Mohammed BenDebba

Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review.

STUDY DESIGN The Cervical Spine Research Society study is a prospective, nonrandomized, multicenter investigation of patients with cervical spondylosis and disc disease. In this analysis, only patients who had radiculopathy without myelopathy as the predominant symptom were considered. OBJECTIVES To determine demographics, surgeon treatment practices, and outcomes in patients with symptomatic radiculopathy. SUMMARY OF BACKGROUND DATA Current data on patient demographics and treatment practices of surgeons do not exist. There are no published prospective studies in which outcomes, including pain, function, neurologic symptoms, and ability to perform activities of daily living, are systematically quantified. METHODS Patients were recruited by participating Cervical Spine Research Society surgeons. Demographic, symptomologic, and functional patient data were compiled from surveys of patients and physicians completed at the time of initial examination, and outcomes were assessed from surveys of patients completed after treatment. Data were compiled and statistically analyzed by a blinded third party. RESULTS Of the 503 patients enrolled by 41 CSRS surgeons, 246 (49%) had radiculopathy. Patients had a mean duration of symptoms of 26.7 months (range, 8 weeks to > 352 months) and a mean age of 48.1 +/- 12.42 years; 44.7% were female. Surgery was recommended for 86 (35%) of these patients. Of the 155 patients on whom there were follow-up data, 51 (33%) underwent surgery, whereas 104 (67%) received medical treatment. Surgically treated patients had a significant improvement in pain, neurologic symptoms, functional status, and ability to perform activities of daily living. A significant number of patients who underwent surgery reported persistent excruciating or horrible pain on follow-up (26%). Patients treated medically also had significant improvement in pain and overall functional status. CONCLUSIONS In summary, this study represents the first in-depth, prospective outcome analysis of patients with cervical spondylotic and discogenic radiculopathy.

Cervical Spine Outcomes Questionnaire: Its development and psychometric properties

Study Design. A cross-sectional study was conducted to analyze a convenience sample of patients seeking treatment for cervical spine conditions. Objective. To develop and evaluate the psychometric properties of a comprehensive, disease-specific questionnaire for characterizing complaints of neck pain and evaluating the outcomes of treatments for these complaints. Summary of Background Data. There currently are a number of generic and disease-specific instruments for assessing complaints of neck pain. None comprehensively cover the wide range of factors considered essential in evaluating treatment outcomes. Methods. The authors developed a comprehensive, disease-specific questionnaire for characterizing complaints of neck pain and evaluating the outcomes of treatments for these complaints. In this study, 216 patients who underwent surgery for cervical spine disorders completed the Cervical Spine Outcomes Questionnaire before treatment, then at 3 and 6 months after treatment. The data were used to evaluate the reliability, validity, and responsiveness of the questionnaire. Results. The authors have shown that the Cervical Spine Outcomes Questionnaire has high test–retest reliability, good construct validity, and responsiveness to change after treatment. Conclusions. The Cervical Spine Outcomes Questionnaire is a comprehensive, disease-specific instrument for assessing complaints of neck pain and evaluating the outcomes of treatments for these complaints. It provides information on demographics, pain severity, functional disability, psychological distress, physical symptoms, health care utilization, and satisfaction. It appears to be acceptable to patients, easy to administer, highly reliable, valid, and responsive. It should be considered for use in monitoring patients with cervical spine conditions and in studies of cervical spine disorders and their treatments.

Association between peridural scar and activity-related pain after lumbar discectomy

The purpose of this study was to investigate the correlation between activity-related pain six months after first surgery for herniated lumbar disc, and the extent of lumbar epidural fibrosis present at the surgical site, assessed by magnetic resonance imaging. The 298 patients who underwent surgery for lumbar disc herniation were studied in a randomized, controlled, double-blind multicenter clinical trial to test the effectiveness of the scar-inhibiting device ADCON-L. Clinical assessments were conducted pre-operatively and at 1, 3, and 6 month intervals post-operatively, and included wound examination, magnetic resonance imaging scar assessment, and the Johns Hopkins activity-related pain questionnaire. In addition, a longer-term follow-up assessment was conducted at 12 months post-operatively. The association between the presence of epidural scar and activity-related pain was analyzed at the 6-month interval, when successful surgical excision of protruding disc material should have eliminated chronic pain. Logistic regression analysis demonstrated a significant association (p = 0.02, odds ratio = 0.7) whereby the odds of extensive scar decreased by 30% for every 31% decrease in activity-related pain score. In addition, those patients receiving ADCON-L at surgery developed significantly less scar in the months following operation (p = 0.01, 6 and 12 months post-operatively). Repeated measures analysis demonstrated that patients who received treatment with ADCON-L at the time of surgery experienced less activity-related pain through the 12-month assessment (p = 0.05). A significant association between extensive epidural scar and activity-related pain is demonstrated. Patients with less scar had less activity related pain, confirming the finding that the use of the scar inhibitor ADCON-L has a positive effect on surgical outcome.

A validated, practical classification procedure for many persistent low back pain patients

&NA; We have developed a simple procedure for assigning persistent low back pain patients to one of four mutually exclusive, hierarchically organized classes. The procedure relies on the spatial distribution of a patients pain and the results of straight leg raise tests to make the assignment. We have applied the procedure to a large group of patients who sought treatment for persistent LBP at several university affiliated tertiary care clinics, and found that the resulting four classes of patients were significantly different from one another in their presentation, and in the way they were evaluated and treated by physicians. We concluded that the procedure may have practical research and clinical applications.

Persistent low back pain and sciatica in the United States: treatment outcomes.

Patients with persistent low back pain (LBP) appear to be different in several important ways from patients who have traditionally been classified as patients with acute or chronic LBP, and data on the effectiveness of the treatments prescribed for them are lacking. The aim of the current study was to evaluate the short- and long-term effectiveness of the treatments currently prescribed for these patients. The data reported in this article were gathered as part of a multicenter, prospective, cross-sectional study of patients who were treated for persistent LBP by neurologic and orthopedic surgeons who are recognized specialists in spinal disorders. At enrollment, patients completed a baseline evaluation, and their physicians recorded relevant clinical and treatment data on standardized study forms. At 3, 6, 12, and 24 months after treatment, patients completed follow-up evaluations. Patients were divided into five treatment groups, and effectiveness was evaluated separately for each group using five patient-reported measures of outcome: pain severity, functional disability, psychologic distress, physical symptoms, and health care use. The data revealed that at the 2-year follow-up, the typical patient of the no-treatment group had improved slightly in terms of pain severity and health care use, but had experienced little or no improvement in functional disability, physical symptoms, and psychologic distress. The average patient in the conservative care group reported small improvements in pain severity, functional disability, physical symptoms, and health care use, with no change in psychologic distress. These small improvements occurred within the first 3 months after enrollment, with essentially no change thereafter. The average patient in the immediate surgical care group showed substantial improvement on all of the outcome measures. The observed improvements were evident shortly after treatment and were maintained for the duration of the study. Patients in the delayed surgical care group had outcomes that were less dramatic than those observed in the immediate surgery care group, but greater than those observed in the conservative care group. The patients who were treated surgically by physicians outside the study, outside surgical care group, did not improve over time. Patients with persistent LBP who received no treatment showed no spontaneous recovery. Conservative care treatments prescribed by surgeons who specialize in spinal disorders, did not appear to be any more effective than no treatment. The outcome of surgery for persistent LBP varied from dramatic for one subgroup of surgical patients, to poor for another subgroup of patients. Patients who were selected immediately for surgical treatment improved substantially. Those treated surgically later by study physicians or by physicians not associated with the study fared less well.

Patient characteristics associated with diagnostic imaging evaluation of persistent low back problems.

Study Design. Post hoc analysis of data from the National Low Back Pain Study, a prospective observational multicenter study of patients referred for the evaluation and treatment of persistent low back problems. Objective. To identify patient characteristics associated with use of particular diagnostic imaging examinations in patients with persistent low back problems. Summary of Background Data. The Agency for Health Care Policy and Research clinical practice guidelines on low back problems suggest that the use of particular diagnostic imaging tests for a given patient should be based on specific characteristics of that patient. Methods. Use of diagnostic imaging examinations in 2,374 patients with persistent low back problems who were enrolled in the National Low Back Pain Study from 1986 to 1991 was analyzed. Stepwise logistic regression was used to identify patient characteristics that distinguish between enrollees who underwent particular imaging studies. Results. Characteristics that distinguished patients who had undergone magnetic resonance imaging from those who had received only lumbo‐sacral spine radiographs included higher socioeconomic status, greater resource use in the preceding 12 months, more functional impairment, presence of sciatica, and presence of neurologic signs/symptoms suggestive of nerve root compromise. Suspected soft tissue involvement was characteristic of enrollees who had undergone magnetic resonance imaging, whereas suspected structural involvement characterized patients who received noncontrast computed tomography. Only nonclinical factors, such as higher annual household income, disability compensation, and male gender distinguished enrollees who had undergone both magnetic resonance imaging and computed tomography‐myelography from those who received only computed tomography‐myelography. Conclusion. Particular patient socioeconomic and clinical characteristics are associated with receipt of specific imaging studies in evaluation of persistent low back problems.

Varieties of pain

VARIETIES OF PAIN. W.S. Torgerson’ and M,_Be_DD_e_b_b_a_, and K.J. Mason’, Dept. of Neurosurgery, The Johns Hopkins School Of Medicine, Baltimore, MD, 21205, USCI. In 1971, Melzack and Torgerson proposed a tentative system for specifying the relationships between the meaning of words people use to describe the qualities of experienced pain. The system represents each word by its membership in one of 16 mutually exclusive classes, with the classes grouped into three major domains: sensory, affective, and evaluative. Direct judgments of the similarities of pains described by pairs of descriptors reveal some serious inadequacies in the classification system. In 1984, Torgerson and BenDebba proposed an alternative system where each word is characterized by its proximity to several ideal pain types. CI mathematical model was developed to identify the underlying ideal types and the proximity of each descriptor to each ideal type, from data consisting of similarity judgments between pairs of descriptors. Several overlapping similarity judgment studies have been completed. The data have been analyzed using the proposed model and the data fit the model very well. The results of the individual studies were combined to obtain an overall structure for all 102 descriptors from the original Melzack Torgerson list. The obtained structure specifies each word in terms of its value on a common intensity dimension and its proximity to each recovered ideal type. The intensity dimension corresponds closely to Melzack-Torgerson evaluative dimension. The recovered ideal types form to relatively distinct subgroups, one related to the sensory domain of the Melzack-Torgerson system and the other to the affective domain. The obtained structure and its implication for the assessment of clinical pain will be discussed.

Oxiplex reduces leg pain, back pain, and associated symptoms after lumbar discectomy

Study Design. Prospective, randomized, blinded clinical trial. Objective. To evaluate effectiveness of Oxiplex gel for reduction of pain and associated symptoms after lumbar discectomy. Summary of Background Data. Oxiplex gel (carboxymethylcellulose, polyethylene oxide, and calcium) is used during discectomy to coat the surgical site for reduction of pain and symptoms after lumbar discectomy. Methods. Patients undergoing single-level lumbar discectomy performed by laminectomy or laminotomy and randomized to receive either surgery plus Oxiplex gel (treatment group) or surgery alone (control group) were assessed 6 months after surgery using (1) a quality of life questionnaire (Lumbar Spine Outcomes Questionnaire [LSOQ]) and (2) clinical evaluations. Results. There were no statistically significant differences in baseline demographics, surgical procedures, LSOQ scores, and clinical evaluations between treatment (N = 177) and control (N = 175) groups. More gel-treated patients were satisfied with outcome of their surgical treatment than control patients (P = 0.05). The gel-treated group showed greater reductions in pain and symptoms from baseline compared with surgery-only controls. Additional benefits of gel were consistently shown in reduction of leg and back pain at 6 months in the patient population having substantial back pain at baseline (greater than or equal to the median LSOQ pain score of 63). In that population, there was a statistically significant reduction of leg pain and back pain (P < 0.01) in the treatment group compared with controls. Fewer patients in the treatment group had abnormal musculoskeletal physical examinations at 6 months compared with controls. There were no cases of cerebrospinal fluid leaks and no differences in laboratory values or vital signs. Patients in the treatment group had less hypoesthesia, paraesthesia, sensory loss, and fewer reoperations during the 6-month follow-up than controls (1 vs. 6). Conclusion. These data demonstrate improvements in clinical outcomes resulting from the use of Oxiplex gel in discectomy procedures for treatment of lumbar disc herniation.

Relationship between pain report and diagnosis in women with dysuria

Dysuriar or painful urination, is a symptom common to infections of the urinary tract and the genital tract. In the absence of a pelvic examination, traditional symptom informat ion and genera1 physical findings cannot distinguish between the different sites of infection. Previous studies have suggested that a distinction can be made on the basis of reported pain. We have recently developed methods for assessing the multiple components of dysuric pain, and applied them to 120 consecutive women presenting with dysuria. Our aim was to determine whether urinary and genital tract infections can be distinguished when detailed information on pain is added to traditional genito-urinary symptom information.

A model for evaluating treatment outcomes in low back pain

tance to injections and decreased compliance of the epidural space at the particular site of injection. Pain levels were consistently raised to higher levels on repeated incremental injections and progressively decreased with local anesthetics. Activity levels also increased fallowing local anesthetic injections. Conclusions: The use of electric stimulation identifies the epidural space and more im-portantly, the site of the injection. The caudal approach is advantageous since it provides