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PLEASE READ MY 'DISCLAIMER' BEFORE ENTERING THIS SITE!
Welcome to my research corner. The above pages represent hundreds of hours of reading, researching and writing on my part, which covers all the classic investigations of our time. These include the famous Weber Study of 1983 which many doctors continue quoting to patients to this very day.
Another must read investigation is the study by Stanford's Eugene Carragee who describes how different types of disc herniations have different surgical success rates. This is the study that pushed me into surgery. (maybe I should have read it closer!)
You also must check-out the investigation done by Ohnmeiss et al; These researches investigate how sciatica can occur, without the presents of disc herniation or stenosis.
Finally, if your contemplating surgery, you MUST read the study by Rothoerl et al. Here they give you the facts about 'When to Have Surgery' and the dangers of prolonging a needed surgery.
The 'What's New' section (below) will give you a quick summary of the latest papers that I read, reviewed and posted. I've mostly finished the outcome studies and am now focusing on 'discogenic' back pain and sciatica.
Education is POWER, so before you see that specialist that your doctor referred you to, GET STUDYING! This way you will know the risks and long-term outcomes of surgery, versus conservative care.
Please go here to see what is new. This section of the site is no longer maintained.
1-24-12: I discovered a paper worthy of making the research corner. Read about a randomized controlled trial that pitted ACDF against an Endoscopic procedure. [Here]
05-29-05: I've updated the Maine 5 Year Outcome study with new information gathered at 10 years. The results further the contention that although patients who underwent discectomy procedures for disc herniation-associated sciatica fared slightly better with respect to satisfaction than those who were treated non-surgically, there was no difference in the rate of future need for surgery and the ability to work. [Maine 10 Year Outcome Results].
12-22-04: I have reviewed Dr. Anthony's Yeung's first published paper on his 'famous' SED procedure, which is designed for the treatment of chronic discogenic low back pain and is one possible alternatives to fusion. Although this was more of a 'pilot' investigation (traditional investigational design was not followed) and contained some errors, it boldly took-on a group of severely disabled patients and certainly demonstrated its efficacy for the treatment of the severely disabled (Oswestry average 59). As an added and unexpected bonus, Dr. Yeung has, graciously, corresponded with me and explained some of the nuances of SED and his patient-inclusion rationale. (Yeung: Selective Endoscopic Discectomy - SED)
12-14-04: At long last I've reviewed an investigation into the efficacy of Endoscopic Lumbar Disc Surgery. Dr. Anthony Yeung, who is fast becoming known as the guru of endoscopic lumbar procedures, has published his endoscopic surgical outcome for over 300 patient-procedures. The paper clearly demonstrates that Endoscopic lumbar discectomy 'seems' to be just as successful for the treatment of lumbar disc herniation-associated radiculopathy as traditional open microdiscectomy; however, at what cost to the structural integrity of the disc and its long term health. Although it was a good study... it could have been GREAT had the investigators included a few of the typical patient outcome tools (Oswestry & VAS), but alas, they chose to use an un-named outcome questionnaire instead! I still, however, have my reservations about this procedure and will wait until we get some longer term data before I will endorse endoscopic discectomy: (Yeung: Endoscopic Disc Surgery - 2002) His SED procedure, which I am reviewing next, may be a different story!
11-28-04: DON'T BELIEVE EVERYTHING THAT YOU READ! I’m supposed to be taking some time-off, but after I received an e-mail claiming that a new investigation confirms that ALIF (spinal fusion performed through the belly) is the "wonder treatment" for failed spinal surgery, I had to take a brief hiatus from my sabbatical to set the record straight. The study was fatally flawed and full of inconsistencies, which the authors admitted to on the very last page; a page that no layperson would have ever seen without purchasing the investigation! READING INVESTIGATION ABSTRACTS CAN BE DANGEROUS! [ Duggal & Dickman: ALIF for the Treatment of Failed Back Surgery Syndrome ]
9-01-04: I've just posted a review of Karppinen's 2001 investigation into the relationship between the 'size' of a patients disc displacement, never root compression and the 'degree' of their pain and disability. Surprisingly, there was no relationship at all, i.e., the patients with large disc extrusions and sequestrations and nerve root compression suffered just as much pain and disability as those with mere disc bulges or no disc defect and no root compression! It was also quite interesting to see that 20% of the 160 sciatica-suffering patients had no MRI evidence of disc herniation at all, yet 62% of these non-herniation patients still presented with classical radicular pain - pain in a distinct dermatomal pattern below the knee. ( Karppinen 2001: Patient Symptoms versus Disc Herniation Size )
8-12-04: I just posted the results of the Davis et al. investigation which used 'independent review personal' to collect the one year outcome results from some post IDET patients.The bottom line of the study was this: at one year status-post IDET, only 1 patient out of 44 reported the procedure to be a complete success! About 60% of these patients reported that their pain was either the same or worse. Over a two-year period, 23% were lost to fusion surgery, one developed severe discitis with bone destruction, and one patient developed instability. Not a very pretty picture! (Davis: IDETs efficacy for Chronic Discogenic Pain)
8-06-04: A NEW TREATMENT FOR IDD? In 2003, Klein et al. proposed that by injecting a ‘biochemical soup’ into symptomatic discs of chronic back pain sufferers, they could “promote a reparative response” and lessen the patients pain and functional disability. Despite some design flaws with this investigation, the results were quite interesting in that there was a marked improvement (74%) within about one-half of the patients, although I believe that the benefits of this improvement can NOT be permanent. (Klein: Biochemical intradiscal injection for IDD)
7-24-04: I've also added another research paper on the subject of Internal Disc Disruption: Schwarzer et al. successfully calculated the prevalence rate of IDD in a group of chronic low back/leg pain patients. The 40% prevalence number is still used today and supports the theory that IDD is the number one cause of lower back pain in the chronically disabled who have normal MRI and normal neurological examinations. (Schwarzer: The prevalence rate of IDD)
7-09-04: I've reviewed one of the few studies that have attempted to prove the existence of 'disc referred' lower limb pain (or discogenic sciatica). The study showed that 94% of discogenic sciatica sufferers obtained 75% to 100% relief of their radiating lower leg pain from an intra-discal injection of anesthetic. This would tend to prove that some cases of sciatica are really a 'referred pain' from the disc and have nothing to do with irritations of the posterior nerve roots. (Milette: To Prove Discogenic Referred Sciatica)
3-19-04: The Famous 'Saal & Saal' Study revisited: Since my recent micro-d surgery has seemed not to have worked, I felt compelled to go back to some of the major, highly quoted, outcome studies of our time, which were the basis for the design of my own treatment treatment plan. This study by the Saal brothers (who live and work within 20 minutes of me) took a group of 64 patients suffering from acute disc herniation induced radiculopathy (confirmed by MRI, EMG, and examination) and treated them with nothing but aggressive conservative care, i.e., exercise, education, epidural steroid injections, prednisone, selective nerve root blocks. He followed them for 2 years and found that about 90% of these patients recovered well enough to resume not only their normal occupation, but also to resume limited recreational sporting activities, WITHOUT surgical innervation! Although only 25% to 30% of them recovered enough to return to unlimited sports! Some of the patients in the group were even warned that they had better have surgery or risk severe disability! I'm adding this to my MUST READ list. (Here: Saal & Saal "Non-operative Treatment of Herniated Lumbar Intervertebral Disc with Radiculopathy".)
3-9-04: The famous and often quoted review of Kuslich et al is up. This study use 193 humans as 'guinea pigs' during disc and stenosis surgery by keeping the patients awake (only local anesthesia) and "stimulating" (via compression or shock) all sorts of different spinal tissues in order to see where the patient would feel that
stimulation. Amazing stimulation of the posterior disc NEVER reproduced sciatica. Only stimulation of a pre-surgically compressed nerve root (because of disc herniation or stenosis) resulted in a reproduction of the patients concordant sciatica! A direct blow to the work of Ohnmeiss et al. (Kuslich 1991: The Tissue Origin of Low Back Pain and Sciatica)
2-19-04: Just what us back pain sufferers need, another source of disc pain! Unfortunately, discogenic pain has grown another dimension. This study confirms that in severely degenerated discs, not only does pain carrying nerve fiber grow deep into the depths of the disc (even the nucleus), but this neural ingrowth is strongly associated with discogenic pain on discogram! Freemont et al. proudly boasts that this is the first study to relate this neural ingrowth with concordant pain on provocative discography. Another reason for IDET failure! (Here: Freemont 1997: Neural Ingrowth in DDD)
1-07-04: NEW Research entry - I've just completed a very interesting review of Ohnmeiss's work on the relationship between sciatica, and the degree of disc disruption. Amazingly they found that completely disrupted disc (bulges and herniations) and non-ruptured disc (IDD) BOTH were associated with lower extremity pain (sciatica) that passed the knee. (So yes, IDD can cause the symptoms of sciatica!) I also included a cool little CT discogram tutorial. (here - Ohnmeiss 1997)
12-17-03: Attention 'Limbo-Club': You're not going to like this study! This 2003 British paper studied the surgical revision rate (re-do rate) of 531 lumbar discectomy patients, 64% of whom were confirmed disc protrusion (aka: contained herniation patients) patients. These small protrusion are known not to do very well with surgery, although Carragee did discover that IF the small protrusion contained a nuclear 'fragment', then the surgery seemed to do very well. This study found that disc protrusion patients had a 2 to 3 time higher surgical revision rate, as compared to the bigger disc extrusions, and sequestrations in this study. They also had a very interesting theory as to why they believe protrusions re-herniated more often than extrusions (Here - Morgan-Hough: 2003)
12-02-03: THIS STUDY IS AN ABSOLUTE 'MUST READ' FOR ANYONE CONSIDERING DISCECTOMY! What a master piece by Stanford's Carragee. In this 2003 outcome study, he used surgical exploration and visualization to create four classes of disc herniation based on: 1) the size and appearance of the herniation, and 2) the size and magnitude of the anular tear which spawned the herniation. He was able to predict patient outcome based on the type of herniation and anular defect discovered on surgery. The exciting thing for me about this study was the fact that a group of 'contained' disc herniation patients, had one of the best outcomes! I had always been under the impression that small contained herniations ALWAYS did poorly with discectomy. NOT SO! I will bet you all that Carragee will win another Volvo Award this study this year!!! (Here - Carragee 2003:)
11-27-03: This is an excellent paper / tutorial by Professor Franco Postacchini of Italy. This famous researcher and author goes through the pros and cons of surgery versus conservative care. A MUST read for anyone who has moderate to severe sciatica. (Here - Postacchini 1996)
11-26-03: What a disappointment! I paid $35 dollars for this study and was so disappointed. It was one of the few studies that MRI'ed and EMG'ed 245 patients and then classified the herniation types, and followed their outcome with conservative care. It was filled with 'stupidities' but did give us some interesting data. Contained disc herniation don't do well with conservative care. (were going to learn from Stanford's Carragee, that contained disc herniation's don't do well with conservative care either!) (Here - Komori 2002)
11-23-03: Here we have a very, very, long term study on the effectiveness of 'traditional wide laminectomy' at 12 years. Amazingly the study reported a zero percent reoperation rate, and a 95% "patient satisfaction rate". The trade off? Instability. Only a small percentage of the original 150 patients were re x-rayed, however there was a 60% rate of instability seen at 12 years. There was a 0% instability rate before surgery. (Here - Padua 1999)
11-22-03: Here is another very important paper on 'how long should one wait before having a surgery'. There is not a whole lot of research in this area but here Rothoeri et al. 2002 did follow 219 patient who had a surgery for lumbar disc herniation induced sciatica. He looked at the 'pre-surgery suffering time' and found that after 2 month, your chances for having a successful surgery seem to decrease. I've also got five other researcher opinion on 'when to have surgery' in there as well. (Here - Rothoerl 2002)
11-21-03: Here is my favorite outcome study of all time! Its a 'must read'! It is better written then the famous Weber study but was not randomized. Nykvist & Hurme followed 276 patients for five years. Some had surgery and other chose conservative care. The follow-up examinations were 6 to 8 hours long. They were thoroughly examined and questioned. My conclusion: "If you're hospitalized for sciatica - you're f*cked; especially if you don't get or qualify for surgery. Surgery was much more satisfying and satisfactory for the patients. (Here - Nykvist 1989)
I've added another study by Weber et al. that was done in 1993. It was one of the few 'Double Blind' studies done on the effectiveness of NSAIDS versus Placebo, for relieving lower back pain and sciatica, and lowering disability. (Here - Weber 1993 NSAID study)
11-18-03: I just added Weber's 'famous', 'Volvo Award Winning', Randomized, Out-Come Study of 1982. Today, this study still sands as the Gold Standard for outcome studies. Again, it follows a rather large group of randomly selected surgical and non-surgical disc herniation sufferers. You're going to be surprised by the out-come. (Here - Weber Study 1982)
11-15-03: I just added the 'meat and potato's' of the famous 'Maine Study of 2001', which is one of our best '5 year follow-up studies' on the comparison between surgery and conservative (non-surgery) care for 'disc herniation induced sciatica'. The result were very very similar to the Volvo Award winning study of Weber in 1982. (Here - Maine Study)
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