Prevalence and Discordance of the "Startle Response" with True Discogenic Pain According to Spine Intervention Society Guidelines for Provocation Discography: A Cohort Study. Issue 11 (28th April 2020)

• Record Type: Journal Article
• Authors: DeFrancesch, Fred; Sperry, Beau P; Aprill, Charles N; Choe, Douglas; McCormick, Zachary L
• Is Part Of: Pain medicine. Volume 21:Issue 11(2020)
• Page Start: 2738
• Page End: 2742
• Publication Date: 2020-04-28
• Subjects: Cervical -- Discography -- Disc -- Startle Response -- Cervical Fusion; Pain -- Periodicals; Pain -- Treatment -- Periodicals; Analgesics -- Periodicals; Pain -- Periodicals; Pain Management -- Periodicals; Douleur -- Périodiques; Douleur -- Traitement -- Périodiques; Analgésiques -- Périodiques; Analgésique; Soulagement de la douleur; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); 616.047205
• DOI: 10.1093/pm/pnaa099
• Languages: English
• ISSNs: 1526-2375

Abstract

Abstract: Summary of Background Data: The literature on cervical provocation discography (C-PD) is sparse. A "Startle Response" during C-PD is a known phenomenon that might be mistaken as an indicator of discogenic pain at the provoked disc level, but this has not been quantitatively described. Objectives: To determine the incidence of the Startle Response and its concordance/discordance with true-positive C-PD in patients referred for surgical planning or evaluation after ruling out other axial pain generators. Methods: Retrospective cohort study of consecutive patients who received C-PD at an outpatient spine center. The primary outcome was the rate of discordance of the Startle Response with true-positive C-PD according to the operational criteria of the Spine Intervention Society (SIS) guidelines. Results: One hundred five discs were provoked in 36 individuals (19 female, mean age [SD] = 45.7 [10.9] years). C-PD was performed at a median of three levels (range = 1–5) with C4/5 (N = 30), C5/6 (N = 30), and C6/7 (N = 31) the most commonly evaluated. Twenty-six of 36 patients reported responses consistent with true-positive C-PD. A Startle Response was observed in 14 patients (39%, 95% confidence interval [CI] = 23–57%), and 22 of 105 (21%, 95% CI = 14–30%) provoked discs. Of the 14 patients who exhibited a Startle Response, four had negative C-PD results (29%, 95% CI = 8–58%). As assessed per disc, C-PD results were positive in 12 of the 22 (55%, 95% CI = 32–76%) provoked discs that generated a Startle Response. Conclusions: The present data demonstrate high discordance, 45% (95% CI = 24–68%), between the Startle Response and true-positive C-PD. Clinicians should be aware of this phenomenon and take care to distinguish it from a true-positive response during C-PD, as defined by the SIS guidelines. Misinterpretation of the Startle Response as a positive C-PD result may lead to inappropriate future care decisions in a substantial proportion of patients.