Lumbosacral spine imaging: physioanatomic method

Thermographic diagnostics in equine back pain

Infrared thermographic imaging (ITI) is the most sensitive objective imaging currently available for the detection of back disease in horses. It is, however, only a physiological study primarily of vasomotor tone overlying other superficial tissue factors. Interpretation requires extreme care in imaging protocol and in understanding the significance of altered sympathetic nervous tone and the sympathetic distribution. Most discussions on back pain have centered on nociception and inflammatory events. ITI provides information and localization for more significant than diagnosing areas of hot spots. Chronic back pain usually involves vasoconstriction at the affected sites and from ITI studies in man, we have an opportunity to appreciate chronic pain phenomena that involves non-inflammatory events. These occur commonly in horses, but are still seldom recognized and treated.

Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation

The changing health care environment necessitates careful re-evaluation of all costly elective procedures. Low back surgery is a typical example. This article reviews the current literature addressing the efficacy of surgery and invasive percutaneous treatments for discogenic sciatica. It also discusses the prospects for the continuation of reimbursement for these procedures under a system of managed health care. Relevant articles were identified using the MEDLINE and Current Contents databases, from bibliographies of articles identified from these databases, from recommendations of experts in the field, and from the Canadian Cochrane++ Collaboration. The review includes randomized clinical trials, meta-analyses, published practice guidelines and large case series. The literature is classified and discussed in these quality strata. The review includes 9 randomized trials, 6 meta-analyses or review articles, one evidence-based practice guideline, 38 surgical case series and 35 additional references. Though incomplete, the existing evidence indicates that open discectomy shortens the duration of discogenic sciatica in selected patients. Neurologic outcomes are similar in operated and unoperated patients. Predominant leg pain, evidence of nerve root tension and concordant symptoms and imaging findings, are associated with favorable surgical results. Chemonucleolysis is also associated with more rapid pain relief than conservative treatment, but provides less certain benefit than standard discectomy. Available data on other percutaneous disc treatments do not currently support a statement on efficacy. Various percutaneous techniques are available but there is no solid scientific evidence of efficacy. The benefits of open discectomy, principally reduced duration of pain, appear to justify its use in carefully selected patients when discogenic sciatica fails to improve with conservative measures. Though elective, the procedure will probably continue to be available under managed care, but with increasing scrutiny of operative indications.