From the Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division.
Department of Physical Medicine & Rehabilitation and Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
Anesth Analg. 2021 Mar 1;132(3):639-651. doi: 10.1213/ANE.0000000000005054.
The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions.
We prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP. Categories of Waddell signs included nonanatomic tenderness, pain during sham stimulation, discrepancy in physical examination, overreaction, and regional disturbances divulging from neuroanatomy. The primary outcome was change in patient-reported "average" numerical rating scale for pain intensity (average NRS-PI), modeled as a function of the number of Waddell signs using simple linear regression. Secondary outcomes included a binary indicator of treatment response. We conducted secondary and sensitivity analyses to account for potential confounders.
We enrolled 318 patients: 152 in the ESI cohort, 102 in the facet cohort, and 64 in the SIJ cohort, having sufficient data for primary analysis on 308 patients. Among these, 62% (n = 192) had no Waddell signs, 18% (n = 54) had 1 sign, 11% (n = 33) had 2, 5% (n = 16) had 3, 2% (n = 7) had 4, and about 2% (n = 6) had all 5 signs. The mean change in average NRS-PI in each of these 6 groups was -1.6 ± 2.6, -1.1 ± 2.7, -1.5 ± 2.5, -1.6 ± 2.6, -1 ± 1.5, and 0.7 ± 2.1, respectively, and their corresponding treatment failure rates were 54% (102 of 192), 67% (36 of 54), 70% (23 of 33), 75% (12 of 16), 71% (5 of 7), and 83% (5 of 6). In the primary analysis, an increasing number of Waddell signs were not associated with a significant decrease in average NRS-PI (coefficient [Coef] = 0.19; 95% confidence interval [CI], -0.43 to 0.05; P = .12). A higher number of Waddell signs were associated with treatment failure, with a 1.35 increased odds of treatment failure per cumulative number of signs (P = .008).
Whereas this study found no consistent relationship between Waddell signs and decreased mean pain scores, a significant relationship between the number of Waddell signs and treatment failure was observed.
注射治疗腰痛（LBP）的应用日益增多，促使人们努力改善选择。已经表明非器质性（Waddell）征象预示着手术和其他治疗方法的治疗失败，但尚未对微创介入进行研究。
我们前瞻性地评估了 3 个队列中 Waddell 征象与治疗结果之间的关联：硬膜外类固醇注射（ESI）治疗腿部疼痛和骶髂关节（SIJ）注射以及关节突介入治疗 LBP。Waddell 征象的类别包括非解剖压痛、假刺激时疼痛、体检差异、过度反应和从神经解剖学上泄露的区域紊乱。主要结局是患者报告的“平均”数字评定量表疼痛强度（平均 NRS-PI）的变化，通过简单线性回归，将其作为 Waddell 征象数量的函数进行建模。次要结局包括治疗反应的二进制指标。我们进行了二次和敏感性分析，以考虑潜在的混杂因素。
我们招募了 318 名患者：ESI 队列 152 名，关节突队列 102 名，SIJ 队列 64 名，其中 308 名患者有足够的数据进行主要分析。其中，62%（n=192）没有 Waddell 征象，18%（n=54）有 1 个征象，11%（n=33）有 2 个征象，5%（n=16）有 3 个征象，2%（n=7）有 4 个征象，约 2%（n=6）有所有 5 个征象。这 6 组中平均 NRS-PI 的平均变化分别为-1.6±2.6、-1.1±2.7、-1.5±2.5、-1.6±2.6、-1.0±1.5 和 0.7±2.1，相应的治疗失败率分别为 54%（192 名中的 102 名）、67%（54 名中的 36 名）、70%（33 名中的 23 名）、75%（16 名中的 12 名）、71%（7 名中的 5 名）和 83%（6 名中的 5 名）。在主要分析中，Waddell 征象的数量增加与平均 NRS-PI 的显著下降无关（系数[Coef]=0.19；95%置信区间[CI]，-0.43 至 0.05；P=0.12）。更多的 Waddell 征象与治疗失败相关，每累积一个 Waddell 征象，治疗失败的几率增加 1.35 倍（P=0.008）。
虽然本研究未发现 Waddell 征象与疼痛评分降低之间存在一致关系，但观察到 Waddell 征象数量与治疗失败之间存在显著关系。
