Randomized Controlled Trial of Percutaneous Intradiscal Radiofrequency Thermocoagulation for Chronic Discogenic Back Pain: Lack of Effect From a 90-Second 70 C Lesion Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography Correlation of clinical examination characteristics with three sources of chronic low back pain. Analysis of Efficacy Differences between Caudal and Lumbar Interlaminar Epidural Injections in Chronic Lumbar Axial Discogenic Pain: Local Anesthetic Alone vs. Local Combined with Steroids Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain A randomized, double-blind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: results of 2-year follow-up. Intradiscal Electrothermal Therapy (IDET) Provides Effective Symptom Relief in Patients With Discogenic Low Back Pain Percutaneous microdiscectomy versus epidural injection for management of chronic spinal pain. Provocative discography in volunteer subjects with mild persistent low back pain. Results of Surgery for Discogenic Low Back Pain: A Randomized Study Using Discography Versus Discoblock for Diagnosis Disc height and motion patterns in the lumbar spine in patients operated with total disc replacement or fusion for discogenic back pain. Results from a randomized controlled trial. Cost utility analysis of caudal epidural injections in the treatment of lumbar disc herniation, axial or discogenic low back pain, central spinal stenosis, and post lumbar surgery syndrome. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 1--Discogenic pain without disc herniation or radiculitis. Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain The Use of Intradiscal Steroid Therapy for Lumbar Spinal Discogenic Pain: A Randomized Controlled Trial Evaluation of the relative contributions of various structures in chronic low back pain. A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain Radiofrequency Lesioning Using Two Different Time Modalities for the Treatment of Lumbar Discogenic Pain: A Randomized Trial One-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis. Endplate Degeneration Observed on Magnetic Resonance Imaging of the Lumbar Spine: Correlation with Pain Provocation and Disc Changes Observed on Computed Tomography Diskography The Relative Contributions of the Disc and Zygapophyseal Joint in Chronic Low Back Pain Two-Year Follow-Up Results of Fluoroscopic Cervical Epidural Injections in Chronic Axial or Discogenic Neck Pain: A Randomized, Double-Blind, Controlled Trial Management of Chronic Discogenic Low Back Pain With a Thermal Intradiscal Catheter: A Preliminary Report Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain The Outcome of Posterolateral Fusion in Highly Selected Patients With Discogenic Low Back Pain A Prospective Study of Centralization of Lumbar and Referred Pain: A Predictor of Symptomatic Discs and Anular Competence Pain and function after intradiscal electrothermal treatment (IDET) for symptomatic lumbar disc degeneration One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study. A randomized, placebo-controlled trial of transdiscal radiofrequency, biacuplasty for treatment of discogenic lower back pain. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Prospective clinical study on natural history of discogenic low back pain at 4 years of follow-up. Multimodal treatment program comparing 2 different traction approaches for patients with discogenic cervical radiculopathy: a randomized controlled trial. Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source A Randomized Controlled Trial of Radiofrequency Denervation of the Ramus Communicans Nerve for Chronic Discogenic Low Back Pain Lumbar total disc arthroplasty in patients older than 60 years of age: a prospective study of the ProDisc prosthesis with 2-year minimum follow-up period. Short-Term Efficacy of Intravenous Pulse Glucocorticoids in Acute Discogenic Sciatica. A Randomized Controlled Trial Intradiscal Electrothermal Treatment for Chronic Discogenic Low Back Pain: Prospective Outcome Study With a Minimum 2-Year Follow-Up No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy® Intradiscal high-voltage, long-duration pulsed radiofrequency for discogenic pain: a preliminary report. A pilot study on the recovery from paresis after lumbar disc herniation. The association between negative affect and opioid analgesia in patients with discogenic low back pain Comparison of four different analgesic discogram protocols comparing the incidence of reported pain relief following local anesthetic injection into concordantly painful lumbar intervertebral discs. [Caudal epidural steroid injection in the treatment of chronic discogenic low back pain. Comparative, prospective and randomized study]. Posterior Lumbar Interbody Fusion for Degenerative Disc Disease Using a Minimally Invasive B-Twin Expandable Spinal Spacer: A Multicenter Study Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review. Lumbar Total Disc Arthroplasty Utilizing the ProDisc Prosthesis in Smokers Versus Nonsmokers: A Prospective Study With 2-Year Minimum Follow-up Disc coablation and epidural injection of steroids: a comparison of strategies in the treatment of mechanical spinal discogenic pain.
Study Design . A prospect i ve double-blind r and omized trial in 28 patients . Objectives . To assess the clinical effect of percutaneous intradiscal radiofrequency thermocoagulation for reducing pain , functional disability , and physical impairment in patients with chronic discogenic low back pain . Summary of Background Data . Chronic discogenic low back pain is a challenging problem in western countries . A treatment option is radiofrequency heating of the affected disc . Its clinical efficacy has never been formally tested in a controlled trial . Methods . Twenty-eight patients with a history of at least 1 year of chronic low back pain were selected on the basis of a diagnostic anesthetization of the lower intervertebral discs . Only patients with one putative painful level were selected and r and omly assigned to one of two treatment groups . Each patient in the radiofrequency treatment group ( n = 13 ) received a 90-second 70 C lesion of the intervertebral disc . Patients in the control group ( n = 15 ) underwent the same procedure , but without use of radiofrequency current . Both the treating physician and the patients were blinded to the group assignment . Before treatment , physical impairment , rating of pain , the degree of disability , and quality of life were assessed by a blinded investigator . Results . Eight weeks after treatment , there was one success in the radiofrequency group ( n = 13 ) and two in the control group ( n = 15 ) . The adjusted and unadjusted odds ratio was 0.5 and 1.1 , respectively ( not significant ) . Also , visual analog scores for pain , global perceived effect , and the Oswestry disability scale showed no differences between the two groups . Conclusions . Percutaneous intradiscal radiofrequency thermocoagulation ( 90 seconds , 70 C ) is not effective in reducing chronic discogenic low back pain BACKGROUND CONTEXT Lumbar discography has been widely used for evaluating discogenic low back pain ( LBP ) . Comparison of pain responses from suspected symptomatic discs with pain responses from asymptomatic negative discs is routine . However , the ability of discography to distinguish asymptomatic morphologically abnormal discs from those that are symptomatic has been understudied . In addition , the discographic characteristics of negative discs in patients with chronic discogenic LBP have not been reported . Criteria for negative morphologically abnormal discs may be valuable for excluding discs from further treatment and examination . PURPOSE To determine if discography can distinguish asymptomatic discs among morphologically abnormal discs in patients with suspected chronic discogenic LBP and establish the st and ard characteristics of negative discs . STUDY DESIGN / SETTING Prospect i ve , experimental with control group . PATIENT SAMPLE Fifty-five discs from a control group of 16 healthy volunteers without current back pain ( 11 men , 5 women , 32 - 61 years of age , mean age : 47 years ) and 282 discs from a patient group of 90 LBP patients ( 59 men , 31 women , 20 - 70 years of age , mean age : 44.7 years ) were recruited . METHODS Discography was performed using a pressure-controlled manometric technique with an injection rate of 0.05 mL/s and a 3.5 mL restricted total volume . Concordance was rated as none/unfamiliar , or familiar . Pain was rated via a 0 - 10 numerical rating scale ( NRS ) . The pressure and volume at which pain was evoked and NRS pain responses at 15 , 30 , and 50 psi were recorded . Annular disruption grade was rated during the procedure by computed tomography discography and fluoroscopic imaging . Negative discogram required no pain described by the participant as " familiar , " with no pain responses > or=6/10 NRS at pressures < or=50 psi above opening pressure and < or=3.5 mL total injected volume . Patient discs were partitioned into two subgroups based on discographic findings : Neg-D ( negative discs ) and Pos-D ( positive discs ) . Only discs with Grade 3 annular tears ( Dallas Discogram Scale ) were included in the study . RESULTS Among 55 asymptomatic control group discs , 32 ( 58.2 % ) exhibited Grade 3 annular tear . All discs in the asymptomatic control group satisfied negative response criteria . Among 282 patient group discs , 199 ( 70.6 % ) exhibited Grade 3 annular tear . Of 199 discs with Grade 3 annular tears , 104 ( 52.3 % ) satisfied negative response criteria and were categorized as the Neg-D group . The other 95 discs were categorized as a Pos-D group . Patients showed significantly lower pain tolerance relative to control subjects ( p<.05 ) . The control and Neg-D groups showed similar pressures and volumes at which pain was initially evoked . Mean control group pain scores were 0.47 NRS at 15 psi and 1.58 NRS at 50 psi . Mean Neg-D group pain scores were 0.11 NRS at 15 psi and 1.1 NRS at 50 psi . Discographic findings for the Pos-D group were significantly different from those of the control and Neg-D groups ( p<.001 ) . CONCLUSIONS Pain tolerance was significantly lower in patients relative to asymptomatic subjects . Negative patient discs and asymptomatic subject discs showed similar characteristics . Pressure-controlled manometric discography using strict criteria may distinguish asymptomatic discs among morphologically abnormal discs with Grade 3 annular tears in patients with suspected chronic discogenic LBP Study Design . This is a prospect i ve study of the validity of a positive test result in provocative lumbar discography for the diagnosis of “ discogenic pain . ” Objective . To investigate the hypothesis that provocative discography by strict criteria accurately identifies a low back pain illness due to a primary disc lesion . Summary and Background Data . According to the Sackett and Haynes criteria for establishing diagnostic test validity , no test without a gold st and ard external st and ard can be meaningfully applied . Provocative discography as a test for determining “ discogenic pain ” has , to date , not been compared against a gold st and ard . Absent a gold st and ard reference , there can be no validity assessment or systematic improvement of test accuracy . This is the first study to apply an external gold st and ard evaluation of the diagnostic validity of discography in any manner . Methods . Over a 5-year period using a strict enrollment protocol , 32 patients with low back pain and a positive single-level low-pressure provocative discogram , underwent spinal fusion . Subjects with known patient selection comorbidities were excluded . Generic surgical limitations /morbidity were controlled by comparison to the clinical outcomes of a strictly-matched cohort of 34 patients having a well-accepted single-level lumbar pathology ( unstable spondylolisthesis ) . Treatment success was compared between groups . Results . In the control-spondylolisthesis group , 23 of 32 patients ( 72 % ) met the highly effective success criteria compared with 8 of 30 in the presumed discogenic pain cohort ( 27 % ) . The proportion of patients who met the “ minimal acceptable outcome ” was 29 of 32 ( 91 % ) in the spondylolisthesis group and 13 of 30 ( 43 % ) in the presumed discogenic pain group . Adjusting for surgical morbidity and dropout failure , by either criteria of success , the best-case positive predictive value of discography was calculated to be 50 % to 60 % . Conclusions . Positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness in this first study comparing discography results to a gold st and ard BACKGROUND CONTEXT Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac ( SI ) joint sources of pain . No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated . PURPOSE To identify significant components of a clinical examination that are associated with symptomatic lumbar discs , zygapophysial joints and SI joints . STUDY DESIGN A prospect i ve , criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics . PATIENT SAMPLE The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections .  OUTCOME MEASURES Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections . Statistical analysis included chi-squared test for independence , phi and odds ratios with confidence intervals . METHOD Patients received blinded clinical examinations by physical therapists , and diagnostic injections were used as the criterion st and ard . RESULTS Significant relationships were found between discogenic pain and central ization of pain during repeated movement testing , and pain when rising from sitting . Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting . Sacroiliac joint pain was related to three or more positive pain provocation tests , pain when rising from sitting , unilateral pain and absence of lumbar pain . CONCLUSIONS Significant correlations exist between clinical examination findings and symptomatic lumbar discs , zygapophysial and SI joints . The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests , central ization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints Study Design : Comparative assessment of r and omized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain . Objective : To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain . Summary of Background Data : Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain , which is pain exclusive of that associated with a herniated intervertebral disc , or that is due to degeneration of the zygapophyseal joints , or due to dysfunction of the sacroiliac joints , respectively . The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited . Methods : The present analysis is based on 2 r and omized controlled trials of chronic axial low back pain not caused by disc herniation , radiculitis , or facet joint pain , utilizing either a caudal or lumbar interlaminar approach , with a total of 240 patients studied , and a 24-month follow-up . Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group . Results : The primary outcome measure was significant improvement , defined as pain relief and functional status improvement of at least 50 % from baseline , which was reported at 24-month follow-ups in 72 % who received local anesthetic only with a lumbar interlaminar approach and 54 % who received local anesthetic only with a caudal approach . In patients receiving local anesthetic with a steroid , the response rate was 67 % for those who had a lumbar interlaminar approach and 68 % for those who had a caudal approach at 12 months . The response was significantly better in the lumbar interlaminar group who received local anesthetic only , 77 % versus 56 % at 12 months and 72 % versus 54 % at 24 months . Conclusion : This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain , epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach Among the multiple causes of chronic low back pain , axial and discogenic pain are common . Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections . However , there is a paucity of evidence regarding the effectiveness , indications , and medical necessity of any treatment modality utilized for managing axial or discogenic pain , including epidural injections . In an interventional pain management practice in the US , a r and omized , double-blind , active control trial was conducted . The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin . However , disc herniation , radiculitis , facet joint pain , or sacroiliac joint pain were excluded . Two groups of patients were studied , with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone . Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the , Oswestry Disability Index , Secondary outcome measurements included employment status , and opioid intake . Significant improvement or success was defined as at least a 50 % decrease in pain and disability . Significant improvement was seen in 77 % of the patients in Group I and 67 % of the patients in Group II . In the successful groups ( those with at least 3 weeks of relief with the first two procedures ) , the improvement was 84 % in Group I and 71 % in Group II . For those with chronic function-limiting low back pain refractory to conservative management , it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain . This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source BACKGROUND Chronic low back with or without lower extremity pain is extremely common , expensive , and disabling . However , all modalities of treatments are directed towards disc herniation which is responsible for a very small proportion of the patients . Thus , chronic low back pain without disc herniation is common . Multiple modalities of treatments are utilized in managing axial or discogenic pain including surgery and epidural injections including surgery , intradiscal therapies , and epidural injections . However , there is continued debate on the effectiveness , indications , and medical necessity of all modalities treatments in managing axial or discogenic pain in the lumbar spine . STUDY DESIGN A r and omized , double-blind , active control trial . SETTING A private practice , specialty referral , interventional pain management practice in the United States . OBJECTIVES To evaluate the ability to assess the effectiveness of lumbar interlaminar epidural injections in managing chronic axial or discogenic low back pain with epidural injections of local anesthetic with or without steroids . METHODS In this study , a total of 120 patients were r and omly allocated to one of the 2 groups receiving either local anesthetic alone or local anesthetic with steroids with 60 patients in each group . The primary outcome measure was at least 50 % improvement in the numeric rating scale ( NRS ) and Oswestry Disability Index ( ODI ) . Outcomes were assessed at 3 , 6 , 12 , 18 , and 24 months post treatment . RESULTS Significant pain relief and functional status improvement defined as at least 50 % or more reduction in scores from baseline were observed in 72 % of patients receiving local anesthetic alone and 67 % of the patients receiving local anesthetic with steroids .  Opioid intake was reduced from baseline in each group for 2 years . LIMITATIONS The results of the study are limited by the lack of a placebo group . CONCLUSION Lumbar interlaminar 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 . TRIAL REGISTRATION NCT00681447 Study Design Single-arm , prospect i ve 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 assessment s of back pain severity by visual analog scale , sitting , st and ing , 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 , st and ing , 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 ≥2-point improvement in pain severity or a ≥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 In this study we present the efficacy of aspiration of disc material employing the Stryker Disc Dekompressor during percutaneous microdiscectomy for the treatment of chronic spinal and radicular pain due to contained lumber disc herniation and compare the short-term outcome in such patients with those who received lumber epidural injection . A total of 50 patients with chronic lumber discogenic pain and radiculopathy were enrolled in this study and were r and omized into two groups . Group 1 ( n=26 ) underwent first time , single-level lumber discectomy at either L3 - 4 , L4 - 5 , or L5-S1 using the Stryker Disc Dekompressor for aspiration of disc material and Group 2 ( n=24 ) received epidural steroid/local anesthetic injection . Data on patient demographics , operative time , length of hospitalization , incidence of postoperative complications , analgesic usage and postoperative complications were obtained . For short-term evaluation of the outcome in the two patient groups , the Visual Analogue Scale ( VAS ) from 0 - 10 for back pain and radicular pain were obtained preoperatively , 24 hr and 1 - 6 wk postoperatively . Also , the straight leg raising test ( SLRT ) was performed and recorded . A significant decrease in the radicular pain scores and an increase in SLRT degrees with a decrease in the back pain scores was seen in the disc Dekompressor group with minimal incidence of postoperative complications . In the epidural injection group , the back pain scores were significantly decreased postoperatively while the radicular pain and the SLRT degrees were insignificantly changed 24 hr postoperatively and at wk 6 . We conclud that when st and ardized patient selection criteria are used , the disc DeKompressor is a safe and more effective treatment for radicular pain of discogenic origin than epidural injection with steroid/local anesthetic .  Back pain of discogenic origin was more effectively treated with the epidural steroid/local anesthetic injection . Treatment of patients with radicular pain associated with contained disc herniation using the Dekompressor can be a safe and more effective procedure BACKGROUND CONTEXT Whether discographic injections would be positive in subjects with benign persistent " backache " who are not seeking treatment is unknown . This information is important , because benign backache undoubtedly co-exists in patients with chronic low back pain ( CLBP ) illness that is not discogenicin origin . If these subjects had a high rate of positive discography , the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness . Conversely , if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections , the basic tenet of discographic diagnosis would be strengthened . PURPOSE To compare , using a strict experimental design , the relative pain and concordancy response to provocative discography in subjects with clinical ly insignificant " backache " and clinical subjects with CLBP illness considering surgical treatment . STUDY DESIGN Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain ( CLBP ) illness . PATIENT SAMPLE Twenty-five subjects with mild persistent low back pain ( LBP ) were recruited for an experimental discography study . Subjects were recruited from a clinical study of patients having had cervical spine surgery . Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP , be taking no medications for backache , have no activity restrictions because of LBP , and have normal psychometric scores . To more closely approximate the pain behavior in CLBP illness , 50 % ( 12 ) of the " backache " group were recruited with a chronic painful condition ( neck/shoulder ) unrelated to the low back . CLBP subjects , patients coming to discography for consideration of surgical treatment , were used as control subjects . OUTCOME MEASURES Results of discography were determined using the criteria of Walsh et al. : pain response of 3 or greater , two or more pain behaviors , a negative " control " discographic injection , and a similar or exact concordancy rating . METHODS Discography was performed on experimental subjects and control patients . Experienced raters , who were blinded to control versus experimental status of the subjects , scored the magnetic resonance image , discogram , psychometric tests and discography videotapes of the subjects ' pain behavior . RESULTS Thirteen of 25 volunteer subjects had pain rated as " bad " or worse with disc injection . There were 12 painful and fully concordant disc injections in 9 of these 25 " backache " subjects ( 36 % ) . These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain . All positive discs had annular disruption to or through the outer annulus . Of the 9 subjects with positive discograms , 3 had no chronic pain states and 6 did . All subjects with positive injections had negative control discs . In comparison , in 52 subjects with CLBP illness 38 ( 73 % ) had at least one positive disc injection . CONCLUSIONS In a group of volunteer subjects with persistent " backache , " 36 % were found to have significant pain on disc injection , which is reported to be concordant with their usual pain . The presence of positive concordant pain responses and negative control discs in 33 % of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinical ly relevant spinal pathology Study Design . R and omized , controlled study . Objective . To evaluate the diagnosis of discogenic low back pain ( LBP ) with discography and discoblock . Summary of Background Data . Discogenic LBP is usually diagnosed by magnetic resonance imaging and discography . However , the reliability of discography is controversial . Previously , we reported the usefulness of discoblock with bupivacaine for diagnosis , and discoblock improved the results of anterior interbody fusion surgery . However , that study was not a r and omized , controlled study . Therefore , the purpose of the current study was to compare the results of surgery after diagnosis of LBP by discography and discoblock . Methods . Patients ( n = 42 ) with severe LBP showing L4–L5 or L5–S1 disc degeneration on magnetic resonance imaging were evaluated by discography ( 1.5 mL of contrast medium ) or discoblock ( intradisc injection of 0.75 mL of 0.5 % bupivacaine ) . We r and omized the patients in turn . Anterior discectomy and interbody fusion were performed in patients who responded to the diagnostic procedures . The visual analogue scale score ( 0 , no pain ; 100 , worst pain ) , Japanese Orthopedic Association Score ( 0 , worst pain ; 3 , no pain ) , Oswestry Disability Index , and patient satisfaction before and 3 years after surgery were recorded and compared between groups . Results . Twelve patients did not show pain provocation by discography or pain relief by discoblock and were excluded . Fifteen patients who showed pain provocation by  discography and 15 patients who experienced pain relief with discoblock were evaluated . Rates of improvement in the visual analogue scale score , Japanese Orthopedic Association Score , and Oswestry Disability Index score in the discoblock group were significantly higher than those in the discography group ( P < 0.05 ) from baseline to 3 years after surgery . Three patients were dissatisfied with surgery after discography compared with one patient after discoblock . Conclusion . Pain relief after injection of a small amount of bupivacaine into the painful disc was a useful tool for the diagnosis of discogenic LBP compared with discography BACKGROUND CONTEXT Fusion is considered the " gold st and ard " in surgical treatment of degenerated disc disease ; the intended postoperative goal is absence of mobility , but treatment may induce degeneration in adjacent segments . Total disc replacement ( TDR ) aims to restore and maintain mobility by replacing a painful disc . Little is known about the degree and quality of mobility in artificial discs in vivo and whether maintained mobility reduces the stress on adjacent segments that is believed to occur after fusion . PURPOSE To see if surgical goals for respective treatments had been reached , if clinical outcome was related to this , and if differences in disc height at treated segments and adjacent segment motion patterns between groups occurred . STUDY DESIGN Comparison of X-ray measurements in a r and omized controlled trial between instrumented posterior fusion and TDR  for chronic low back pain ( CLBP ) assumed to be discogenic . Results were compared with clinical outcome . PATIENT SAMPLE The material consisted of 152 patients suffering from CLBP assumed to be discogenic . Seventy-two patients were treated with fusion and 80 with TDR . OUTCOME MEASURES Results of X-ray measurements were compared between groups and related to self-reported clinical results regarding back pain and disability . METHODS Flexion-extension X-rays were analyzed preoperatively and 2 years postoperatively using distortion-compensated Roentgen analysis ( DCRA ) at treated and adjacent levels , and mobility after fusion and TDR was estimated . Changes in disc height and range of motion ( ROM ) respective translation in adjacent segments were compared between groups . Results of DCRA measurements were also compared with the clinical outcome . RESULTS Preoperative flexion-extension ROM was similar between the fusion and TDR groups , and preoperative disc heights of segments to be treated were between one and two st and ard deviation less than that previously established in a normative data base . Seventy percent of fused patients had no mobility , whereas 85 % of TDR patients were mobile . Fulfillment of surgical goals was correlated to neither back pain nor disability . Fused segments were lower and TDR segments were higher than normative values postoperatively . There were also significant differences at adjacent segments , there being more translation and flexion-extension in the fusion group than in the TDR group . CONCLUSIONS This very accurate X-ray method ( DCRA ) indicates that surgical goals were reached in most patients . This , however , was not correlated to clinical outcome . Differences between the groups in postoperative disc height at treated segments , respective ROM , and translation at adjacent segments did not affect the clinical outcome after 2 years BACKGROUND In this era of escalating health care costs and the question able effectiveness of multiple interventions , cost effectiveness or cost utility analysis has become the cornerstone of evidence -based medicine , and has an influence coverage decisions . Even though multiple cost effectiveness analysis studies have been performed over the years , extensive literature is lacking for interventional techniques . Cost utility analysis studies of epidural injections for managing chronic low back pain demonstrated highly variable results including a lack of cost utility in r and omized trials and contrasting results in observational studies . There has not been any cost utility analysis studies of epidural injections in large r and omized trials performed in interventional pain management setting s. OBJECTIVES To assess the cost utility of caudal epidural injections in managing chronic low back pain secondary to lumbar disc herniation , axial or discogenic low back pain , lumbar central spinal stenosis , and lumbar post surgery syndrome . STUDY DESIGN This analysis is based on 4 previously published r and omized trials . SETTING A private , specialty referral interventional pain management center in the United States . METHODS Four r and omized trials were conducted assessing the clinical effectiveness of caudal epidural injections with or without steroids for lumbar disc herniation , lumbar discogenic or axial low back pain , lumbar central spinal stenosis , and post surgery syndrome . A cost utility analysis was performed with direct payment data for a total of 480 patients over a period of 2 years from these 4 trials . Outcome included various measures with significant improvement defined as at least a 50 % improvement in pain reduction and disability status . RESULTS The results of 4 r and omized controlled trials of low back pain with 480 patients with a 2 year follow-up with the actual reimbursement data showed cost utility for one year of quality -adjusted life year ( QALY ) of $ 2,206 for disc herniation , $ 2,136 for axial or discogenic pain without disc herniation , $ 2,155 for central spinal stenosis , and $ 2,191 for post surgery syndrome . All patients showed significant improvement clinical ly and showed positive results in the cost utility analysis with an average cost per one year QALY of $ 2,172.50 for all patients and $ 1,966.03 for patients judged to be successful . The results of this assessment show a better cost utility or lower cost of managing chronic , intractable low back pain with caudal epidural injections at a QALY that is similar or lower in price than medical therapy only , physical therapy , manipulation , and surgery in most cases . LIMITATIONS The limitations of this cost utility analysis include that it is a single center evaluation , even though 480 patients were included in the analysis . Further , only the costs of interventional procedures and physician visits were included . The benefits of returning to work were not assessed . CONCLUSION This cost utility analysis of caudal epidural injections in the treatment of disc herniation , axial or discogenic low back pain , central spinal stenosis , and post surgery syndrome in the lumbar spine shows the clinical effectiveness and cost utility of these injections at less than $ 2,200 per one year of QALY BACKGROUND Intervertebral discs , facet joints , ligaments , fascia , muscles , and nerve root dura have been described as tissues capable of transmitting pain in the low back . The pathophysiology of spinal radicular pain is the subject of ongoing research and controversy with discogenic pain assuming a major role as a cause of non-specific low back pain . Even though epidural injections are frequently administered in managing axial low back pain , the evidence is lacking . STUDY DESIGN A r and omized , double-blind , equivalence trial . SETTING An interventional pain management practice , a specialty referral center , a private practice setting in the United States . OBJECTIVES To evaluate the effectiveness of caudal epidural injections with or without steroids in managing chronic low back pain without disc herniation or radiculitis in providing effective and long-lasting pain relief and to evaluate the differences between local anesthetic with or without steroids . METHODS Patients were r and omly assigned to one of 2 groups , Group I patients received caudal epidural injections with local anesthetic ( lidocaine 0.5 % ) , whereas Group II patients received caudal epidural injections with 0.5 % lidocaine 9 mL mixed with 1 mL of steroid . R and omization was performed by computer-generated r and om allocation sequence by simple r and omization . OUTCOMES ASSESSMENT Multiple outcome measures were utilized which included the Numeric Rating Scale ( NRS ) , the Oswestry Disability Index 2.0 ( ODI ) , employment status , and opioid intake with assessment at 3 months , 6 months , and 12 months post-treatment . Significant pain relief was defined as 50 % or more , whereas significant improvement in disability score was defined as reduction of 40 % or more . RESULTS Significant pain relief ( > or = 50 % ) was demonstrated in 72 % to 81 % of patients and functional status improvement was demonstrated by a reduction of 40 % in the ODI scores in 81 % of the patients . The overall average procedures per year were 3.6 + /- 1.05 in Group I and 3.9 + /- 1.33 in Group II with an average total relief per year of 32.3 + /- 16.93 weeks in Group I and 30.7 + /- 17.94 weeks in Group II over a period of 52 weeks . LIMITATIONS The results of this study are limited by lack of a placebo group and a preliminary report of 36 patients in each group . CONCLUSION Caudal epidural injections with or without steroids may be effective in patients with chronic function-limiting low back pain without facet joint pain , disc herniation , and /or radiculitis in over 70 % of the patients This article was a preliminary report of prospect i ve 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 clinical ly 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 Study Design . A prospect i ve r and omized study of the therapeutic effect of intradiscal steroid injection compared to a saline placebo . Objectives . To determine whether intradiscal steroid injection influences the clinical outcome at 1 year in patients with chronic low back pain of discogenic origin . Summary of Background Data . Steroids have been used empirically in the treatment of back pain . They have been used in the epidural space and around nerve roots and have been used as an alternative to chymopapain within the disc . Previous studies have , however , shown variable results . Methods . A total of 120 patients with chronic low back pain of discogenic origin were enrolled in the study . At discography , if they had concordant pain , they were r and omized to injection of normal saline or methylprednisolone into the disc space . These patients were prospect ively followed up for 12 months , and they were asked to report pain according to a visual analogue score and their Oswestry Disability Index was recorded . The primary outcome measure was determined as a percentage change in disability , and the results were analyzed using independent sample s t test . The secondary outcome measure was a change in the pain score , and this was analyzed using the Mann-Whitney U test . Results . There was no significant difference in the primary outcome between the two groups ( P = 0.71 ) . The steroid group had a mean change of 2.28 ( SE 2.49 ) in percentage disability , while the saline group had a mean change of 3.42 ( SE 1.79 ) . With respect to the change in pain score , there was no significant difference between the two groups ( P = 0.72 ) . Those patients who had saline injection had a median change in pain score of 0 ( interquartile range −1 to 1 ) , whereas those given steroid treatment had a median change in pain score of 0 ( interquartile range −0.25 to 1 ) . Conclusions . This study demonstrates that intradiscal steroid injections do not improve the clinical outcome in patients with discogenic back pain compared with placebo An attempt was made to determine the relative contribution of various structures to chronic low back pain , including facet joint(s ) , disc(s ) , and sacroiliac joint(s ) in a prospect i ve evaluation . Precision diagnostic blocks , including disc injections , facet joint blocks , and sacroiliac joint injections , are frequently used . In contrast , selective nerve root blocks or transforaminal epidural injections are used occasionally to evaluate persistent or recurrent low back pain in patients without appropriate radiologic or neurophysiologic diagnosis . One hundred and twenty patients with a chief complaint of low back pain were evaluated with precision diagnostic injections , which included medial branch blocks , provocative discography and sacroiliac joint injections . In 40 % ( 95 % CL , 31 % , 49 % ) , of the patients , facet joint pain was diagnosed ; and in 26 % ( 95 % CL , 18 % , 34 % ) of the patients discogenic pain was diagnosed ; and 2 % of the patients were diagnosed with sacroiliac joint pain & NA ; 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 r and omized 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 Study Design . A prospect i ve r and omized trial . Objective . To evaluate the efficacy of percutaneous intradiscal radiofrequency thermocoagulation by modifying the duration of heating , using two different time methods , for relieving pain and improving functional disability . Summary of Background Data . Lumbar discogenic pain is the major problem in lumbar degenerative disc disease that percutaneous intradiscal radiofrequency thermocoagulation has been suggested for as a nonsurgical invasive treatment technique for lumbar discogenic pain . In a previous controlled study , this method was found to be ineffective with 8 weeks of follow-up . Material s and Methods . Sixty patients with chronic low back pain were selected for provocative discography to diagnose the discogenic pain and to locate the discs to be treated . From this group , 39 patients were r and omly selected and divided into two groups . In the first group , treatment was performed for 120 seconds , and in the second group for 360 seconds , both at 80C . Patients were assessed with a visual analogue scale for pain relief and functional improvement . Evaluations were performed before , immediately after treatment , at 1 and 2 weeks , and at 1 , 3 , and 6 months after the procedure . Results . A total of 39 patients with positive provocative discographies were found to eligible for the study . There were no statistical differences in pain relief and functional improvement between two groups ( P > 0.05 ) . The immediate , 1-week and 2-week , and 1-month visual analogue scale ( VAS ) scores were decreased significantly in both groups when comparing them with the pretreatment scores ( P < 0.05 ) . However , the final values after 6 months were similar to those measured at the beginning of the study ( P > 0.05 ) . Conclusion . Percutaneous intradiscal radiofrequency thermocoagulation has been suggested and performed to relieve discogenic pain . In the previous controlled study , no effective pain relief has been obtained . In this study , the authors increased the duration of radiofrequency thermocoagulation to improve the effectiveness of this method . Yet , the authors have not found any significant differences between the application of lesioning at two different times in percutaneous intradiscal radiofrequency thermocoagulation BACKGROUND Lumbar radicular pain pathophysiology continues to be the subject of research and debate as discogenic pain is increasingly seen as a cause of non-specific low back pain . Among non-surgical methods used to manage chronic low back pain with or without disc herniation , epidural injections are one of the most common modalities . However , there is little evidence utilizing contemporary methodology for using epidural injections in patients with discogenic pain . STUDY DESIGN A r and omized , double-blind , active-controlled trial . SETTING An interventional pain management practice , a specialty referral center , a private practice setting in the United States . OBJECTIVES To evaluate the effectiveness of caudal epidural injections with local anesthetic , with or without steroids , in managing chronic low back pain without disc herniation or radiculitis . METHODS A total of 120 patients were assigned to one of 2 groups . Group I patients received caudal epidural injections with local anesthetic ( lidocaine 0.5 % 10 mL ) ; Group II patients received caudal epidural injections with 9 mL of 0.5 % lidocaine mixed with 1 mL of steroid ( either br and name or non-particulate betamethasone [ 6 mg ] or methylprednisolone [ 40 mg ] ) . Computer-generated r and omization and r and om allocation sequence by simple r and omization were the r and omization techniques utilized . OUTCOMES ASSESSMENT Multiple outcome measures were utilized which included the Numeric Rating Scale ( NRS ) , the Oswestry Disability Index 2.0 ( ODI ) , employment status , functional status , and opioid intake at 3 , 6 , and 12 months post treatment . Significant pain relief and functional status improvement were described as a 50 % or more reduction in scores from baseline . RESULTS Significant pain relief and functional status improvement were observed in 55 % of the patients in Group I and 68 % of the patients in Group II . In contrast , 84 % of patients in Group I and 85 % in Group II saw significant pain relief and functional status improvement in the successful group ( 62 % in Group I and 68 % in Group II ) . The average procedures per year were 3.8 ± 0.9 for Group I and 4.3 ± 0.9 for Group II . Average pain scores decreased from 8.0 ± 0.9 to 4.3 ± 1.79 for Group I and from 7.9 ± 1.0 to 3.8 ± 1.59 for Group II . There were no differences among the patients receiving one of the 3 steroids . LIMITATIONS The results of this study are limited by lack of a placebo group . CONCLUSION  Caudal epidural injections with local anesthetic with or without steroids are effective in patients with chronic low back pain of discogenic origin without facet joint pain , disc herniation , and /or radiculitis Study Design . One hundred and three lumbar intervertebral discs ( L3/4-L5/S1 ) of 36 patients with low back pain were examined with computed tomography ( CT ) diskography and magnetic resonance imaging ( MRI ) . Objectives . To determine whether lumbar endplate degeneration correlates with the degree of disc degeneration or disc rupture and to determine if there is an association between pain provocation during diskography and lumbar endplate degeneration . Summary of Background Data . There have been numerous attempts to explain the pathogenesis of pain provocation during diskography , but the possibility of endplate degeneration as a source of pain has not been widely assessed . Methods . One hundred and three lumbar intervertebral discs ( 36 L3/4 , 36 L4/5 , and 31 L5/S1 intervertebral discs ) of 36 patients were examined . On the basis of MRI , the intervertebral discs were divided into four categories based on the degree of endplate degeneration . Based on pain provocation on diskography , the intervertebral discs were divided into three categories : no pain , indifferent/untypical pain , and familiar/typical pain . Based on disc degeneration and disc rupture , the intervertebral discs were divided into four categories in accordance with the Dallas Discogram Description : Grade s 0–3 of both degeneration and rupture . Results . There was a positive correlation between endplate degeneration and disc degeneration and a positive correlation between disc rupture and pain provocation , but there was no association between endplate degeneration and disc rupture and no correlation between endplate degeneration and pain provocation on diskography . Conclusions . This study showed a stronger association between endplate degeneration and disc degeneration than between endplate degeneration and disc rupture . The results indicate that the contrast injection during diskography reflects mainly pain of discogenic origin , whereas the possible pain associated with endplate damage can not be depicted by CT diskography Study Design . A prospect i ve cross-sectional analytic approach was taken . Objectives . This study sought to determine the relative contribution of the disc and the zygapophyseal Joint as a pain source in patients with chronic low back pain . Summary of Background Data . Previous studies have employed either zygapophyseal joint blocks or discography , but in no studies have both procedures been performed . Methods . Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints . Results . Thirty-six patients ( 39 % ) had at least one positive discogram as defined by exact pain reproduction , an abnormal image , and a negative control . Eight patients responded to both a screening zygapophyseal joint block using lignocaine and confimatory block using bupivacaine . Only three patients had both a positive discogram and a symptomatic zygapophyseal joint . Conclusions . In patients with chronic low back pain , the combination of discogenic pain and zygapophyseal joint pain is uncommon Study Design : A r and omized , double-blind , active-controlled trial . Objective : To assess the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of axial or discogenic pain in patients without disc herniation , radiculitis , or facet joint pain . Summary of Background Data : Cervical discogenic pain without disc herniation is a common cause of suffering and disability in the adult population . Once conservative management has failed and facet joint pain has been excluded , cervical epidural injections may be considered as a management tool . Despite a paucity of evidence , cervical epidural injections are one of the most commonly performed nonsurgical interventions in the management of chronic axial or disc-related neck pain . Methods : One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain as determined by means of controlled diagnostic medial branch blocks were r and omly assigned to one of the 2 treatment groups . Group I patients received cervical interlaminar epidural injections of local anesthetic ( lidocaine 0.5 % , 5 mL ) , whereas Group II patients received 0.5 % lidocaine , 4 mL , mixed with 1 mL or 6 mg of nonparticulate betamethasone . The primary outcome measure was ≥ 50 % improvement in pain and function . Outcome assessment s included numeric rating scale ( NRS ) , Neck Disability Index ( NDI ) , opioid intake , employment , and changes in weight . Results : Significant pain relief and functional improvement ( ≥ 50 % ) was present at the end of 2 years in 73 % of patients receiving local anesthetic only and 70 % receiving local anesthetic with steroids . In the successful group of patients , however , defined as consistent relief with 2 initial injections of at least 3 weeks , significant improvement was illustrated in 78 % in the local anesthetic group and 75 % in the local anesthetic with steroid group at the end of 2 years . The results reported at the one-year follow-up were sustained at the 2-year follow-up . Conclusions : Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and functioning in patients with chronic discogenic or axial pain that is function-limiting and not related to facet joint pain Study Design . A prospect i ve nonr and omized clinical trial . Objective . To determine the outcome in a group of patients with chronic , function-limiting low back pain who met the criteria for interbody fusion surgery , but were instead treated with an intradiscal thermal catheter ( SpineCath , Oratec Interventions , Inc. , Menlo Park , CA ) . Summary of Background Data . This study represents the first reported trial of treatment for chronic discogenic low back pain with a novel thermal intradiscal catheter . Methods . The authors evaluated 25 consecutive patients . The minimum duration of nonoperative care with the authors was 6 months . The visual analog pain scores , sitting tolerance times , and SF-36 summary scores were tabulated . Results . The mean follow-up period was 7 months , and the mean duration of symptoms 58.5 months . Of the 25 patients , 20 ( 80 % ) reported a reduction of at least 2 points in visual analog pain scores , and 18 ( 72 % ) reported an improvement in sitting tolerance as well as reduction or discontinuance of analgesic medication . Visual analog pain scores improved by a mean reduction of 3.74 , a 51 % change ( P = 0.0001 ) . On the SF-36 physical function subscale , 72 % of the patients improved by a mean increase of 15 points ( P = 0.001 ) , a mean change of 38 % , and by a mean increase of 14 points on the bodily pain subscale ( P = 0.004 ) , a mean change of 48 % . Conclusions . A statistically significant improvement in functional outcome was obtained in patients with chronic discogenic low back pain treated thermally by the SpineCath BACKGROUND CONTEXT The " central ization phenomenon " ( CP ) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing ( a McKenzie evaluation ) . A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain . PURPOSE Estimation of the diagnostic predictive power of central ization and the influence of disability and patient distress on diagnostic performance , using provocation discography as a criterion st and ard for diagnosis , in chronic low back pain patients . STUDY DESIGN / SETTING This study was a prospect i ve , blinded , concurrent , reference st and ard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain . PATIENT SAMPLE Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures . Patients were typically disabled and displayed high levels of psychosocial distress . The sample included patients with previous lumbar surgery , and most had unsuccessful conservative therapies previously . OUTCOME MEASURES DIAGNOSIS results of provocation discography . INDEX TEST The CP . Psychometric evaluation : Rol and -Morris , Zung , Modified Somatic Perception question naires , Distress Risk Assessment Method , and 100-mm visual analog scales for pain intensity . METHODS Patients received a single physical therapy examination , followed by lumbar provocation discography .  Sensitivity , specificity , and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures . RESULTS A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography .  Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis . Disability and pain intensity ratings were high , and distress was common . Sensitivity , specificity , and positive likelihood ratios for central ization observed during repeated movement testing for pain distribution and intensity changes were 40 % , 94 % , and 6.9 respectively . In the presence of severe disability , sensitivity , specificity , and positive likelihood ratios were 46 % , 80 % , 3.2 and for distress , 45 % , 89 % , 4.1 . In the subgroups with moderate , minimal , or no disability , sensitivity and specificity were 37 % , 100 % and for no or minimal distress 35 % , 100 % . CONCLUSIONS Central ization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress 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 r and omized , 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 r and omized 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 Study Design A prospect i ve analysis of the clinical outcome of a consecutive series of patients treated with posterior lumbar arthrodesis .  Preoperative data were collected retrospectively by chart review . Objectives To measure by independent review the clinical outcome of posterolateral intertransverse fusion as a treatment for discogenic low back pain in a highly selected group of patients . Summary of Background Data Although numerous studies have reported on the surgical management of degenerative disc disease , they have been difficult to interpret because they lack patient‐oriented outcome assessment and objective pain measurement criteria , independent review , and include patients with diagnoses other than degenerative disc disease . Methods Between 1991 and February 1993 all patients seen by a single surgeon , evaluated with magnetic resonance imaging and discography , and treated with posterolateral lumbar fusion were review ed by independent investigation . Outcome was assessed in the areas of radiographic fusion , pain , function , and patient satisfaction . Results Twenty‐three patients ( 12 women , 11 men ; 100 % follow‐up an average of 47 months after surgery [ range , 24–84 months ] ) met the inclusion criteria . Overall , 39 % had a good or excellent result , 13 % fair , and 48 % poor . Nine of 10 patients receiving worker 's compensation had a poor result ; four of five patients with radiographic pseudarthrosis  had a poor result . Statistically significant improvement in the visual analogue scale was noted in the good and excellent group ( P = 0.0001 ) and the fair group ( P = 0.002 ) with no change in the poor group . Patients out of work more than 3 months before surgery tended to have poor results . Overall , 56 % of patients were extremely satisfied with the result of their surgery . Conclusion Posterolateral intertransverse fusion can be used to successfully manage chronic discogenic back pain . However , patient selection remains a challenge , and successful outcome appears to be limited in the subset of patients receiving worker 's compensation and those chronically disabled . Prospect i ve and r and omized study with objective pain criteria , independent review , and patient‐oriented outcome is recommended Study Design . The presence or absence of rapidly central izing , peripheralizing , or abolishing low  back and radiating pain , as identified during a McKenzie mechanical lumbar assessment of patients with chronic lumbar pain , was compared prospect ively with discographic pain provocation and anular competency . Objectives . To evaluate any relation between the responses of central ization and peripheralization with discographic findings . Summary of Background Data . Central ization of referred pain has been reported as a very common occurrence during McKenzie assessment and treatment . Patients whose pain central izes have been shown to achieve superior treatment outcomes . A dynamic internal disc model has been hypothesized as an underlying mechanism for central ization that has not been studied previously . Methods . Patients with chronically disabling low back pain who were referred for discography underwent preliminary blinded McKenzie clinical assessment and were categorized into three groups by their pain response . Patterns , or lack thereof , of pain response were then compared with blinded discographic pain provocation and anular findings . Results . During the McKenzie assessment , the referred pain of 50 % central ized with 74 % having positive discograms , of which 91 % had an intact anulus . The pain of 25 % peripheralized only ( would not central ize ) ; 69 % of these had positive discograms , but only 54 % had an intact anulus . The distal pain of 25 % did not respond at all , and only 12.5 % of these had positive discograms . Conclusion . The McKenzie assessment process reliably differentiated discogenic from nondiscogenic pain ( P < 0.001 ) as well as competent from an incompetent anulus ( P < 0.042 ) in symptomatic discs and was superior to magnetic resonance imaging in distinguishing painful from nonpainful discs Abstract . The goal of this study was to evaluate the short-term effects of intradiscal electrothermal treatment ( IDET ) for chronic discogenic low back pain . Twenty consecutive patients with symptomatic degenerative discs were treated with IDET and evaluated preoperatively , and 3 and 6 months postoperatively . Pain was measured with a 100-mm visual analog scale ( VAS ) and function was evaluated with the Oswestry score and SF-36 question naire . The VAS scores improved by 14 mm on average ( P=0.046 ) , but the individual scores show great variation . The Oswestry scores did not improve significantly . The SF-36 showed improvement , but only for the subscales vitality ( P=0.023 ) and bodily pain ( P=0.047 ) . Based on these results , we conclude that IDET is not effective in reducing pain and improving functional performance in a sample of 20 patients treated for chronic discogenic low back pain after 6 months follow-up BACKGROUND CONTEXT The clinical entity " discogenic back pain " remains controversial at fundamental levels , including its pathophysiology , diagnostic criteria , and optimal treatment . This is true despite availability of four r and omized trials comparing the efficacy of surgical and nonsurgical treatments . One trial showed benefit for lumbar fusion compared with unstructured nonoperative care , and three others showed roughly similar results for lumbar surgery and structured rehabilitation . PURPOSE To compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels . DESIGN Prospect i ve observational cohort study . PATIENT SAMPLE Patients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area . OUTCOME MEASURES Rol and -Morris back disability score ( primary outcome ) , current rating of overall pain severity on a numerical scale , back and leg pain bothersomeness measures , the physical function scale of the short-form 36 version 2 question naire , use of medications for pain , work status , emergency department visits , hospitalizations , and further surgery . METHODS Patients receiving spine surgery within 6 months of enrollment were design ated as the " surgical treatment " group and the remainder as " nonsurgical treatment . " Outcomes were assessed at 3 , 6 , 9 , and 12 months after enrollment . RESULTS We enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons . Eighty-six patients ( 17 % ) had surgery within 6 months of enrollment . Surgery consisted of instrumented fusion ( 79 % ) , disc replacement ( 12 % ) , laminectomy , or discectomy ( 9 % ) . Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery . Adjusting for baseline differences among groups , surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified ( 23-point ) Rol and disability question naire ( primary outcome ) 1 year after enrollment . Using a composite definition of success incorporating 30 % improvement in the Rol and score , 30 % improvement in pain , no opioid pain medication use , and working ( if relevant ) , the 1-year success rate was 33 % for surgery and 15 % for nonsurgical treatment . The rate of reoperation was 11 % in the surgical group ; the rate of surgery after treatment design ation in the nonsurgical group was 6 % at 12 months after enrollment . CONCLUSIONS The surgical group showed greater improvement at 1 year compared with the nonsurgical group , although the composite success rate for both treatment groups was only fair . The results should be interpreted cautiously because outcomes are short term , and treatment was not r and omly assigned . Only 5 % of nonsurgical patients received  cognitive behavior therapy .  Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines OBJECTIVE The aim was to compare the efficacy of intradiscal biacuplasty ( IDB ) with that of placebo treatment for discogenic low back pain . DESIGN This is a r and omized , placebo-controlled trial . Subjects were r and omized on a 1:1 basis to IDB and sham groups . Follow-ups were conducted at 1 , 3 , and 6 months . Subjects and coordinators were blinded to r and omization until 6 months . Of the 1,894 subjects screened , 64 subjects were enrolled , and 59 were treated : 29 r and omized to IDB and 30 to sham .  All subjects had a history of chronic low back pain for longer than 6 months . INTERVENTIONS Two cooled radiofrequency ( RF ) electrodes placed in a bipolar manner in affected discs to lesion the nociceptive fibers of the annulus fibrosus . The sham procedure was identical to the active treatment except that probes were not directly inserted into the disc space , and RF energy was not actively delivered . RESULTS The principal outcome measures were physical function , pain , disability , and opioid usage . Patients in the IDB group exhibited statistically significant improvements in physical function ( P = 0.029 ) , pain ( P = 0.006 ) , and disability ( P = 0.037 ) at 6-month follow-up as compared to patients who received sham treatment . Treatment patients reported a reduction of 16 mg daily intake of opioids at 6 months ; however , the results were not statistically different from sham patients . CONCLUSIONS The results suggest that the clinical benefits observed in this study are the result of non-placebo treatment effects afforded by IDB . IDB should be recommended to select the patients with chronic discogenic low back pain . ( Clinical trials.gov number , NCT00750191 . ) BACKGROUND Intradiscal electrothermal therapy ( IDET ) is a treatment for discogenic low back pain the efficacy of which has not been rigorously tested . PURPOSE To compare the efficacy of IDET with that of a placebo treatment . STUDY DESIGN / SETTING R and omized , placebo-controlled , prospect i ve trial . PATIENT SAMPLE Patients were recruited by referral and the media . No inducements were provided to any patient in order to have them participate . Of 1,360 individuals who were prepared to su bmi t to r and omization , 260 were found potentially eligible after clinical examination and 64 became eligible after discography . All had discogenic low back pain lasting longer than 6 months , with no comorbidity . Thirty-seven were allocated to IDET and 27 to sham treatment . Both groups were satisfactorily matched for demographic and clinical features . METHODS IDET was performed using a st and ard protocol , in which the posterior annulus of the painful disc was heated to 90 C. Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure . Thirty-two ( 85 % ) of the patients r and omized to the  IDET  group and 24 ( 89 % ) of those assigned to the sham group complied fully with the protocol of the study , and complete follow-up data are available for all of these patients . OUTCOME MEASURES The principal outcome measures were pain and disability , assessed using a visual analog scale for pain , the Short Form (SF)-36 , and the Oswestry disability scale . RESULTS Patients in both groups exhibited improvements , but mean improvements in pain , disability and depression were significantly greater in the group treated with IDET . More patients deteriorated when subjected to sham treatment , whereas a greater proportion showed improvements in pain when treated with IDET . The number needed to treat , to achieve 75 % relief of pain , was five . Whereas approximately 40 % of the patients achieved greater than 50 % relief of their pain , approximately 50 % of the patients experienced no appreciable benefit . CONCLUSIONS Nonspecific factors associated with the procedure account for a proportion of the apparent efficacy of IDET , but its efficacy can not be attributed wholly to a placebo effect . The results of this trial can not be generalized to patients who do not fit the strict inclusion criteria of this study , but IDET appears to provide worthwhile relief in a small proportion of strictly defined patients undergoing this treatment for intractable low back pain BACKGROUND To accurately assess the effect of any therapy for treating discogenic low back pain , the natural history of such pain should be known beforeh and . However , until now , no pathological characteristic could be used to predict the disease course of low back pain . OBJECTIVE To better instruct the clinical treatment of discogenic low back pain , a prospect i ve clinical study was performed to observe the natural history of the disease . STUDY DESIGN A prospect i ve clinical study during a 4-year follow-up period . SETTING The study was performed at a spinal center in China . METHODS A total of 279 patients with chronic low back pain were included from June 2006 through October 2007 . Using discography , 156 patients ( 56 % ) were diagnosed to have discogenic back pain . A 101-point numerical rating scale ( NRS ) was used to assess the back pain symptoms and the Oswestry Disability Index ( ODI ) was used to assess lumbar function . RESULTS Of the 156 patients , 131 ( 84 % ) completed the study at 4-year follow-up . At the end of follow-up , 17 patients ( 13.0 % ) had their low back pain symptoms alleviated and lumbar function improved ; 10 patients ( 7.6 % ) were slightly improved ; 16 patients ( 12.2 % ) had their symptoms aggravated ; and 88 patients ( 67.2 % ) experienced the same pain and disability as before . Although the average NRS and ODI scores obtained during the 4-year follow-up study gradually decreased , statistical significance s were found in such changes ( P < 0.05 , and P < 0.05 , respectively ) ; however , the improvement rates of both pain ( 7.6 % ) and disability ( 5.2 % ) were very low . LIMITATIONS The shortcoming of this study is its relatively small sample size . CONCLUSION The present study indicated that the natural history of discogenic low back pain was chronic but persistent , and that the pain and disability in most patients did not improve over time OBJECTIVE The purpose of this study was to investigate the immediate and long-term effects of a 1-year multimodal program with the addition of 2 different traction approaches on the pain , function , disability , and nerve root function in patients with discogenic cervical radiculopathy ( CR ) . This study also attempted to identify the optimal traction angle based on the maximum recovery of the peak-to-peak amplitude of the flexor carpi radialis ( FCR ) H-reflex . METHODS This r and omized clinical trial with one-year follow-up included a total of 216 ( 101 female ) patients with unilateral lower discogenic CR were r and omly assigned to 1 of 3 groups . The st and ard care group ( C ) received the multimodal program ( pain relief methods , muscle strengthening , and thoracic spine manipulation ) . The ventroflexion traction group ( A ) received the same multimodal program as group C , with added traditional ventroflexion traction . The novel traction group ( B ) received the same multimodal program as group C in addition to a flexor carpi radialis ( FCR ) H-reflex-based traction method . Primary outcomes were the Neck Disability Index ( NDI ) and secondary outcomes included neck pain , arm pain , and the amplitude and latency of the H-reflex . Patients were assessed at 3 intervals ( pre-treatment , 4 weeks post-treatment , and the 1-year follow-up ) . RESULTS The mixed linear model with repeated measures indicated a significant group × time effect in favor of the novel cervical traction group ( B ) for measures of NDI ( F = 412.6 , P < .0005 ) , neck pain ( F = 108.9 , P < .0005 ) , arm pain ( F = 91.3 , P < .0005 ) , H- reflex amplitude ( F = 207.7 , P < .0005 ) , and H-reflex latency ( F = 58.9 P < .0005 ) . We found that the extension position of cervical spine ( 5 ° extension ) was the position that achieved the maximum improvement in the novel cervical traction method . CONCLUSIONS This preliminary study showed that a multimodal program with a novel cervical traction method added improved NDI , neck pain , arm pain , and the amplitude and latency of FCR H-reflex for a group of patients with chronic discogenic CR Background Minimal interventional procedures are frequently applied in patients with mechanical low back pain which is defined as pain presumably result ing from single sources : facet , disc , sacroiliac joint or a combination of these . Usually , these minimal interventional procedures are an integral part of a multidisciplinary pain programme . A recent systematic review issued by the Dutch Health Insurance Council showed that the effectiveness of these procedures for the total group of patients with chronic low back pain is yet unclear and cost-effectiveness unknown . The aim of the study is to evaluate whether a multidisciplinary pain programme with minimal interventional procedures is cost-effective compared to the multidisciplinary pain programme alone for patients with chronic mechanical low back pain who did not respond to conservative primary care and were referred to a pain clinic . Methods All patients with chronic low back pain who are referred to one of the 13 participating pain clinics will be asked to participate in an observational study . Patients with a suspected diagnosis of facet , disc or sacroiliac joint problems will receive a diagnostic block to confirm this diagnosis . If confirmed , they will be asked to participate in a R and omized Controlled Trial ( RCT ) . For each single source a separate RCT will be conducted . Patients with a combination of facet , disc or sacroiliac joint problems will be invited for participation in a RCT as well . An economic evaluation from a societal perspective will be performed alongside these four RCTs . Patients will complete question naires at baseline , 3 and 6 weeks , 3 , 6 , 9 and 12 months after start of the treatment . Costs will be collected using self-completed cost question naires . Discussion No trials are yet available which have evaluated the cost-effectiveness of minimal interventional procedures  in patients with chronic mechanical low back pain , which emphasizes the importance of this study .Trial registration numberNational Trial Register : Abstract Disagreement still exists in the literature as to the significance of the high-intensity zone ( HIZ ) demonstrated on magnetic resonance imaging ( MRI ) as a potential pain ¶indicator in patients with low back pain . A prospect i ve blind study was therefore conducted to evaluate the lumbar disc high-intensity zone with the pain provocation response of lumbar discography . Consecutive patients with low back pain unresponsive to conservative treatment and being considered for spinal fusion were subjected to MRI followed by lumbar discography as a pre-operative assessment . The discographer was blinded to the results of the MRI scans . We used the chi-squared test to analyse our results . Ninety-two HIZs were identified in 73 patients , mainly occurring at L4/5 ( 48 % ) and L5/S1 ( 35 % ) . Significant correlation was found between abnormal disc morphology and the HIZ ( P < 0.001 ) . In morphologically abnormal discs ( grade s 3 , 4 and 5 ) , there was a significant correlation between the HIZ and exact or similar pain reproduction ( P < 0.001 ) . The sensitivity , specificity and positive predictive value for pain reproduction were high , at 81 % , 79 % and 87 % respectively . The nature of the HIZ remains unknown , but it may represent an area of secondary inflammation as a result of an annular tear . We conclude from our study that the lumbar disc HIZ observed on MRI in patients with low back pain is likely to represent painful internal disc disruption Objective The objective of this study was to determine the efficacy of percutaneous radiofrequency ( RF ) thermocoagulation of the ramus communicans nerve in patients suffering from chronic discogenic low back pain . Methods Forty-nine patients who suffered chronic discogenic low back pain at only 1 painful vertebral level , and whose pain continued after undergoing intradiscal electrothermal annuloplasty ( IDET )  , were r and omly assigned to 1 of 2 treatment groups . The lesion group ( n = 26 ) received RF thermocoagulation of the ramus communicans nerve . Patients in the control group ( n = 23 ) received an injection of lidocaine without radiofrequency .  Visual analog scale ( VAS ) pain scores , analgesic requirements , SF-36 subscales , and the overall patient satisfaction with the procedure were tabulated . Results The average follow-up period was 4 months . The patient-reported VAS pain scores were significantly lower ( P < 0.05 ) in the lesion group . The scores of the RF lesion group improved by a mean increase of 11.3 points ( P < 0.05 ) on the SF-36 bodily pain subscale , and by a mean increase of 12.4 points on the physical function subscale ( P < 0.05 ) . In a follow-up analysis within the RF lesion group , VAS pain scores improved by a mean reduction of 3.32 ( P = 0.001 ) . The scores improved by a mean increase of 14.5 points ( P = 0.005 ) on the SF-36 bodily pain subscale and 15.2 points(P = 0.002 ) on the physical function subscale within the RF lesion group . One patient in the lesion group complained of mild lower limb weakness , but he completely recovered at postoperative 15 days without any serious problems . Discussion In patients with chronic discogenic low back pain , percutaneous RF denervation of the ramus communicans nerve should be considered as a treatment option OBJECT The authors conducted a prospect i ve longitudinal study to obtain outcome ( minimum follow-up period 2 years ) regarding the safety and efficacy of single-level lumbar disc ( ProDisc prosthesis ) replacement in patients 60 years of age or older . METHODS This prospect i ve analysis involved 22 patients treated in whom the lumbar ProDisc prosthesis was used for total disc arthroplasty .  All patients presented with disabling discogenic low-back pain ( LBP ) with or without radicular pain . The involved segments ranged from L-2 to S-1 . Patients in whom there was no evidence of radiographic circumferential spinal stenosis and with minimal or no facet joint degeneration were included . Patients were assessed preoperatively and outcome was evaluated postoperatively at 3 , 6 , 12 , and 24 months by administration of st and ardized tests ( the visual analog scale [ VAS ] , Oswestry Disability Index [ ODI ] , and patient satisfaction ) . Secondary parameters included analysis of pre- and postoperative radiographic results of disc height at the affected level , adjacent-level disc height and motion , and complications . Twenty-two ( 100 % ) fulfilled all follow-up criteria . The median age of all patients was 63 years ( range 61 - 71 years ) . There were 17 single-level cases , four two-level cases , and one three-level case . Statistical improvements in VAS , ODI , and patient satisfaction scores were observed at 3 months postoperatively . These improvements were maintained at 24-month follow-up examination . Patient satisfaction rates were 94 % at 24 months ( compared with 95 % reported in a previously reported ProDisc study ) . Radicular pain also decreased significantly . Patients in whom bone mineral density was decreased underwent same-session vertebroplasty following implantation of the ProDisc device(s ) . There were two cases involving neurological deterioration : unilateral foot drop and loss of proprioception and vibration in one patient and unilateral foot drop in another patient . Both deficits occurred in patients in whom there was evidence preoperatively of circumferential spinal stenosis . There were two cases of implant subsidence and no thromboembolic phenomena . CONCLUSIONS Significant improvements in patient satisfaction and ODI scores were observed by 3 months postoperatively and these improvements were maintained at the 2-year follow-up examination . Although the authors ' early results indicate that the use of ProDisc lumbar total disc arthroplasty in patients older than 60 years of age reduces chronic LBP and improves clinical functional outcomes , they recommend the judicious use of artificial disc replacement in this age group . Until further findings are reported , the authors cautiously recommend the use of artificial disc replacement in the treatment of chronic discogenic LBP in patients older than age 60 years in whom bone quality is adequate in the absence of circumferential spinal stenosis Study Design . Double-blinded r and omized controlled trial . Objective . To test the short-term efficacy of a single intravenous ( IV ) pulse of glucocorticoids on the symptoms of acute discogenic sciatica . Summary of Background Data . The use of glucocorticoids in the treatment of acute discogenic sciatica is controversial . A potential advantage of the IV pulse therapy is the ability to distribute high glucocorticoid concentrations to the area surrounding the prolapsed disc without the risks and inconveniences of an epidural injection . Methods . Patients with acute sciatica ( < 6-week duration ) of radiologically confirmed discogenic origin were r and omized to receive either a single IV bolus of 500 mg of methylprednisolone or placebo . Clinical evaluation was performed in a double-blind manner on days 0 , 1 , 2 , 3 , 10 , and 30 . The primary outcome was reduction in sciatic leg pain during the first 3 days following the infusion ; secondary outcomes were reduction in low back pain , global pain , functional disability , and signs of radicular irritation . The analysis was performed on an intent-to-treat basis using a longitudinal regression model for repeated measures . Results . A total of 65 patients were r and omized , and 60 completed the treatment and the follow-up assessment s. A single IV bolus of glucocorticoids provided significant improvement in sciatic leg pain ( P = 0.04 ) within the first 3 days . However , the effect size was small , and the improvement did not persist . IV glucocorticoids had no effect on functional disability or clinical signs of radicular irritation . Conclusions . Although an IV bolus of glucocorticoids provides a short-term improvement in leg pain in patients with acute discogenic sciatica , its effects are transient and have small magnitude Study Design . Prospect i ve longitudinal study with a minimum 2-year follow-up . Objective . To assess the long-term outcome of a group of patients with chronic discogenic low back pain who had failed to improve with comprehensive nonoperative care and who were subsequently treated with intradiscal electrothermal therapy ( IDET ) .  Summary of Background Data . Previous reports of patient outcomes at 1 year after IDET have demonstrated statistically significant improvement . Methods . The study group comprised 58 patients with chronic symptoms of more than 6 months who failed to improve with nonoperative care and subsequently underwent IDET .  VAS pain scores , SF-36 scores , and sitting tolerance times were collected pretreatment and at 6 , 12 , and 24 months . Results . Mean duration of pre-IDET symptoms was 60.7 months . The minimum follow-up at data collection was 24 months . The study group ( n = 58 ) demonstrated a significant improvement in pain as demonstrated by statistically significant improvement in VAS scores and bodily pain SF-36 scores . The IDET-treated group demonstrated a significant improvement in physical function as noted by statistically significant improvement in sitting tolerance times and physical function SF-36 scores . Bodily pain and physical function scores demonstrated significant improvement between the 1- and 2-year observation points . Additionally , quality of life improvement was demonstrated by a statistically significant improvement in all the SF-36 subscales . Conclusions . A cohort of patients with chronic discogenic low back pain who had failed to improve with comprehensive nonoperative care demonstrated a statistically significant improvement in pain , physical function , and quality of life at 2 years after IDET Low back pain ( LBP ) poses a significant problem to society . Although initial conservative therapy may be beneficial , persisting chronic LBP still frequently leads to expensive invasive intervention . A novel non-invasive therapy that focuses on discogenic LBP is Intervertebral Differential Dynamics Therapy ® ( IDD Therapy , North American Medical Corp. Reg U.S. ) . IDD Therapy consists of intermittent traction sessions in the Accu-SPINA device ( Steadfast Corporation Ltd , Essex , UK ) , an FDA approved , class II medical device . The intervertebral disc and facet joints are unloaded through axial distraction , positioning and relaxation cycles . The purpose of this study is to investigate the effect of IDD Therapy when added to a st and ard grade d activity program for chronic LBP patients . In a single blind , single centre , r and omized controlled trial ; 60 consecutive patients were assigned to either the SHAM or the IDD Therapy . All subjects received the st and ard conservative therapeutic care ( grade d activity ) and 20 sessions in the Accu-SPINA device . The traction weight in the IDD Therapy was systematic ally increased until 50 % of a person ’s body weight plus 4.45 kg ( 10 lb ) was reached . The SHAM group received a non-therapeutic traction weight of 4.45 kg in all sessions . The main outcome was assessed using a 100-mm visual analogue scale ( VAS ) for LBP . Secondary outcomes were VAS scores for leg pain , Oswestry Disability Index ( ODI ) , Short-Form 36 ( SF-36 ) . All parameters were measured before and 2 , 6 and 14 weeks after start of the treatment . Fear of (re)injury due to movement or activities ( Tampa Scale for Kinesiophobia ) , coping strategies ( Utrecht Coping List ) and use of pain medication were recorded before and at 14 weeks . A repeated measures analysis was performed . The two groups were comparable at baseline in terms of demographic , clinical and psychological characteristics , indicating that the r and om allocation had succeeded . VAS low back pain improved significantly from 61 ( ±25 ) to 32 ( ±27 ) with the IDD protocol and 53 ( ±26 ) to 36 ( ±27 ) in the SHAM protocol . Moreover , leg pain , ODI and SF-36 scores improved significantly but in both groups . The use of pain medication decreased significantly , whereas scores for kinesiophobia and coping remained at the same non-pathological level . None of the parameters showed a difference between both protocol s. Both treatment regimes had a significant beneficial effect on LBP , leg pain , functional status and quality of life after 14 weeks . The added axial , intermittent , mechanical traction of IDD Therapy to a st and ard grade d activity program has been shown not to be effective BACKGROUND Intradiscal radiofrequency , with the electrode placed in the center of the nucleus pulposus , has been a controversial procedure in patients with discogenic pain . Possibly the effect has not been due to the production of heat , but to exposure to electric fields . DESIGN We have investigated the effect of high-voltage , long- duration intradiscal pulsed radiofrequency in patients with one-level discogenic low back pain , as confirmed by discography . OUTCOME MEASURE The pain intensity score on a 0 - 10 numeric rating scale ( NRS ) was taken as outcome measure . PATIENTS Eight patients were reported . The  mean duration of pain was 6.3 years ( range 0.5 - 16 , median 4 ) . The mean NRS score was 7.75 ( range 5 - 9 ) . Disc height was reduced 60 % in one patient and up to 30 % in the others . INTERVENTION A 15-cm , 20-gauge needle with a 15-mm active tip was placed central ly in the disc . Pulsed radiofrequency was applied for 20 min at a setting of 2 x 20 ms/s and 60 V. RESULTS There was a very significant fall in the NRS scores over the first 3 months ( P < 0.0001 ) . On an individual basis , all patients had a fall of the NRS score of at least 4 points at the 3-month follow-up . A follow-up of 12.8 months ( range 6 - 25 , median 9 ) was available for five patients . All these patients are now pain free , except for one patient with an NRS score of 2 . Conclusion . It is concluded that this method merits a controlled , prospect i ve study BACKGROUND Although the existence of a motor defect in discogenic sciatica is a sign of severity , the literature does not provide evidence for an immediate requirement for surgery . OBJECTIVE To assess the course of sciatica with discogenic paresis and to determine possible prognostic factors for recovery or improvement . STUDY DESIGN This open prospect i ve multicenter study included patients with discogenic sciatica with paresis that had been developing for less than 1 month and was rated < or =3 on a 5- grade scale .  Pain , the strength of 11 muscles , return to work , and analgesic intake were assessed at 1 , 3 , and 6 months . Recovery and improvement were defined by pain not exceeding 20 mm or < or = 50 % of the initial pain score and a score of either 5 ( recovery ) or 4 ( improvement ) for the weakest muscle at inclusion . RESULTS Sixty-seven patients were enrolled ; 39 ( 58 % ) patients were treated surgically and 28 ( 42 % ) medically . Surgically treated patients differed from medically treated patients by a higher rate of extruded herniation , a higher number of paretic muscles ( 6.3 vs. 5 ; P = 0.051 ) , and a longer course of sciatica ( 31.4 vs. 17.3 days ; P = 0.034 ) . At 6 months , 7 ( 10.4 % ) patients were lost to follow-up ; 32 ( 53.3 % ) had improved , including 18 ( 30 % ) recovered , 33 ( 85 % ) back to work and having a professional activity , and 22 ( 39 % ) still taking analgesics . The only significant difference between recovered and not recovered patients was mean age at inclusion ( 43 vs. 51 years , P = 0.034 ) . There were no significant differences between improved and not improved patients . Moreover , the outcome was not different in the two treatment groups : there were 17 ( 53 % ) improvements in surgically treated patients , including 8 ( 25 % ) recoveries , and 14 ( 56 % ) improvements in medically treated patients , including 8 ( 40 % ) recoveries . CONCLUSION This pilot study showed no difference between surgical or medical management for recovery or improvement in patients with discogenic paresis . These results need confirmation by a r and omized study & NA ; Comprised mainly of depression , anxiety , and high neuroticism , psychopathology diminishes the effectiveness of many chronic pain treatments . But , it is not known if it is associated with diminished  opioid analgesia in patients with chronic , noncancer pain . We tested the hypothesis that psychopathology diminishes  opioid analgesia  in patients with discogenic low back pain in 60 patients not on opioids  in a double blind , placebo controlled , r and om crossover design ed trial . Patients were stratified into three groups of psychological symptom severity ( LOW , MOD , and HIGH ) , based on composite scores on depression , anxiety for pain , and neuroticism scales . Subjects were given intravenous morphine ( 4–6 mg dosed by ideal body weight ) and placebo in r and om order on separate visits , and completed serial pain ratings over three hours at each session . With 20 subjects per group , there were nonsignificant differences between groups in the distribution of age , gender , baseline pain ( avg . 6.1/10 ) , radicular pain , and morphine dose ( 5.0 mg ) . For morphine analgesia , using a total pain relief calculation ( TOTPAR ) , the LOW group had 65.1 % TOTPAR vs. 41.0 % in the HIGH group , P=.026 . For placebo analgesia the LOW group had 7.7 % TOTPAR vs. 23.5 % in the HIGH group , P=.03 . A morphine minus placebo analgesia calculation revealed 59.2 % TOTPAR in the LOW group vs. 21.7 % in the HIGH group , P=.0001 . High levels of psychopathology are associated with diminished opioid analgesia in patients with discogenic low back pain . These results have implication s for the prescription of oral opioids to patients with chronic low back pain and psychopathology OBJECTIVE To compare the incidence of pain relief following injection of local anesthetic ( LA ) into lumbar discs that caused concordant pain during provocation testing . DESIGN Prospect i ve collected data review from two centers and compare with published results . OUTCOME MEASURES We compared subjective reported pain relief following provocative testing using the following protocol s at three separate facilities : 23 patients undergoing routine provocative discography using contrast alone ( PD ) ; 47 patients undergoing provocative discography performed using an equal combination of LA and contrast ( CPD ) ; 120 patients injected with LA following routine PD ( ADPD ) ; 33 patients undergoing st and -alone analgesic discography ( SAAD ) ; and 28 patients injected with LA through a catheter ( FAD ) placed during provocative discogaphy testing . RESULTS Pressure-controlled PD showed a positive response rate of 34 % per disc in patients with a clinical diagnosis of discogenic pain . None of the PD group without LA had pain relief and less than 10 % of the CPD group reported pain relief . Forty percent of the SAAD group with positive pain reproduction reported ≥50 % relief and 20 % reporting ≥80 % relief . Forty-six percent of the ADPD group reported ≥50 % relief and 30 % reporting ≥80 % relief . The FAD group had a greater 80 % patients reporting ≥50 % pain relief although fewer 26 % reporting more convincing ≥80 % relief . CONCLUSIONS If the criterion st and ard to confirm painful annular tears is concordant pain provocation and 80 % or greater pain relief following LA injected into lumbar discs , the SAAD , ADPD , and FAD protocol s show statistically similar 20 % to 30 % prevelance OBJECTIVE There is no consensus on the treatment of chronic low back pain of disc origin in the medical literature . The few prospect i ve , r and omized , controlled studies evaluating the effectiveness of caudal epidural steroid injections ( CESI ) have obtained contradictory results . The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability . MATERIAL AND METHOD This is a prospect i ve , r and omized , case-control study of a group of 46 patients with chronic low back disc pain . Patients were r and omly allocated into 2 groups to either receive fluoroscopy guided CESI ( CESI-group ) , or oral non-steroidal anti-inflammatory drugs ( NSAID-group ) . All patients were clinical ly evaluated at 4 , 12 , and 24 weeks , and according to the indications of the Spanish Society for Study of Diseases of the Spine ( GEER ) . RESULTS Lumbar pain , measured by the visual analog scale ( VAS ) and the Oswestry Low Back Pain Disability Question naire ( ODQ ) , did not improve significantly during follow-up in any of the two study groups ( P>.05 ) . Younger patients , women , patients with shorter duration of symptoms , low physical job dem and , without leg pain , and sport-active , included in CESI-group showed a trend towards better results , but none reached statistical significance ( P>.05 ) . CONCLUSIONS The present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disc origin . While CESI could show some improvement in patients with degenerative lumbar disc disease , we consider it should be used with caution , informing patients about realistic expectations on the success of treatment Acquired degenerative disc disease causes gradual disc space collapse , concurrent discogenic or facet-induced pain , and possible compression radiculopathy . Surgical treatment aims to re-exp and the intervertebral space and stabilize the involved segment in balanced alignment until fusion is complete . The prevailing methods make use of a twin cage device of predetermined size . Their implantation requires extensive exposure , entailing the sacrifice of posterior stabilizing structures . The procedure also results in significant traction on the dural sac and the cauda equina and is thereby a potential source of neurologic damage . The new exp and able spinal spacer ( ESS ) was design ed to mitigate all the shortcomings alluded to above . A prospect i ve multicenter clinical study was conducted of 87 patients with chronic low back pain due to degenerative disc disease , treated by posterior lumbar interbody fusion ( PLIF ) using a newly design ed ESS . The study protocol was approved by the ethics committees of all the participating institutions . The objective was to test the safety and efficacy of the device . Each participant was followed periodically for > 1 postoperative year . The ongoing record included intraoperative difficulties and complications , if any , radiologic evidence of fusion and clinical outcome as scored by pre- and postoperative question naires pertaining to pain intensity and degree of disability . No dural lacerations or neurologic deficit occurred . There were no mechanical failures of the spacer . Radiologic study demonstrated fusion in all but one patient . Disc space height that averaged 7.53 ± 2.42 mm before surgery increased to 10.03 ± 2.00 mm at the time of surgery and stabilized at 9.47 ± 2.10 mm upon final follow-up . Visual Analog Scale and Oswestry Index decreased by 60 % and 58 % , respectively . PLIF using the ESS achieves the same ultimate outcome as do other methods currently in use but does not share the h and icaps and hazards and is more user-friendly to the surgeon BACKGROUND This study 's goal was a retrospective chart audit of 100 out patients with discogenic low back pain ( LBP ) lasting more than 12 weeks treated with a 2-month course of motorized spinal decompression via the DRX9000 ( Axiom Worldwide , Tampa , FL , U.S.A. ) . METHODS Patients at a convenience sample of four clinics received 30-minute DRX9000 sessions daily for the first 2 weeks tapering to 1 session/week . Treatment protocol included lumbar stretching , myofascial release , or heat prior to treatment , with ice and /or muscle stimulation afterwards . Primary outcome was verbal numerical pain intensity rating ( NRS ) 0 to 10 before and after the 8-week treatment . RESULTS Of the 100 initial subjects , three withdrew their protected health information , and three were excluded because their LBP duration was less than 12 weeks . The remaining 94 subjects ( 63 % female , 95 % white , age = 55 ( SD 16 ) year , 52 % employed , 41 % retired , LBP median duration of 260 weeks ) had diagnoses of herniated disc ( 73 % of patients ) , degenerative disc disease ( 68 % ) , or both ( 27 % ) . Mean NRS equaled 6.05 ( SD 2.3 ) at presentation and decreased significantly to 0.89 ( SD 1.15 ) at end of 8-week treatment ( P < 0.0001 ) . Analgesic use also appeared to decrease ( charts with data = 20 ) and Activities of Daily Living improved ( charts with data = 38 ) . Follow-up ( mean 31 weeks ) on 29/94 patients reported mean 83 % LBP improvement , NRS of 1.7 ( SD 1.15 ) , and satisfaction of 8.55/10 ( median 9 ) . CONCLUSIONS This retrospective chart audit provides preliminary data that chronic LBP may improve with DRX9000 spinal decompression . R and omized double-blind trials are needed to measure the efficacy of such systems Study Design . Prospect i ve nonr and omized clinical series . Objectives . To evaluate the efficacy of ProDisc lumbar artificial disc replacement ( ADR ) in smokers versus nonsmokers . Summary of Background Data . Smoking is a negative predictor in fusion surgery . To date , a prospect i ve study of the treatment of incapacitating discogenic low back pain using ADR in smokers versus nonsmokers has not been described . Methods . A prospect i ve analysis was performed on 104 patients with disabling discogenic low back pain treated with single-level lumbar ProDisc total disc arthroplasty . Smokers and nonsmokers were assessed before surgery and after surgery using patient satisfaction , Oswestry , and Visual Analog Scores . Additionally , preoperative and postoperative neurologic , radiographic , and pain medication assessment s were performed at similar postoperative intervals . Results . Oswestry , Visual Analog Scores , and patient satisfaction scores revealed statistical improvement beginning 3 months after surgery and were maintained at minimum 2-year follow-up . Patient satisfaction scores were higher in smokers ( 94 % ) than in nonsmokers ( 87 % ) at 2-year follow-up ( P = 0.07 ) . Radiographic analysis revealed an affected disc height increase from 4 mm to 13 mm ( P < 0.05 ) and an affected disc motion from 3 ° to 7 ° ( P < 0.05 ) . No cases of loosening , dislodgment , mechanical failure , infection , or fusion of the affected segment occurred . Conclusions . The results of our study indicate that smokers do equally well compared with nonsmokers  when ProDisc ADR is used in the treatment of debilitating lumbar spondylosis . Patient outcome and radiographic scores showed significant improvement compared with preoperative levels . Although not evident in our series , additional surveillance for intraoperative and postoperative vascular spasm and occlusion may be warranted in smokers In this study two strategies in the treatment of Mechanical Spinal Discogenic Pain have been compared : Disc Coablation and Epidural Injection of Steroids . In 2003 50 patients treated with one or two epidural injections have been selected " ad r and om " and 50 patients treated with disc coablation .  Comparison of the data indicated an improvement of average VAS when relaxed for both groups ( p < 0.01 ) , while after slight-moderate strain , this value was significant only after coablation ( p < 0.001 ) . Finally , average VAS was clearly lower ( p < 0.01 ) after coablation as compared to epidural injections
RESULTS The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain .
Our findings show that suspected discogenic pain , despite its extensive affirmation in the literature and enormous re sources regularly devoted to it , currently lacks clear diagnostic criteria and uniform treatment or terminology
BACKGROUND CONTEXT Pain innate to intervertebral disc , often referred to as discogenic pain , is suspected by some authors to be the major source of chronic low back and neck pain .
Current management of suspected discogenic pain lacks st and ardized diagnosis , treatment , and terminology .
PURPOSE In an attempt to determine whether patterns existed that may facilitate st and ardization of care , we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain .