomy allowed shortened sick leave without increased complications. Postoperative precautions in these patients may not be necessary.

    View details for Web of Science ID A1996VD36700013

    View details for PubMedID 8875722

  • SPONDYLOLISTHESIS IN THE YOUNG ATHLETE PHYSICIAN AND SPORTSMEDICINE Comstock, C. P., Carragee, E. J., OSULLIVAN, G. S. 1994; 22 (12): 39-?
  • INCREASED RATES OF COMPLICATIONS IN PATIENTS WITH SEVERE ANKLE FRACTURES FOLLOWING INTERINSTITUTIONAL TRANSFERS JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Carragee, E. J., CSONGRADI, J. J. 1993; 35 (5): 767-771

    Abstract

    A retrospective review of 80 consecutive patients treated at a county hospital for ankle fracture/dislocations (initial displacement > 10 mm) was undertaken. Seventy-seven patients fulfilled the requirements for documentation and follow-up. Eighteen patients were transferred from another facility and 59 patients were seen at our institution primarily. The transfer and no-transfer groups were similar in age, sex, follow-up, type of ankle fracture, and number of concomitant injuries. The no-transfer group had a slightly higher Injury Severity Score and incidence of active medical problems. Patients were transferred to this public hospital for financial considerations in 89% of the cases. The patients seen in transfer had a higher rate of overall complications (67% vs. 26%; p = 0.0001), including deep infections (11% vs. 1.7%) and major reduction failures (17% vs. 7%). Higher rates of complications were also found in patients with delayed time to operation, psychiatric or substance abuse problems, and those with skin abrasions or blisters. Analysis of variance indicated that transfer status was the strongest predictor of complications. Hospital stays were also longer in the transferred group.

    View details for Web of Science ID A1993MJ27700020

    View details for PubMedID 8230344

  • Pudendal nerve palsy after femoral intramedullary nailing. Journal of orthopaedic trauma Kao, J. T., Burton, D., Comstock, C., McClellan, R. T., Carragee, E. 1993; 7 (1): 58-63

    Abstract

    Pudendal nerve palsy after femoral intramedullary (IM) nailing was retrospectively reviewed in 65 nailings performed on 63 patients. Ten pudendal nerve palsies (15%) were noted in eight male patients and two female patients. Three male patients had autonomic involvement affecting erections. All palsies were transient (3-173 days), and occurred in patients done in the supine position as opposed to the lateral position. A possible etiology is the smaller perineal post used in the supine position that may penetrate the pelvis deeper, compressing the pudendal nerve. Other factors may be operating time and amount of traction. As prevention, the perineal post must always be adequately padded, and the operating time and amount of traction should be minimized to decrease the incidence of pudendal nerve palsy. Because pudendal nerve palsy appears to be a common complication in femoral IM nailing, the patient must be informed of this possibility.

    View details for PubMedID 8433201

  • EARLY COMPLICATIONS IN THE OPERATIVE TREATMENT OF ANKLE FRACTURES - INFLUENCE OF DELAY BEFORE OPERATION JOURNAL OF BONE AND JOINT SURGERY-BRITISH VOLUME Carragee, E. J., CSONGRADI, J. J., BLECK, E. E. 1991; 73 (1): 79-82

    Abstract

    We have reviewed the early complications of 121 surgically treated closed ankle fractures; the complication rate was 30%, with 14 major and 22 minor complications. Fractures with skin blisters or abrasions had more than double the overall complication rate. Fracture-dislocations had three times as many major complications as simple fractures, and those not fixed within 24 hours had a 44% major complication rate compared to 5.3% in those operated upon as emergencies. Patients transferred from another medical facility had high complication rates, especially if they had fracture-dislocations. We conclude that operative treatment of ankle fractures must be delivered in a timely fashion, especially in severe fractures. We would caution against the practice of transferring patients with serious ankle fractures before completion of definitive care.

    View details for Web of Science ID A1991EV32500020

    View details for PubMedID 1991782

  • REPETITIVE TRAUMA AND NERVE COMPRESSION ORTHOPEDIC CLINICS OF NORTH AMERICA Carragee, E. J., Hentz, V. R. 1988; 19 (1): 157-164

    Abstract

    Repetitive movement of the upper extremity, whether recreational or occupational, may result in various neuropathies, the prototype of which is the median nerve neuropathic in the carpal canal. The pathophysiology of this process is incompletely understood but likely involves both mechanical and ischemic features. Experimentally increased pressures within the carpal canal produced reproducible progressive neuropathy. Changes in vibratory (threshold-type) sensibility appears to be more sensitive than two-point (innervation density-type) sensibility. The specific occupational etiologies of carpal neuropathy are obscured by methodologic and sociological difficulties, but clearly some occupations have high incidences of CTS. History and physical examination are usually sufficient for the diagnosis, but diagnostic assistance when required is available through electrophysiological testing, CT scanning, and possibly MRI. Each of these tests has limitations in both sensitivity and specificity. Treatment by usual conservative means should be combined with rest from possible provocative activities. Surgical release of the carpal canal is helpful in patients failing conservative therapy. Occupational modifications are important in both treatment and prevention of median neuropathy due to repetitive trauma.

    View details for Web of Science ID A1988L630200015

    View details for PubMedID 3275923

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