Systematic review of thoracic discography as a diagnostic test for chronic spinal pain

Pain Diagnostics Associates, Niagara, WI 54151, USA.
Pain physician (Impact Factor: 3.54). 11/2007; 11(5):631-42.
Source: PubMed

ABSTRACT Even though the prevalence of thoracic pain has been reported to be 15% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well researched. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain.
To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography.
A systematic review of provocation thoracic discography.
A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. Studies meeting the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher were included for the assessment of the level of evidence. Level of evidence was based on the United States Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. Based on the level of evidence, recommendations were made according to Guyatt et al's criteria.
The clinical value of thoracic provocation discography is limited (Level II-3) with 2C/weak recommendation derived from low quality or very low quality evidence indicating that other alternatives may be equally reasonable.
Based on the available evidence for this systematic review, thoracic provocation discography is provided with a weak recommendation for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed. This is qualified by the need to appropriately evaluate and diagnose other causes of chronic thoracic pain including pain originating from thoracic facet joints.

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    • "Thoracic pain has been described to originate from multiple structures, including intervertebral discs and facet joints, both of which can be evaluated by proven diagnostic techniques [15] [16] [19] [21]. The accuracy of diagnostic blocks of thoracic facet joints is superior to discography. "
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    ABSTRACT: Study Design. A randomized, double-blind, active-control trial. Objective. To determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain. Summary of Background Data. The prevalence of thoracic facet joint pain has been established as 34% to 42%. Multiple therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include medial branch blocks, radiofrequency neurotomy, and intraarticular injections. Methods. This randomized double-blind active controlled trial was performed in 100 patients with 50 patients in each group who received medial branch blocks with local anesthetic alone or local anesthetic and steroids. Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months. Results. Significant improvement with significant pain relief and functional status improvement of 50% or more were observed in 80% of the patients in Group I and 84% of the patients in Group II at 2-year followup. Conclusions. Therapeutic medial branch blocks of thoracic facets with or without steroids may provide a management option for chronic function-limiting thoracic pain of facet joint origin.
    Anesthesiology Research and Practice 07/2012; 2012:585806. DOI:10.1155/2012/585806
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    • "Studies show false positive results with discograms to be as high as 25% 13,15. A recent systematic review reported the published evidence to be of low quality 16. The authors identified only two studies by the same authors for inclusion, each over 10 years old. "
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    ABSTRACT: Discogenic pain or herniation causing neural impingement of the thoracic vertebrae is less common than that in the cervical or lumbar regions. Treatment of thoracic discogenic pain usually involves conservative measures. If this fails, conventional fusion or discectomy can be considered, but these procedures carry significant risk. To assess the efficacy and safety of percutaneous laser disc decompression (PLDD) for the treatment of thoracic disc disease. Ten patients with thoracic discogenic pain who were unresponsive to conservative intervention underwent the PLDD procedure. Thoracic pain was assessed using the Visual Analog Scale (VAS) scores preoperatively and at 6-month intervals with a minimum of 18-months follow-up. Patients were diagnosed and chosen for enrollment based on abnormal MRI findings and positive provocative discograms. Patients with gross herniations were not included. Length of follow-up ranged from 18 to 31 months (mean: 24.2 mo). Median pretreatment thoracic VAS score was 8.5 (range: 5-10) and median VAS score at final follow-up was 3.8 (range: 0-9). Postoperative improvement was significant with a 99% confidence interval. Of interest, patients generally fell into two groups, those with significant pain reduction and those with little to no improvement. Although complications such as pneumothorax, discitis, or nerve damage were possible, no adverse events occurred during the procedures. The study is limited by its small size and lack of a sham group. Larger controlled studies are warranted. With further clinical evidence, PLDD could be considered a viable option with a low risk of complication for the treatment of thoracic discogenic pain that does not resolve with conservative treatment.
    International journal of medical sciences 06/2010; 7(3):155-9. · 2.00 Impact Factor
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    ABSTRACT: Disability, societal, and health impact of chronic intractable pain secondary to various failed therapies is a major issue. As advanced therapy, implantable therapies, which include intrathecal devices and spinal cord stimulation systems, are frequently used in managing chronic intractable pain. Thus, continuous infusion of intrathecal medication is one of the methods used for the control of chronic, refractory, cancer, and non-cancer pain. However, despite the high costs of chronic non-cancer pain, it has been claimed that there is a lack of evidence for intrathecal infusion systems and the cost effectiveness of these systems has been questioned in improving pain and function. A systematic review of intrathecal infusion devices for chronic non-cancer pain. To determine the efficacy, utilization, safety, and complications associated with the use of intrathecal infusion devices for long-term management of chronic non-cancer pain. Literature search was performed through EMBASE, Medline, Cochrane databases, and systematic reviews identified from 1966 to December 2008. Studies were then reviewed and assessed using the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and the Cochrane Musculoskeletal Review Group criteria for randomized trials. The level of evidence was determined using 5 levels of evidence, ranging from Level I to III with 3 subcategories in Level II, based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). The primary outcome measure was pain relief (short-term relief < or = one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were also utilized. The level of evidence for intrathecal infusion systems indicated either Level II-3 or Level III (limited) based on U.S. Preventive Services Task Force (USPSTF) criteria. The limitations of this study include the paucity of literature, lack of quality evidence, and lack of randomized trials. This systematic review illustrates Level II-3 or Level III (limited) evidence for intrathecal infusion systems for long-term relief in chronic non-cancer pain.
    Pain physician 11/2008; 12(2):345-60. · 3.54 Impact Factor
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