Outcome of unoperated discogram-positive low back pain

Efficacy of stepped care treatment for chronic discogenic low back pain patients with Modic I and II changes

Objective

This study investigated whether patients with Modic changes (MC) of types I, I/II, and II would respond to an anti-inflammatory-based, stepped care treatment with three treatment steps: first, oral administration of NSAIDs, 2 × 200 mg celecoxib daily for two weeks; second, an intradiscal steroid injection (ID) with dexamethasone and cefazolin; and third, oral treatment with antibiotics (AB), 3 × 1 g amoxicillin daily for 100 days.

Design

This was an observational clinical study based on analyses of categorical data of patient-reported outcome measurements.

Subjects

Subjects were consecutive patients with chronic low back pain (CLBP), diagnosed by assessment of anamnestic signs of inflammation; a pain score ≥6 on the Numeric Pain Rating Scale (NPRS); a mechanical assessment; MC I, I/II, or II based on MRI; and lack of response to conservative treatment.

Methods

From January 1, 2015, to December 31, 2021, 833 eligible patients were selected for the stepped care treatment. A total of 332 patients completed requested follow-up questionnaires at baseline and 12 months (optional at 3 and 6 months). Primary outcomes were pain (at least 50 % pain relief) and/or a minimum of 40 % improvement in functionality as measured by the Roland Morris Disability Questionnaire (RMDQ) or the Oswestry Disability Questionnaire (ODI). Secondary outcome measures were use of pain medication and return to work.

Results

At 1 year of follow-up, 179 (53.6 %) of 332 patients reported improvement according to the responder criteria. Of the 138 patients that had received only NSAIDs, 88 (63.8 %) had improved. In addition, 50 (56.8 %) of the 183 patients that had received ID had improved, and 41 (38.7 %) of the 106 patients treated with AB had improved. None of the patients reported complications. 12.0 % of patients using AB stopped preterm due to undesirable side effects.

Conclusion

Treatment with a stepped care model for inflammatory pain produced clinically relevant, positive reported outcomes on pain and/or function. Our stepped care model appears to be a useful, safe, and cost-saving treatment option that is easily reproducible. Further studies, including randomized controlled trials and analyses of subgroups, may help to develop a more patient-tailored approach and further avoidance of less-effective treatments and costs.

Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management

There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.

Is There Clinical Improvement Associated With Intradiscal Therapies? A Comparison Across Randomized Controlled Studies

STUDY DESIGN

Post hoc comparison using single-site data from 4 multicenter randomized controlled trials.

OBJECTIVES

Discogenic back pain is associated with significant morbidity and medical cost. Several terminated, unreported randomized controlled trials have studied the effect of intradiscal biologic injections. Here we report single-center outcomes from these trials to determine if there is clinical improvement associated with these intradiscal injections.

METHODS

Post hoc comparison was performed using single-site data from 4 similar multi-center randomized controlled trials. All trials evaluated an injectable therapy (growth factor, fibrin sealant, or stem cells) for symptomatic lumbar disc disease with near-identical inclusion and exclusion criteria. Demographics and patient reported outcomes were analyzed across treatment arms postinjection.

RESULTS

A total of 38 patients were treated with biologic agents and 12 were treated with control saline injections. There was a significant decrease in visual analogue score (VAS) pain for both the investigational and saline groups up to 12 months postinjection (P < .01). There was no significant difference in VAS scores between the saline and investigational groups at 12 months. Similarly, there was significant improvement in patient-reported disability scores in both the investigational and saline groups at all time points. There were no significant differences in disability score improvement between the saline and investigational treatment groups at 12 months postinjection.

CONCLUSIONS

A single-center analysis of 4 randomized controlled studies demonstrated no difference in outcomes between therapeutic intradiscal agents (growth factor, fibrin sealant, or stem cells) and control saline groups. In all groups, patient reported pain and disability scores decreased significantly. Future studies are needed to evaluate the therapeutic benefit of any intradiscal injections.

What can we learn from long-term studies on chronic low back pain? A scoping review

PURPOSE

A scoping review was conducted with the objective to identify and map the available evidence from long-term studies on chronic non-specific low back pain (LBP), to examine how these studies are conducted, and to address potential knowledge gaps.

METHOD

We searched MEDLINE and EMBASE up to march 2021, not restricted by date or language. Experimental and observational study types were included. Inclusion criteria were: participants between 18 and 65 years old with non-specific sub-acute or chronic LBP, minimum average follow-up of > 2 years, and studies had to report at least one of the following outcome measures: disability, quality of life, work participation, or health care utilization. Methodological quality was assessed using the Effective Public Health Practice Project quality assessment. Data were extracted, tabulated, and reported thematically.

RESULTS

Ninety studies met the inclusion criteria. Studies examined invasive treatments (72%), conservative (21%), or a comparison of both (7%). No natural cohorts were included. Methodological quality was weak (16% of studies), moderate (63%), or strong (21%) and generally improved after 2010. Disability (92%) and pain (86%) outcomes were most commonly reported, followed by work (25%), quality of life (15%), and health care utilization (4%). Most studies reported significant improvement at long-term follow-up (median 51 months, range 26 months-18 years). Only 10 (11%) studies took more than one measurement > 2 year after baseline.

CONCLUSION

Patients with persistent non-specific LBP seem to experience improvement in pain, disability and quality of life years after seeking treatment. However, it remains unclear what factors might have influenced these improvements, and whether they are treatment-related. Studies varied greatly in design, patient population, and methods of data collection. There is still little insight into the long-term natural course of LBP. Additionally, few studies perform repeated measurements during long-term follow-up or report on patient-centered outcomes other than pain or disability.

Translational Studies on Biologic Fusion of a Vertebral Segment as a Novel Treatment Modality for Low Back Pain

STUDY DESIGN

Preclinical studies: Efficacy and toxicological studies on lactic acid (LA)-induced sclerozation in pig lumbar discs. Clinical study: Prospective, randomized, double-blinded, placebo-controlled, single ascending dose study investigating the safety and local tolerability of LA.

OBJECTIVE

To determine if LA produces sclerozation of the porcine nucleus pulposus (NP) followed by a phase Ib study to evaluate preliminary safety, tolerability, and efficacy of LA in patients with chronic discogenic low back pain.

SUMMARY OF BACKGROUND DATA

Surgical stabilization of a motion segment harboring a painful degenerated disc often affords symptomatic relief. In the present study, the hypothesis was tested that LA can produce sclerozation and stabilization of the NP.

METHODS

LA (0.2 mL; 60, 120, or 240 mg/mL) or vehicle was injected into the NP or close to the extra spinal region of spinal nerves of young female pigs. The size of the NP, MRI changes, flexural stiffness, and histology of the disc was studied after up to 84 days of survival. Fifteen patients injected intra discally with placebo (iohexol, 1.5 mL, n = 6) or iohexol plus LA (30, 60, or 120 mg/mL; three patients in each group) were followed for up to 12 months.

RESULTS

Injection of LA in the pig reproducibly induced sclerozation of the NP and increased flexural rigidity. Histological changes included generation of connective tissue and increased expression of collagen I. No safety concerns were raised. Adverse events in patients were limited to transiently increased low back pain with no obvious difference between treatment groups. There was indication of lower water content of NP injected with the two highest doses of LA.

CONCLUSION

LA has a sclerozing effect on the NP in pigs and patients and is therefore a candidate for further clinical studies powered to determine its potential as a treatment of chronic discogenic low back pain.

LEVEL OF EVIDENCE

2.

Perioperative adverse events after different fusion approaches for single-level lumbar spondylosis

Background

Low back pain from lumbar spondylosis affects a large proportion of the population. In select cases, lumbar fusion may be considered. However, cohort studies have not shown clear differences in long-term outcomes between PSF, TLIF, ALIF, and AP fusion. Thus, differences in perioperative complications might affect choice between these procedures for the given diagnosis. The current study seeks to compare perioperative adverse events for patients with lumbar spondylosis treated with single-level: posterior spinal fusion (PSF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or combined anterior and posterior lumbar fusion (AP fusion).

Methods

Patients with a diagnosis of lumbar spondylosis who underwent single-level lumbar fusion without decompression were identified in the 2010-2016 National Quality Improvement Program (NSQIP) database. Patients were categorized based on their procedure (PSF, TLIF, ALIF, or AP fusion). Unadjusted Fisher's exact and Pearson's chi-squared tests were used to compare demographics and comorbid factors. Analysis was secondarily done with propensity score matching to address potential differences in patient selection between the study cohorts.

Results

In total, 1816 patients were identified: PSF n=322, TLIF n=800, ALIF n=460, AP fusion n=234. The procedures did not have different thirty-day individual or aggregated (any, serious, minor, or infection) adverse events. Further, propensity score matched analysis also revealed no differences in individual or aggregated thirty-day perioperative events.

Conclusion

The current study demonstrates a lack of difference in thirty-day perioperative adverse events for different fusion procedures performed for lumbar spondylosis, consistent with prior longer-term outcome studies. These findings suggest that patient/surgeon preference and other factors not captured here should be considered to determine the best surgical technique for the select patients with the given diagnosis who are considered for lumbar fusion.

Summary Sentence

Using the NSQIP 2010-2016 databases, this study showed that perioperative adverse events were similar for different surgical approaches of single-level fusion for single-level lumbar spondylosis.

Two-year Outcomes from a Single Surgeon's Learning Curve Experience of Oblique Lateral Interbody Fusion without Intraoperative Neuromonitoring

Introduction

Oblique lumbar interbody fusion (OLIF) is a newer procedure that avoids the psoas and lumbosacral plexus due to its oblique trajectory into the retroperitoneal space. While early experience with OLIF is reassuring, the longer-term clinical efficacy has not been well established. The purpose of this study was to describe two-year clinical outcomes with OLIF performed by a single surgeon during the learning curve without the aid of the neuromonitoring.

Materials and methods

Chart review was performed for the consecutive patients who underwent OLIF by a single surgeon. Back pain severity on a visual analog scale (VAS) and Oswestry Disability Index (ODI) were collected preoperatively and postoperatively at six weeks, three months, six months, one year and two years.

Results

A total of 21 patients (38 levels) were included in this study. The indications for surgery were degenerative disc disease (n=10, 47.6%), spondylolisthesis (n=9, 42.9%) and spinal stenosis (n=6, 28.6%). The median operating room time was 351 minutes (interquartile range (IQR): 279-406 minutes), blood loss was 40 ml (IQR: 30-150 ml), and hospital stay was 2.0 days (IQR: 1.0-3.5 days). The complication rate was 9.5%, both venous injuries. There were no other perioperative complications. Back pain severity decreased by 70%, on average, over two years (p <0.001). A total of 17 (81%) patients reported at least a two-point decrease from the baseline. The ODI scores decreased by 55%, on average, over two years (p <0.001), with 16 (76%) patients reporting at least a 15-point decrease from the baseline. Over two years, no symptomatic pseudarthrosis, hardware failure, reoperations, or additional complications were reported.

Conclusions

The oblique lateral interbody fusion performed without the intraoperative neuromonitoring was safe and clinically efficacious for up to two years. The complication rate in this cohort is similar to other published OLIF series and appears acceptable when compared to the lateral lumbar interbody fusion (LLIF) and the anterior lumbar interbody fusion (ALIF). No motor or sensory deficits were observed in this study, supporting the premise that the neuromonitoring is unnecessary in OLIF.

Single Intradiscal Administration of the Tumor Necrosis Factor-Alpha Inhibitor, Etanercept, for Patients with Discogenic Low Back Pain

OBJECTIVE

To examine the analgesic effect of intradiscal administration of a tumor necrosis factor-αα (TNF-α) inhibitor in patients with discogenic low back pain (LBP).

DESIGN

Prospective, randomized study.

SETTING

Department of Orthopaedic Surgery, Chiba (Japan) University Hospital.

SUBJECTS

Seventy-seven patients diagnosed with discogenic LBP.

METHODS

Discogenic LBP patients were randomly assigned to the etanercept (n = 38; bupivacaine [2 mL] with etanercept [10 mg]) or control (n = 39; bupivacaine [2 mL]) groups. Patients received a single intradiscal injection. Numerical rating scale (NRS) scores for LBP at baseline, 1 day, and 1, 2, 4, and 8 weeks after the injection were recorded. The Oswestry disability index (ODI) scores at baseline and at 4 and 8 weeks after injection were evaluated. Postinjection complications were recorded and evaluated.

RESULTS

In the etanercept group, the NRS scores were significantly lower than in the control group at every time point after the injection for 8 weeks (P < 0.05). Similarly, 4 weeks after the injection, the ODI score was lower in the etanercept group than in the control group (P < 0.05). However, the ODI scores were not significantly different at 8 weeks. Complications were not observed.

CONCLUSIONS

Single intradiscal administration of a TNF-α inhibitor can alleviate intractable discogenic LBP for up to 8 weeks. TNF-α may be involved in discogenic pain pathogenesis. This procedure is a novel potential treatment; longer-term effectiveness trials are required in the future.

Multiexpandable cage for minimally invasive posterior lumbar interbody fusion

The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results.

The activL(®) Artificial Disc: a next-generation motion-preserving implant for chronic lumbar discogenic pain

Degeneration of the lumbar intervertebral discs is a leading cause of chronic low back pain in adults. Treatment options for patients with chronic lumbar discogenic pain unresponsive to conservative management include total disc replacement (TDR) or lumbar fusion. Until recently, only two lumbar TDRs had been approved by the US Food and Drug Administration - the Charité Artificial Disc in 2004 and the ProDisc-L Total Disc Replacement in 2006. In June 2015, a next-generation lumbar TDR received Food and Drug Administration approval - the activL(®) Artificial Disc (Aesculap Implant Systems). Compared to previous-generation lumbar TDRs, the activL(®) Artificial Disc incorporates specific design enhancements that result in a more precise anatomical match and allow a range of motion that better mimics the healthy spine. The results of mechanical and clinical studies demonstrate that the activL(®) Artificial Disc results in improved mechanical and clinical outcomes versus earlier-generation artificial discs and compares favorably to lumbar fusion. The purpose of this report is to describe the activL(®) Artificial Disc including implant characteristics, intended use, surgical technique, postoperative care, mechanical testing, and clinical experience to date.

Single intradiscal injection of the interleukin-6 receptor antibody tocilizumab provides short-term relief of discogenic low back pain; prospective comparative cohort study

BACKGROUND

Inflammatory cytokines, such as interleukin-6 and tumor necrosis factor-α, are gaining attention as important etiologic factors associated with discogenic low back pain. We conducted a prospective cohort study to evaluate the efficacy and safety of intradiscal injection of the interleukin-6 receptor antibody tocilizumab in patients with discogenic low back pain.

METHODS

Thirty-two consecutive patients were intradiscally injected with 2 mL of 0.5% bupivacaine (control group). Another 31 consecutive patients were intradiscally injected with 40 mg tocilizumab and 1-2 mL of 0.5% bupivacaine (tocilizumab group) at the same time. Prior to treatment, the vertebral origin of low back pain was confirmed in all patients based on pain provocation during discography and pain relief with 1 mL of 1% xylocaine. Numeric rating scale and Oswestry disability index scores were used to evaluate pain level before and after treatment between the 2 groups. The association between pain relief with tocilizumab and intervertebral disc degeneration grade was also determined.

RESULTS

At the end of the study (8 weeks after treatment), 30 patients in each group were evaluable. In the tocilizumab group, numeric rating scale and Oswestry disability index scores improved significantly at 2 and 4 weeks after treatment, respectively. Intervertebral disc degeneration was not associated with improvement of numeric rating scale score in the tocilizumab group. Local infection (i.e., discitis) was observed in 1 patient in the tocilizumab group.

CONCLUSIONS

The results demonstrate the clinical relevance of interleukin-6 in discogenic low back pain. Intradiscal tocilizumab injection was shown to exert a short-term analgesic effect in patients with discogenic low back pain. Further research is required to determine the long-term effects of intradiscal tocilizumab therapy in patients with discogenic low back pain.

Prevalence and Characteristics of Discogenic Pain in Tertiary Practice: 223 Consecutive Cases Utilizing Lumbar Discography

BACKGROUND

Between 26% and 42% of chronic low back pain is attributed to internal disc disruption of lumbar intervertebral discs. These prevalence estimates and data characterizing discogenic pain originate largely from research at elite practices, conducted 20 years ago. With few studies since, their concordance with rates in community practice has rarely been addressed.

OBJECTIVE

To assess the prevalence and key features of discogenic pain within community-based tertiary practice, and to evaluate the accuracy and clinical utility of discography.

DESIGN

This prospective, three-year study of 223 consecutive cases of chronic low back pain used image-guided lumbar discography to identify symptomatic and flanking asymptomatic discs. A subset of patients (n = 195) had previously undergone posterior column blocks to investigate spinal facet and/or sacroiliac joints as contributing pain sources.

RESULTS

A total of 644 discs were tested without infection or complication. Positive discograms were recorded in 74% of patients, with 22.9% negative and 3.1% assessed as indeterminate. Among patients receiving both discography and diagnostic blocks, 63% had proven discogenic pain, 18% had pain of mixed etiology and 14% remained undiagnosed. Taking into account all low back pain cases during this study (n = 756), discogenic pain prevalence was 21.8% (95% CI: 17-26%).

CONCLUSION

The prevalence of discogenic pain in this community practice is below the range, but within confidence intervals, previously reported. Prevalence is considerably elevated, however, among well-selected patients and discography enabled a firm diagnosis in most such cases. These findings are broadly in keeping with those reached in key publications and support the clinical utility of discography.

A 10-year follow-up of transpedicular screw fixation and intervertebral autogenous posterior iliac crest bone graft or intervertebral B-Twin system in failed back surgery syndrome

Background:

The spine surgeons have been combining anterior and posterolateral fusion (circumferential fusion) as the final solution to treat spinal disorders and many have been using it to treat failed back surgery syndrome (FBSS). In present study, we analyzed and compared the clinical and radiological outcomes in patients with transpedicular screw fixation and intervertebral autogenous posterior iliac crest bone graft or in patients with transpedicular screw fixation and intervertebral B-Twin system for FBSS with a follow-up period of 10 years after the surgery.

Materials and Methods:

This study was a retrospective case study performed on 55 patients with FBSS. Clinical and radiological changes were compared between the two groups of patients on the basis of improvement of back pain, radicular pain, and work capacity. Outcome was measured in terms of Oswestry Low Back Pain Disability Index, and the changes in pain and function were documented every year from before surgery until 2012. We analyzed the evolution of 55 cases of FBSS those underwent segmental circumferential posterior fusions from June 2001 to February 2003, operated by a single surgeon and followed up during 10 years until February 2012. The patients were divided into 2 groups: In 25 patients, posterolateral fusions with Legacy™ (Medtronic, Inc. NYSE: MDT) screws and intersomatic autogenous posterior iliac crest bone graft was performed, and, in 30 patients, posterolateral fusions with the same screws and intersomatic fusion B-Twin (Biomet Spain Orthopaedics, S.L.) system was performed. In all cases, we used posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) approach for intervertebral graft, and the artrodesis was supplemented at intertransverse level with Autologus Growth Factor (AGF-MBA INCORPORADO, S.A.). The outcome was measured in terms of Oswestry Low Back Pain Disability Index, and the changes in pain and function were documented every year and compared from before surgery to the final follow-up visit. Preoperative and postoperative scores were available for all patients.

Results:

The average age of these patients was comparable in both groups (mean age 42.6 versus 50.2 years). The average follow-up period was 200.6 months in the first group (screws and intersomatic bone) and 184.4 months in the second group (screws and B-Twin). In the autologus bone graft group, the CT scan and Rx study revealed loss of height of intervertebral space between 25% and 45% of 24 h postoperative height of intervertebral operated disc, and the patients continued to lose the height until 20 months after the surgery. In the B Twin group, the CT scan and Rx study revealed a loss of height of the intervertebral level of 8-12% over a period of 9 months follow-up, followed by stability. A total of 31 patients (55%) had improved Oswestry Low Back Pain Disability Index >40% of the total possible points, although this did not reflect in PSI or return to work rate.

Conclusions:

The patients with rigid fixation do well in terms of correction of lumbar lordosis, but they do not do well in terms of recurrence of pain. Furthermore, they need some kind of intervention to control pain after the first year after surgery. In patients in whom bone graft is used, although they do not maintain and sustain the lumbar lordosis in the long term, they have less recurrence of pain with less chances of intervention for pain control.

Clinical and radiographic outcomes with L4-S1 axial lumbar interbody fusion (AxiaLIF) and posterior instrumentation: a multicenter study

Introduction

Previous studies have confirmed the benefits and limitations of the presacral retroperitoneal approach for L5–S1 interbody fusion. The purpose of this study was to determine the safety and effectiveness of the minimally invasive axial lumbar interbody approach (AxiaLIF) for L4–S1 fusion.

Methods

In this retrospective series, 52 patients from four clinical sites underwent L4–S1 interbody fusion with the AxiaLIF two-level system with minimum 2-year clinical and radiographic follow-up (range: 24–51 months). Outcomes included back pain severity (on a 10-point scale), the Oswestry Disability Index (ODI), and Odom’s criteria. Flexion and extension radiographs, as well as computed tomography scans, were evaluated to determine fusion status. Longitudinal outcomes were assessed with repeated measures analysis of variance.

Results

Mean subject age was 52 ± 11 years and the male:female ratio was 1:1. Patients sustained no intraoperative bowel or vascular injury, deep infection, or neurologic complication. Median procedural blood loss was 220 cc and median length of hospital stay was 3 days. At 2-year follow-up, mean back pain had improved 56%, from 7.7 ± 1.6 at baseline to 3.4 ± 2.7 (P < 0.001). Back pain clinical success (ie, ≥30% improvement from baseline) was achieved in 39 (75%) patients at 2 years. Mean ODI scores improved 42%, from 60% ± 16% at baseline to 35% ± 27% at 2 years (P < 0.001). ODI clinical success (ie, ≥30% improvement from baseline) was achieved in 26 (50%) patients. At final follow-up, 45 (87%) patients were rated as good or excellent, five as fair, and two as poor by Odom’s criteria. Interbody fusion observed on imaging was achieved in 97 (93%) of 104 treated interspaces. During follow-up, five patients underwent reoperation on the lumbar spine, including facet screw removal (two), laminectomy (two), and transforaminal lumbar interbody fusion (one).

Conclusion

The AxiaLIF two-level device is a safe, effective treatment adjunct for patients with L4–S1 disc pathology resistant to conservative treatments.

Operative and nonoperative treatment approaches for lumbar degenerative disc disease have similar long-term clinical outcomes among patients with positive discography

OBJECTIVE

It remains unclear whether fusion for lumbar degenerative disc disease with positive discography produces better outcomes compared with nonoperative treatment. The aim of this study was to compare outcomes of patients with discography-concordant lumbar degenerative disc disease electing for fusion versus nonoperative treatment.

METHODS

We retrospectively reviewed consecutive patients with back pain and concordant lumbar discogram who were offered fusion. Follow-up questionnaires included pain score, Oswestry disability index, short form-12, and satisfaction scale. Patients were stratified based on whether they elected for fusion or nonoperative treatment.

RESULTS

Overall follow-up was 48% (96/200). Patients lacking follow-up were slightly older (P = 0.021) and less likely to be smokers (P = 0.013). Between patients with and without follow-up, there were no significant differences in pain score at initial visit, body mass index, or gender (P ≥ 0.40). The 96 patients for whom follow-up was obtained included 53 in the operative and 43 in the nonoperative groups. At baseline, there were no significant differences between these groups based on age, pain score, body mass index, smoking, or gender (P ≥ 0.25). Mean follow-up was 63 months for operative and 58 months for nonoperative patients (P = 0.20). The mean pain score at last follow-up improved significantly for operative and nonoperative patients (P < 0.001). At follow-up, operative and nonoperative groups did not differ significantly with regard to pain scores, Oswestry disability index, short form-12, or satisfaction scale.

CONCLUSIONS

Comparison of long-term outcomes for patients with back pain and concordant discography did not demonstrate a significant difference in outcome measures of pain, health status, satisfaction, or disability based on whether the patient elected for fusion or nonoperative treatment.

Recombinant human bone morphogenetic protein-2-augmented transforaminal lumbar interbody fusion for the treatment of chronic low back pain secondary to the homogeneous diagnosis of discogenic pain syndrome: two-year outcomes

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

To assess clinical outcomes, perioperative complications, revision surgery rates, and recombinant human bone morphogenetic protein-2 (BMP-2)-related osteolysis, heterotopic bone, and unexplained postoperative radiculitis (BMPP) in a group of patients treated with BMP-2-augmented transforaminal lumbar interbody fusion (bTLIF) for the homogeneous diagnosis of discogenic pain syndrome (DPS) and to put forth the algorithm used to make the diagnosis.

SUMMARY OF BACKGROUND DATA

There is a paucity of literature describing outcomes of TLIF for the homogeneous diagnosis of DPS, an old but controversial member of the lumbar degenerative disease family.

METHODS

The registry from a single surgeon was queried for patients who had undergone bTLIF for the homogeneous diagnosis of DPS, which was made via specific diagnostic algorithm. Clinical outcomes were determined by analyzing point improvement from typical outcome questionnaires and the data from Patient Satisfaction and Return to Work questionnaires. Independent record review was used to assess all outcomes.

RESULTS

Eighty percent of the cohort (36/45) completed preoperative and postoperative outcome questionnaires at an average follow-up of 41.9 ± 11.9 months, which demonstrated significant clinical improvement: Oswestry Disability Index = 16.4 (P < 0.0001), 12-Item Short Form Health Survey physical component summary score = 10.0 (P < 0.0001), and a Numeric Rating Scale for back pain = 2.3 (P < 0.0001). The median patient satisfaction score was 9.0 (10 = complete satisfaction), and 84.4% (27/32) of the cohort were able to return to their preoperative job, with or without modification. There were 3 perioperative complications, 4 revision surgical procedures, and 11 cases of benign BMPP. There were no incidents of the intraoperative dural tears or nerve root injury, and litigation involvement (11/36, P > 0.17), preoperative depression (15/36, P > 0.19) or prior discectomy/decompression (14/36, P < 0.37) was not a predictor of outcomes.

CONCLUSION

Although limited by retrospective design and small cohort, the results of this investigation suggest that bTLIF is a reasonable treatment option for patients who experience DPS and affords high patient satisfaction. A larger study is needed to confirm these findings.

LEVEL OF EVIDENCE

4.

Axial lumbar interbody fusion: a 6-year single-center experience

Introduction

Methods

Results

Conclusion

Surgical outcome and postoperative work status of lumbar discogenic pain following transforaminal interbody fusion

The clinical outcome and resumption of work were investigated in 21 patients with lumbar discogenic pain (15 males and 6 females, mean age 37.2 years), who failed to respond to intensive conservative therapy, treated by transforaminal lumbar interbody fusion (TLIF) augmented with the pedicle screw system from January 2005 to December 2007. Perioperative assessment was performed using the modified Japanese Orthopaedic Association (mJOA) score, the Oswestry Disability Index, and the visual analogue scale (VAS). Type of occupation and work status of the patients were also assessed before and after surgery. Preoperative occupation was divided into two groups according to the work content (heavy labor vs. light labor). Follow-up period was mean 26.1 months, and greater than 1 year in all patients. Perioperative assessment showed postoperative improvement with statistical significance. Recovery rates at final follow-up examination were 53% of the mJOA score and 65% of the VAS. This study showed that postoperative overall resumption rate was 90%. However, only 23% of the heavy labor group returned to the previous work compared with 71% of the light labor group. TLIF is thought to be a safe and effective technique in patients with intractable chronic lumbar discogenic pain with an acceptable overall work resumption rate, whereas complete return to previous jobs was limited in the heavy labor group.

Effect of Intradiscal Methylene Blue Injection for the Chronic Discogenic Low Back Pain: One Year Prospective Follow-up Study

Objective

To evaluate the efficacy of intradiscal methylene blue (MB) injection in patients with chronic discogenic low back pain.

Method

Twenty patients with discogenic low back pain (4 males, 16 females; mean age 45.6 years) refractory to conservative management were recruited. All subjects underwent MB injection in target lumbar intervertebral discs confirmed by provocative discography. The clinical outcome was assessed by visual analog scale (VAS) and Oswestry disability index (ODI) at baseline and 1, 3, 6 and 12 months after treatment. Successful outcome was described as minimum of 2 points reduction in pain intensity compared with the baseline.

Results

VAS and ODI significantly decreased after one injection. The average VAS and ODI were reduced significantly from 5.1 and 38.0 at baseline to 3.2 and 27.4 at 3 months after injection (p<0.05). However, the mean score of VAS at 12 month follow-up was 4.5 and we could not observe any difference between 12 months after injection and pretreatment. Eleven of twenty patients (55%) reported successful outcomes after intradiscal MB injection at 3 month follow up and the average VAS was reduced by 3.3±1.1 (p<0.05). At the time of 12 month follow up, pain had relapsed in 6 patients who have had satisfactory effect at 3 month follow up. Successful outcome was maintained in only 5 patients (20%) for 1 year.

Conclusion

The intradiscal MB injection is a short-term effective minimally invasive treatment indicated for discogenic back pain but it may lose its effectiveness long-term.

Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain

Background

Chronic low back pain without disc herniation is common. Various modalities of treatments are utilized in managing this condition, including epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections.

Methods

A randomized, double-blind, actively controlled trial was conducted. The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation, radiculitis, facet joints, or sacroiliac joints. A total of 120 patients were randomized to two groups; one group did not receive steroids (group 1) and the other group did (group 2). There were 60 patients in each group. The primary outcome measure was at least 50% improvement in Numeric Rating Scale and Oswestry Disability Index. Secondary outcome measures were employment status and opioid intake. These measures were assessed at 3, 6, 12, 18, and 24 months after treatment.

Results

Significant pain relief and functional status improvement (primary outcome) defined as a 50% or more reduction in scores from baseline, were observed in 54% of patients in group 1 and 60% of patients in group 2 at 24 months. In contrast, 84% of patients in group 1 and 73% in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months.

Conclusion

Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.

Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes

STUDY DESIGN

Retrospective case series.

OBJECTIVE

The primary aim of this study was to evaluate and report the 2-year clinical and radiographic outcomes associated with a L5-S1 interbody fusion procedure that employs an axial presacral surgical approach.

SUMMARY OF BACKGROUND DATA

There are a number of lumbar interbody fusion procedures used to treat painful, degenerated discs. However, despite their procedural differences (e.g., anterior vs. posterior), all of the current surgical approaches are undertaken in the same anatomical plane that requires disruption of musculoligamentous and osseous support structures as well as vascular and neurologic tissue to gain access the intervertebral disc space. The presacral procedure is distinct in that it uses an approach along an axis essentially perpendicular to the anatomical plane of traditional fusion procedures.

METHODS

One hundred fifty-six patients from four clinical sites were selected for inclusion if they underwent a L5-S1 interbody fusion via the presacral approach with the AxiaLIF system (TranS1, Wilmington, NC) and had both presurgical and 2-year radiographic or clinical follow-up. Back pain and functional impairment were evaluated with an 11-point numeric scale and the Oswestry Disability Index (ODI), respectively, preoperatively and at 2 years. Standard radiographic imaging techniques were used to determine fusion status.

RESULTS

Marked clinical improvements were realized in back pain severity and functional impairment through 2 years of follow-up. Mean pain scores improved from 7.7 ± 1.6 (n = 155) preoperatively to 2.7 ± 2.4 (n = 148) at 24 months, reflecting an approximate 63% overall improvement (P < 0.001). Mean ODI scores improved from 36.6 ± 14.6% (n = 86) preoperatively to 19.0 ± 19.2% (n = 78) at 24 months, or approximately 54% (P < 0.001). Two-year clinical success rates on the basis of change relative to baseline of at least 30% were 86% (127 of 147) and 74% (57 of 77) for pain and function, respectively. The overall radiographic fusion rate at 2 years was 94% (145 of 155).

CONCLUSION

Findings from this clinical series of patients treated with a presacral interbody fusion procedure, stabilized with the AxiaLIF rod, reflect favorable and durable outcomes through 2 years of follow-up.

Intradiscal injection therapy for degenerative chronic discogenic low back pain with end plate Modic changes

BACKGROUND CONTEXT

The effect of intradiscal steroid therapy for patients with degenerative chronic discogenic low back pain remains an issue of debate.

PURPOSE

To evaluate the effect of various intradiscal injection regimens for patients with degenerative chronic discogenic low back pain and end plate Modic changes.

STUDY DESIGN

Double-blind, randomized, controlled, prospective clinical study.

PATIENT SAMPLE

One hundred twenty patients with discogenic low back pain and end plate Modic changes on magnetic resonance imaging (MRI) who received discography but were unwilling to accept surgical operation.

OUTCOME MEASURES

Pain and function were determined by the visual analog scale (VAS) and the Oswestry Disability Index (ODI) assessment.

METHODS

Patients who received diagnostic discography for suspected degenerative discogenic low back pain were recruited. A total of 120 patients with positive discography and end plate Modic changes at a single level were enrolled in the study and allocated into Groups A and B according to the type of Modic changes on MRI. Then, the patients in Groups A and B were randomized into three subgroups, respectively. Intradiscal injection of normal saline was performed in Subgroups A1 and B1, intradiscal injection of diprospan was performed in Subgroups A2 and B2, and intradiscal injection of a mixed solution of diprospan+songmeile (cervus and cucumis polypeptide) was performed in Subgroups A3 and B3. The clinical outcome of each patient was evaluated and recorded by using the VAS and ODI at 3 and 6 months after the procedure.

RESULTS

The subgroups were comparable with respect to gender, age, pain, and percentage disability. Neither VAS pain scores nor Oswestry function scores of the patients within Group A had any improvement at 3 or 6 months after saline injection, but both of them improved significantly at the two time points after diprospan and diprospan+songmeile injection, respectively. Meanwhile, the latter two injection protocols led to no significant difference in pain relief and functional recovery. Similar results were obtained in patients within Group B. Furthermore, no difference of the improvement of VAS pain scores or Oswestry function scores was found between the patients within Group A and within Group B at different time points after various interventions.

CONCLUSION

Intradiscal injection of corticosteroids could be a short-term efficient alternative for discogenic low back pain patients with end plate Modic changes on MRI who were still unwilling to accept surgical operation when conservative treatment failed.

Treatment of discogenic low back pain with Intradiscal Electrothermal Therapy (IDET): 24 months follow-up in 50 consecutive patients

BACKGROUND

Degeneration of the intervertebral disc can be the source of severe low back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption nonresponsive to conservative medical care.

METHODS

Using MRI and discographic findings, 50 patients with lumbar discogenic pain were identified, underwent IDET treatment and were followed for 24 months. Outcomes included assessments of back pain severity by an 11-point numeric scale and back function by the Oswestry disability index (ODI).

FINDINGS

There was an average 68 and 66% improvement in pain and ODI, respectively, between pre-treatment and 24 months (p < 0.0001 for both comparisons). The global clinical success rate was 78% (39 of 50). Clinical success was associated with discographic concordance (p < 0.0001), HIZ (p = 0.003), Pfirrmann grade (p = 0.0002), and percent annulus coverage (p < 0.0001).

CONCLUSIONS

The findings of this study suggest that durable clinical improvements can be realized after IDET in highly selected patients with mild disc degeneration, confirmatory imaging evidence of annular disruption and concordant pain provocation by low pressure discography.

6-month results of TransDiscal Biacuplasty on patients with discogenic low back pain: preliminary findings

STUDY DESIGN

Prospective observational study.

OBJECTIVE

Our aim is to investigate the efficacy and safety of TransDiscal Biacuplasty.

SUMMARY OF BACKGROUND DATA

Chronic discogenic pain is one of the leading causes of low back pain; however, the condition is not helped by most non-invasive methods. The results of major surgical operations for these patients are unsatisfactory. Recently, attention has shifted to disk heating methods for treatment. TransDiscal Biacuplasty is one of the minimally invasive treatment methods. The method was developed as an alternative to spinal surgical practices and Intradiscal Electrothermal Therapy for treatment of patients with chronic discogenic pain.

METHODS

The candidates for this study were patients with chronic discogenic pain that did not respond to conservative treatment. The main criteria for inclusion were: the existence of axial low back pain present for 6 months; disc degeneration or internal disc disruption at a minimum of one level, and maximum of two levels, in MR imaging; and positive discography. Physical function was assessed using the Oswestry Disability Index when measuring the pain with VAS. Patient satisfaction was evaluated using a 4-grade scale. Follow-ups were made 1, 3, and 6 months after treatment.

RESULTS

15 patients were treated at one or two levels. The mean patient age was 43.1 ± 9.2 years. We found the mean symptom duration to be 40.5 ± 45.7 months. At the sixth month, 57.1% of patients reported a 50% or more reduction in pain, while 78.6% of patients reported a reduction of at least two points in their VAS values. In the final check, 78.6% of patients reported a 10-point improvement in their Oswestry Disability scores compared to the initial values. No complications were observed in any of the patients.

CONCLUSIONS

TransDiscal Biacuplasty is an effective and safe method.

A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain

A preliminary report of clinical study revealed that chronic discogenic low back pain could be treated by intradiscal methylene blue (MB) injection. We investigated the effect of intradiscal MB injection for the treatment of chronic discogenic low back pain in a randomized placebo-controlled trial. We recruited 136 patients who were found potentially eligible after clinical examination and 72 became eligible after discography. All the patients had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-six were allocated to intradiscal MB injection and 36 to placebo treatment. The principal criteria to judge the effectiveness included alleviation of pain, assessed by a 101-point numerical rating scale (NRS-101), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. At the 24-month follow-up, both the groups differed substantially with respect to the primary outcomes. The patients in MB injection group showed a mean reduction in pain measured by NRS of 52.50, a mean reduction in Oswestry disability scores of 35.58, and satisfaction rates of 91.6%, compared with 0.70%, 1.68%, and 14.3%, respectively, in placebo treatment group (p<0.001, p<0.001, and p<0.001, respectively). No adverse effects or complications were found in the group of patients treated with intradiscal MB injection. The current clinical trial indicates that the injection of methylene blue into the painful disc is a safe, effective and minimally invasive method for the treatment of intractable and incapacitating discogenic low back pain.

Prospective assessment of axial back pain symptoms before and after bariatric weight reduction surgery

BACKGROUND

The prevalence of obesity in developed countries has reached alarming levels, doubling in the United States since 1980. Although obese patients with chronic low back pain are frequently advised to lose weight, the association between these medical conditions remains unproven.

PURPOSE

This study prospectively assessed clinically reported changes in chronic axial low back pain symptoms after weight reduction from bariatric surgery for morbid obesity.

STUDY DESIGN

Prospective longitudinal study.

PATIENT SAMPLE

Fifty-eight consecutive patients with morbid obesity and chronic axial low back pain undergoing bariatric surgery over a period of 6 months. Patients were considered morbidly obese if they were 50% to 100% above their ideal body weight or having a body mass index (BMI) greater than 40.

OUTCOME MEASURES

Visual Analog Scale (VAS) for axial low back pain, Short Form-36 (SF-36) Health Survey, and Oswestry Disability Index (ODI) METHODS: Patients undergoing weight reduction surgery were assessed preoperatively and postoperatively at 12 months with validated clinical measures for axial back pain and disability (VAS, SF-36, and ODI). Bariatric surgery parameters included demographic data, weight, and BMI. Statistical analysis included paired t tests and multiple regression techniques.

RESULTS

Of the initial 58 patients, 38 (65%) completed both preoperative (Pre-Op) and postoperative (Post-Op) questionnaires at 12 months. These 38 subjects included 30 women and 8 men, with an age range of 20 to 68 years (mean 48.4+/-10.1). Overall, these patients showed a decrease in mean weight from 144.52+/-41.21kg Pre-Op to 105.59+/-29.24 Post-Op (p<.0001) and BMI from 52.25+/-12.61kg/m(2) Pre-Op to 38.32+/-9.66 Post-Op (p<.0001). Patients demonstrated a statistically significant mean 44% decrease in axial back pain on the VAS scale (p=.006; 5.2+/-3.35 Pre-Op, to 2.9+/-3.1 Post-Op). Analysis of the SF-36 major components revealed that patients experienced significant increases in mean physical health by 58% (p<.0001; 44.5+/-20.09 to 70.24+/-26.84) and in median mental health by 6% (p=.03; 70+/-7.14 to 73.39+/-11.78). Patients also showed statistically significant 24% decrease in Post-Op ODI score for physical disability (p=.05) from 26.75+/-16.56 Pre-Op to 20.35+/-18.71 Post-Op (p=.05).

CONCLUSION

This study suggests that the substantial weight reduction after bariatric surgery may be associated with moderate reductions in preexisting back pain at early-follow-up. This effect did not appear to be the result only of an overall improvement in well-being associated with weight loss. However, larger randomized controlled clinical studies with longer-term follow-up are needed to definitively determine a causal relationship.

Success of lumbar microdiscectomy in patients with modic changes and low-back pain: a prospective pilot study

STUDY DESIGN

Prospective case controlled.

OBJECTIVE

To determine the outcome after microdiscectomy in patients with disc herniation, concordant sciatica, and low-back pain with Modic I and II degenerative changes compared with similar patients without Modic changes.

SUMMARY OF BACKGROUND DATA

The decision to perform a microdiscectomy versus a fusion or total disc replacement in a patient with a disc herniation and sciatica may be confounded by the presence of low-back pain, degenerative disc disease, and marrow and endplate (Modic) changes.

METHODS

Thirty consecutive patients underwent a microdiscectomy by a single surgeon. Group 1 consisted of 15 patients, 6 men and 9 women, with a mean age of 36.7 years (range, 21 to 48 y), with Modic I and II changes. Group 2 contained 15 patients, 9 men and 6 women, with a mean age of 34.1 years (range, 20 to 68 y), without Modic changes. The average duration of low-back pain before surgery was 25.6 months (range 4 to 120 mo) in group 1 and 17.5 months (range 5 to 120 mo) in group 2. The visual analog scale (VAS) was used to grade low-back pain and the Oswestry score was used to grade overall disability.

RESULTS

There was no significant difference in preoperative sciatica, low-back pain, VAS or Oswestry scores for group 1 versus group 2 patients. Postoperatively, all patents had improved sciatica and resolution of any nerve tension sign. Eighty-six percent of patients in group 1 versus 93% of patients in group 2 had improvements in postoperative VAS score for low-back pain at 6 months. Average improvement within each group was 67% and 75%, respectively. VAS scores for low-back pain at 6 months improved from 6.9 to 2.3 (P=0.0005) in group 1 and 6.3 to 1.6 (P=0.0002) in group 2. Group 1 and 2 had 89% and 100% of patients show improvement in postoperative Oswestry score at 6 months with an average improvement of 58% and 84%, respectively. Oswestry scores at 6 months improved from 68.7% to 28.8% (P=0.0007) in group 1 and 61.2% to 9.9% (P=0.00003) in group 2.

CONCLUSIONS

There was a trend toward greater improvement in Oswestry scores in patients without Modic changes (P=0.09). Both groups reported statistically significant improvement in sciatica, low-back pain, and disability after microdiscectomy. Microdiscectomy was therefore an effective treatment for disc herniation and concordant sciatica despite low-back pain and Modic I and II degenerative changes.

LEVELS OF EVIDENCE

Therapeutic II.

Intradiscal electrothermal therapy (IDET) for low back pain in worker's compensation patients: can it provide a potential answer? Long-term results

OBJECTIVE

This prospective study was conducted to evaluate improvements in pain and disability in a series of 53 consecutive worker's compensation patients with low back pain (LBP) after treatment with the intradiscal electrothermal therapy (IDET) procedure.

MATERIALS AND METHODS

All patients seen in the out-patient clinic of the Spine Institute of Louisiana for LBP of discogenic origin were screened for eligibility to receive IDET procedure. A total of 134 patients were treated using IDET for their discogenic LBP during the study period. Fifty-three patients presented to us via the worker's compensation claim program. The outcomes of these 53 patients were analyzed statistically for the current study by physical examination and self-assessment questionnaires of pain and disability at baseline and at 12-months postprocedure. Pain and disability outcomes were assessed by visual analog scale (VAS) pain score and Oswestry disability index, respectively.

RESULTS

The mean patient age was 41.83 years (range 20 to 61 y). Whites (52.8%), African-Americans (30.2%), and Hispanics (17%) formed the majority of population. Forty-nine percent were using narcotics. The first definitive end point was considered at 12 months after the procedure. Median follow-up period was 56 months (range 29 to 72 mo). A mean reduction (P<0.001) of 62.6% in the VAS score and 69.3% in the Oswestry scores was noted after IDET. The patient's initial VAS and Oswestry scores (P<0.05) significantly affected the final outcomes. About 47.2% of the patients had some degree of economic productivity and only 7 (initial 26) consumed narcotic analgesics.

CONCLUSIONS

IDET procedure can be a useful, safe, and cost-effective option in the management of carefully selected workers compensation claimants with chronic LBP of discogenic etiology.

Intradiscal electrothermal therapy (IDET) provides effective symptom relief in patients with discogenic low back pain

STUDY DESIGN

Single-arm, prospective clinical trial.

OBJECTIVE

To evaluate back pain severity, physical function, and quality of life outcomes in highly selected patients with lumbar discogenic pain treated with intradiscal electrothermal therapy (IDET).

SUMMARY OF BACKGROUND DATA

Degeneration and disruption of the intervertebral disc can be the source of severe low back pain and the associated physical dysfunction. IDET is a minimally invasive treatment option in the continuum of care between conservative nonoperative management and spinal surgery.

METHODS

Using magnetic resonance imaging, pressure-controlled discography, and postdiscogram computed tomography findings, 56 patients with lumbar discogenic pain were identified, underwent IDET treatment and followed for 20.5+/-4.4 months, on average. Outcomes included assessments of back pain severity by visual analog scale, sitting, standing, and walking tolerances, and health-related quality of life using the SF-36.

RESULTS

Mean pain severity scores (visual analog scale) improved from 6.1+/-1.8 pretreatment to 2.4+/-2.6 at final follow-up (P=0.0001). Mean tolerance times (minutes) improved from 40.9+/-40.6 to 84.5+/-54.4, 46.8+/-42.9 to 84.4+/-54.2, and 39.2+/-39.6 to 77.9+/-50.8 between baseline and final follow-up for sitting, standing, and walking, respectively (P=0.0001 for all comparisons). Seven of 8 quality of life domains showed significant (P=0.0001 for all comparisons) improvement over baseline. Forty-two patients (75%) were classified as a treatment success by virtue of a >or=2-point improvement in pain severity or a >or=10-point improvement in either the physical functioning or bodily pain domain of the SF-36.

CONCLUSIONS

The findings of this study suggest that durable clinical improvements can be realized after IDET in highly selected patients with mild disc degeneration, confirmatory imaging evidence of annular disruption, and concordant pain provocation by low pressure discography.

Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain

This article was a preliminary report of prospective clinical trial of a group of patients with chronic discogenic low back pain who met the criteria for lumbar interbody fusion surgery but were treated instead with an intradiscal injection of methylene blue (MB) for the pain relief. Twenty-four patients with chronic discogenic low back pain underwent diagnostic discography with intradiscal injection of MB. The principal criteria to judge the effectiveness included alleviation of pain, assessed by visual analog scale (VAS), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. The mean follow-up period was 18.2 months (range 12-23 months). Of the 24 patients, 21 (87%) reported a disappearance or marked alleviation of low back pain, and experienced a definite improvement in physical function. A statistically significant and clinically meaningful improvement in the changes in the ODI and the VAS scores were obtained in the patients with chronic discogenic low back pain (P=0.0001) after the treatment. The study suggests that the injection of MB into the painful disc may be a very effective alternative for the surgical treatment of chronic discogenic low back pain.

Intradiscal electrothermal coagulation and percutaneous neuromodulation therapy in the treatment of discogenic low back pain

Low back pain (LBP) is a major physical and socioeconomic entity. A significant percentage of LBP is attributable to internal disc disruption. The management of internal disc disruption has traditionally been limited to either conservative treatment or spinal fusion. Intradiscal electrothermal coagulation (IDET) and percutaneous neuromodulation therapy (PNT) are now being performed as an alternative to these therapies. Scientific data regarding the pathophysiology, biologic effects, and clinical results are relatively scarce. Early biomechanical and histologic investigations into the effects of IDET are conflicting. However, in early prospective human trials, IDET seems to provide some benefit with little risk. PNT represents a new less invasive technique for the treatment of discogenic pain, but limited research is available to determine long-term clinical efficacy. IDET and PNT are potentially beneficial treatments for internal disc disruption in carefully selected patients as an alternative to spinal fusion. More basic science and clinical research with long-term follow-up evaluation is necessary.

Diagnosis and minimally invasive treatment of lumbar discogenic pain--a review of the literature

Diagnosis and treatment of lumbar discogenic pain due to internal disc disruption (IDD) remains a challenge. It accounts for 39% of patients with low back pain. The mechanism of discogenic pain remains unclear and its clinical presentation is atypical. Magnetic resonance imaging (MRI) can find high-intensity zone as an indirect indication of IDD. However, relative low sensitivity (26.7% to 59%) and high false-positive (24%) and false-negative (38%) rates reduce the value of MRI in screening for the existence of painful IDD. Provocative discography can provide unique information about the pain source and the morphology of the disc. It may also provide information for selecting appropriate treatment for the painful annular tear. Adjunctive therapies, including nonsteroidal anti-inflammatory drugs, physical therapy, rehabilitation, antidepressants, antiepileptics, and acupuncture, have been used for low back pain. The value of these treatments for discogenic pain is yet to be established. Intradiscal steroid injection has not been proved to provide long-term benefits. Intradiscal electrothermal therapy may offer some pain relief for a group of well-selected patients. No benefits have been found for the intradiscal radiofrequency thermocoagulation. A block in the ramus communicans may interfere with the transition of painful information from the discs to the central nervous system. Disc cell transplantation is in the experimental stage. It has the potential to become a useful tool for the prevention and treatment of discogenic pain. Minimally invasive treatments provide alternatives for discogenic pain with the appeal of cost-effectiveness and, possibly, less long-term side effects. However, the value of most of these therapies is yet to be established. More basic science and clinical studies are needed to improve the clinical efficacy of minimally invasive treatments.

The Relation Between Annular Disruption on Computed Tomography Scan and Pressure-Controlled Diskography

OBJECTIVE

To analyze the relation between annular disruption determined by computed tomography (CT) scan and diskographic findings using pressure-controlled manometric diskography.

DESIGN

Cross-sectional using prospectively gathered data.

SETTING

Ambulatory spine intervention unit.

SPECIMENS

Two hundred seventy-nine disks from 86 patients (55 men, 31 women) who were referred for diskography of suspected chronic diskogenic low back pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The grade of annular disruption was rated using CT diskography and fluoroscopic imaging as follows: 0 (no disruption); 1 (extension into the inner third of the annulus); 2 (extension into the middle third of the annulus); 3 (extension into the outer third of the annulus); 4 (circumferential extension with a >30 degrees arc at the disk center); and 5 (contrast media leakage into the outer space). Diskography was performed via a pressure-controlled manometric technique using an injection rate of .05 mL/s and a restricted total volume of 3.5 mL. Pain was rated on a 0 to 10 numeric rating scale (NRS). Criteria for symptomatic disks included provocation of patient concordant pain (NRS score, > or =6/10) at 50psi or less above opening pressure, with 3.5 mL or less of total volume. Symptomatic disks were classified as "low pressure sensitive" or "high pressure sensitive" based on the pressure level that evoked pain. Disks classified as low pressure sensitive required an NRS score of 6 out of 10 or higher at 15 psi or less above opening pressure. Disks classified as high pressure sensitive required an NRS score of 6 out of 10 or higher at pressures within a range of 15 to 50 psi.

RESULTS

The numbers of disks at each annular disruption grade were 19 (6.8%) at grade 0, 29 (10.4%) at grade 1, 35 (12.5%) at grade 2, 42 (15.1%) at grade 3, 69 (24.7%) at grade 4, and 85 (30.5%) at grade 5. A total of 93 disks met the criteria for a symptomatic disk. The extent of annular disruption and the rate of symptomatic disks correlated significantly (P<.001). The highest symptomatic disk rate was observed in grade 4 disks. Of 93 symptomatic disks, 88 (94.6%) showed annular disruption of grade 3 or greater. Disks with grades 0 to 2 and grades 3 to 5 annular disruption differed significantly when the mean NRS relative to intradiskal pressure was compared (P<.001). Comparing the disk type of symptomatic disks at each annular disruption grade, there was a decreasing trend of low pressure sensitive disks relative to the extent of annular disruption (62.5% at grade 3, 39.4% at grade 4, 34.2% at grade 5).

CONCLUSIONS

Annular disruption reaching the outer annulus fibrosus is a key factor in pain generation. Disk morphology, including annular disruptions extending beyond the outer annulus, may permit increased diskography specificity.

Clinical results of ProDisc-II lumbar total disc replacement: report from the United States clinical trial

The much-awaited clinical use of lumbar artificial discs has begun in the United States. The United States Investigational Device Exemption (US IDE) clinical trial of the ProDisc-II prosthetic disc (Synthes, Paoli, PA) was recently completed, with all indications that it meets or surpasses the test of equivalence against fusion controls. This is a review of the clinical performance of the ProDisc-II artificial disc and includes an interim report from the US IDE trial at one site.

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: magnetic resonance imaging and discography for patient selection for lumbar fusion

Discography is an exquisitely sensitive but not specific diagnostic test for the diagnosis of discogenic low-back pain. The restriction of the definition of a positive discographic study to one that elicits concordant pain from a morphologically abnormal disc improves the definition's accuracy. Fusion surgery based on discography alone, however, is not reliably associated with clinical success. Therefore, discography is not recommended as a standalone test for treatment decisions in patients with low-back pain. Magnetic resonance imaging is a sensitive and noninvasive test for the presence of degenerative disc disease. Discography should not be attempted in patients with normal lumbar MR images. Discography appears to have a role in the evaluation of patients with low-back pain, but it is best limited to the evaluation of abnormal interspaces identified on MR imaging, the investigation of adjacent-level disc disease, and as a means to rule out cases of nonorganic pain from surgical consideration.

The pathogenesis of discogenic low back pain

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres.

The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain.

Percutaneous Laser Disc Decompression in the Treatment of Discogenic Back Pain

OBJECTIVE

Our aim was to evaluate the effects of percutaneous laser disc decompression (PLDD) as discogenic pain treatment using the MacNab criteria.

BACKGROUND DATA

Discogenic back pain is believed to be produced from tears in the posterior longitudinal ligament and annulus fibrosus. This pain is exacerbated through increases in intradiscal pressure via provocative discograms and transmitted through the sinuvertebral nerve.

MATERIALS AND METHODS

A total of 37 patients were selected based on clinical findings and provocative discograms. These patients underwent PLDD to the affected disc and were interviewed via telephone and outcome evaluated based on the MacNab criteria.

RESULTS

Survey results revealed that 14 patients (44%) reported a good response, 14 (44%) reported a fair response, and four (12.5%) reported a poor response. The 28 patients (88%) who reported a good and fair response were considered to be successful cases.

CONCLUSION

PLDD is a safe, effective, and minimally invasive procedure that can be used to treat patients with discogenic back pain.

Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment

OBJECTIVE

To provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disk herniations (LDH) and to estimate the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH.

DATA SOURCES

Relevant case reports, review articles, surveys, and investigations regarding treatment of lumbar disk herniations with spinal manipulation and adverse effects and associated risks were found with a search of the literature.

DATA SYNTHESIS

Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH.

RESULTS

An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million.

CONCLUSION

The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography

STUDY DESIGN

A prospective controlled longitudinal study.

OBJECTIVES

To determine whether subjects, asymptomatic for lower back problems, who undergo experimental discography, will develop lower back problems during the medium term to the full term.

SUMMARY OF BACKGROUND DATA

Previous work has shown significant pain on discographic injection in approximately 40% of asymptomatic subjects. It has been suggested that those subjects with painful injections would soon develop lower back pain (LBP) syndromes in the near future: that is, the experimental discography was detecting an imminent "pain generator" before clinically symptomatic. METHODS.: Fifty subjects without low back pain were recruited for clinical and psychometric testing, MRI scanning, and experimental lumbar discography to determine the rate of painful lumbar disc injections in select subjects without LBP history. After determining which subjects had painful injections, all subjects completing the discography protocol were prospectively followed at yearly intervals to determine the occurrence of LBP and LBP disability over time. Statistical methods were then used to determine the correlation, if any, between the asymptomatic subjects' clinical, MRI, and discography findings, and the subsequent LBP measures. Controls, not participating in the lumbar discography study, were also followed. Controls were matched for clinical features, sex, age, and occupational/recreational exposure. Follow-up examinations were performed at yearly intervals by blinded researchers using a scripted interview and completing standard questionnaires.

RESULTS

A total of 46 of 50 completed the discogram, and all 46 subjects completed the final 4-year follow-up examination. There was a low incidence of LBP episodes in the experimental groups and control. A painful disc injection, independent of psychological profile, did not predict LBP or any other functional outcome measure at follow-up on multivariate analysis. The presence of an anular fissure seen on discography was weakly associated with the cumulative incidence of LBP episodes after discography (P = 0.08). The presence of high intensity zone on MRI in any disc was also weakly associated with the development of LBP episodes (P = 0.09). Psychometric profiles at the start of the study strongly and independently predicted future back pain (P = 0.01), medication usage (P = 0.002), and work loss (P = 0.01) over the 4-year study. Compared with controls not having undergone discography, there was no significant difference in back pain, function, work loss, doctors visits for back pain, or medication intake in any group. A subset in the injection group with somatization disorder had a higher LBP visual analog score compared with somatization disorder controls at 1 year,but this was not significant at 4 years after testing.

CONCLUSIONS

Painful disc injections are poor independent predictors of subsequent LBP episodes in subjects initially without active lower back complaints. Anular disruption is a weak predictor of future LBP problems. Psychological distress and preexisting chronic pain processes are stronger predictors of LBP outcomes.

Percutaneous disc decompression in the management of chronic low back pain

Although there has not yet been a percutaneous intradiscal procedure developed with the superior therapeutic efficacy of open surgery, these procedures are less invasive and avoid the complications of open surgery. All of these procedures have limitations, but their therapeutic effect increases substantially given careful patient selection and proper technique. New appliances and techniques to treat LBP or sciatica continue to evolve, and numerous controlled studies are underway. With tremendous technologic advances, use of minimally invasive techniques to treat chronic back pain continues to expand.

Lumbar discography: an update

Discogenic pain most commonly affects the low back, buttocks, and hips and is thought to be a byproduct of internal disk degeneration. It is postulated that progressive annular breakdown and tearing results in biomechanical and/or biochemical stimulation of the pain fibers that reside in the outer one third of the annulus. Although multiple imaging modalities, most notably MRI, can show morphologic abnormalities of the spine, discography remains the only test that provides physiologic information regarding what role a given intervertebral disk plays in a patient's symptom complex. The controversy surrounding discography is here to stay until more definitive, well-designed studies are performed. In the meantime, there are certain things that can help the discographer maximize the accuracy of the test: 1. Always try to inject one "normal" disk as a "control level." 2. Be alert for factors that are associated with an increased false-positive rate (abnormal non-anatomic pain maps, a history of chronic pain of spinal or nonspinal origin, abnormal psychometric testing, and prior surgery at the injected disk level). In these cases, special attention should be directed to both the patient's verbal and nonverbal cues during disk injection. 3. Do not give any audible clues as to what level is being injected or when the injection is starting or finishing. In this regard, we find it very helpful to have one of our personnel talk with the patient during this portion of the procedure while closely observing the patient for any nonverbal cues regarding their pain response. This distraction is preferable to a silent room where the patient is intensely focused on what is going on with the injections. We also find that music playing during the procedure helps to relax and often distract the patient as well. 4. If the results are equivocal at a level (i.e., you are unable to determine whether or not the patient's pain response was truly concordant), go on to inject another disk level and then come back to reinject more contrast into the disk in question. As radiologists, we tend to focus on the technical aspects of a procedure and the anatomic/morphologic information it provides. However, it cannot be emphasized enough that when performing lumbar discography, the assessment of the patient's pain response during the injection is the most important component of the procedure, and requires not only technical skills, but an understanding of how best to avoid some of the pitfalls that can lead to inaccurate results.

Image-guided spinal injection for diagnosis and therapy

Over the past decade, major advances have been made in our ability to identify a putative cause of patients' spinal pain using image-guided injection techniques. These techniques might also provide a means of temporarily relieving patients' pain and facilitating increased mobility. This article aims to review the rationale for and the techniques of the more commonly used spinal injection techniques.

Intradiscal electrothermal therapy: a treatment option in patients with internal disc disruption

STUDY DESIGN

A literature review was conducted.

OBJECTIVES

To review the anatomy, pathophysiology, diagnosis, procedure, and clinical results of intradiscal electrothermal therapy (IDET).

SUMMARY OF BACKGROUND DATA

Low back pain is a major physical and socioeconomic entity. A significant percentage of low back pain is attributable to internal disc disruption. The management of internal disc disruption has traditionally been limited to either conservative treatment or spinal fusion. IDET has been performed as an alternative to these therapies.

METHODS

The available literature was reviewed.

RESULTS

Scientific data regarding the pathophysiology, biologic effects, and clinical results are relatively scarce. Early biomechanical and histologic investigations into the effects of IDET are conflicting. However, in early prospective human trials, IDET seems to provide some benefit with little risk.

CONCLUSIONS

IDET is potentially beneficial treatment for internal disc disruption in carefully selected patients as an alternative to spinal fusion. More basic science and clinical research with long-term follow-up evaluation is necessary.

Lumbar discography

STUDY DESIGN

A comprehensive review of the literature dealing with lumbar discography was conducted.

OBJECTIVE

The purpose of the review is to update the North American Spine Society position statement published in 1994 that addressed criticisms of lumbar discography, to identify indications for

SUMMARY OF BACKGROUND DATA

Lumbar discography remains a controversial diagnostic procedure. There are concerns about its safety and clinical value, although many support its use in specific applications.

METHODS

Articles dealing with lumbar discography were reviewed and are summarized in this report.

RESULTS

Most of the recent literature supports the use of discography in selected patients. Although not to be taken lightly, many of the serious complications and high complication rates reported before 1970 have decreased since then because of improvement in injection technique, imaging and contrast materials.

CONCLUSIONS

Most of the current literature supports the use of discography in select situations. Indications for discography include, but are not limited to: (1) Further evaluation of demonstrably abnormal discs to help assess the extent of abnormality or correlation of the abnormality with the clinical symptoms. Such symptoms may include recurrent pain from a previously operated disc and lateral disc herniation. (2) Patients with persistent, severe symptoms in whom other diagnostic tests have failed to reveal clear confirmation of a suspected disc as the source of pain. (3) Assessment of patients who have failed to respond to surgical intervention to determine if there is painful pseudarthrosis or a symptomatic disc in a posteriorly fused segment and to help evaluate possible recurrent disc herniation. (4) Assessment of discs before fusion to determine if the discs within the proposed fusion segment are symptomatic and to determine if discs adjacent to this segment are normal. (5) Assessment of candidates for minimally invasive surgical intervention to confirm a contained disc herniation or to investigate dye distribution pattern before chemonucleolysis or percutaneous procedures. Lumbar discography should be performed by those well experienced with the procedure and in sterile conditions with a double-needle technique and fluoroscopic imaging for proper needle placement. Information assessed and recorded should include the volume of contrast injected, pain response, with particular emphasis on its locations and similarity to clinical symptoms, and the pattern of dye distribution. Frequently, discography is followed by axial computed tomography scanning to obtain more information about the condition of the disc.

Indications, techniques, and outcomes of posterior surgery for chronic low back pain

This article summarizes a number of issues surrounding the diagnosis, indications, and techniques of posterior lumbar spine surgery for chronic low back pain. It would not be entirely unjustified for a spine surgeon to adhere to a totally avoidant approach to chronic low back pain, rationalized by a reasonably legitimate nihilism regarding the presently available means of diagnosing and surgically managing low back pain [64]. Judging by the number of lumbar fusions performed in North America and the tremendous intellectual and financial investment currently being made in technologies to enhance spinal fusion, such an approach is evidently not achieving wide-spread acceptance on this continent. A rationale approach is therefore required for the many low back pain sufferers with degenerative disk disease who arrive in the office having exhausted almost every imaginable form of nonoperative therapy. Every effort should be made to establish a pathoanatomic etiology of the back pain with a combination of diagnostic modalities. Surgical intervention should be approached cautiously and only after extensive dialog with the patient to establish realistic goals and expectations. Posteriorly performed interbody fusion procedures may provide a high fusion rate and satisfactory clinical outcomes for this challenging problem, although further research is necessary to determine more conclusively the role of surgery and the relative effectiveness of the various arthrodesis techniques.

Circumferential and posterolateral fusion for lumbar disc disease

Clinical outcome of low back fusion is unpredictable. There are various reports discussing the merits and clinical outcome of these two procedures. The patients were selected from a population of patients who had chronic low back pain unresponsive to conservative treatment. Thirty-six instrumented posterolateral fusions and 35 instrumented circumferential fusions with posterior lumbar interbody fusions were done simultaneously. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging scans, and provocative discography in all the patients. Posterolateral fusion or anterior lumbar interbody fusion was done for internal disc disruption. The Oswestry disability index, subjective scoring, and assessment of fusion were done at a minimum followup of 2 years. On subjective scoring assessment there was a satisfactory outcome of 63.9% (23 patients) in the posterolateral fusion group and 82.8% (29 patients) in the posterior lumbar interbody fusion group. On assessment by the Oswestry index no difference was found in outcome between the two groups. The posterolateral fusion group had a 63.9% satisfactory outcome and the posterior lumbar interbody fusion group had an 80% satisfactory outcome using the Oswestry disability index for postoperative assessment. There was 61.1% improvement in working ability in the posterolateral fusion group and 77.1% improvement in the posterior lumbar interbody fusion group which was not statistically significant. The authors consider instrumented circumferential fusion with posterior lumbar interbody fusion better than instrumented posterolateral fusion for managing chronic disabling low back pain.