106 assigned to receive either Depomedrol (80 mg/ml) or Bupivicaine (Marcaine) (1.5 ml) and were re-evaluated 10–14 days after the injection. To measure the clinical response, a pain diagram grid score, a visual analog scale, and the Oswestry Pain questionnaire were used before injection and after 10–14 days. Patients with objective signiﬁcant improvement were entered into the appropriate rehabilitation program, and conservative care was continued. Patients who reported no improvement were considered clinical failures and offered surgery when indicated. Of the 25 patients studied, 14 received intradiscal Depomedrol and 11 received intradiscal Bupivicaine. In the Depomedrol group, 21% showed subjective improvement and 79% showed no improvement. In the Marcaine group, 9% showed clinical improvement and 91% showed no improvement. They concluded that there was no statisti- cally signiﬁcant beneﬁt in using intradiscal steroids. Khot et al. [7] performed a prospective randomized trial comparing intradiscal steroids to placebo in patients with lumbar discogenic pain. A total of 120 patients with chronic discogenic low back pain who failed at least 6 weeks of conservative care were randomized at the time of discog- raphy to either an injection of normal saline or methylpred- nisolone into the disc space. The patients were followed for 12 months and were asked to report their pain according to a visual analog scale (VAS) and Oswestry Disability Index. The primary outcome measure was the percentage change in their disability. They found that there was no signiﬁcant difference in the outcome between the two groups as the steroid group had a mean change of 2.28% disability, while the saline group had a mean percentage change of 3.42. Also, with respect to pain scores, there was no signiﬁcant difference. The results of these two recent studies suggest that intradiscal steroid injections do not improve clinical out- comes in patients with discogenic back pain. MRI changes after steroid injection There have been several studies which suggest that a patient’s clinical response to intradiscal steroids can be predicted from their ﬁndings on MRI (i.e., Modic changes). Modic changes on MRI were originally described by Modic in 1988 [24]. MRI type 1 Modic changes are decreased signal on T1, increased on T2, usually represent marrow edema, and are associated with an acute process. Type 2 changes, the most common type, are deﬁned as increased signal on T1 and isointense or slightly hyperintense signal on T2. They represent fatty degeneration of subchon- dral marrow and are associated with a chronic process. Type 3 changes represent decreased signal on both T1 and T2. It correlates with bony sclerosis (no marrow) on radiographs. Curr Rev Musculoskelet Med (2008) 1:103–107 Mayahi et al. [25] sought to determine whether clinical outcome of patients with discogenic back pain who underwent intradiscal steroid injections could be predicted from MRI Modic changes. Six months after an intradiscal steroid injection, clinical outcomes were measured using visual analog scale and Oswestry disability index. They observed that in patients with Modic 1 vertebral end-plate changes, there was sig- niﬁcant relief in 64% of patients and moderate relief in 29%. In those with Modic 2 changes, there was signiﬁcant relief in 27% and moderate relief in 27%. In patients with no Modic changes, there was improvement of low back pain in only 9%. They concluded that patients with Modic 1 changes on MRI are most likely to beneﬁt from intradi- scal steroid injections. Bull et al. [26] studied the imaging of 125 patients who had undergone discography and intradiscal steroid injec- tions for low back pain. They were divided into Non-Modic (61 patients), Type 1 Modic changes (20 patients), and Type 2 Modic changes (24 patients). At 8 weeks post- injection, the patients were assessed and classiﬁed as bet- ter, the same, or worse. ‘‘Better’’ was deﬁned as complete resolution of symptoms, or signiﬁcant reduction that allowed return to normal activities. In the Non-Modic group, 8 of 61 patients (13%) had improved. In comparison, in the Type 1 Modic group, 4 of the 20 patients (20%) improved and in the type 2 Modic group, 13 of the 24 patients (54%) were better. From these results, the authors concluded that many patients with Type 2 Modic changes on MRI, may have a chronic inﬂamma- tory process which responds well to steroid injections. More recently, Buttermann [27] studied the effect of epi- dural and intradiscal steroid injections in patients with degenerative disc disease (DDD), in an attempt to determine whether patients with inﬂammatory end-plate changes on MRI would respond more favorably to treatment. Epidural steroid injections (ESI) were performed in 93 patients with degenerative disc disease and inﬂammatory end-plate changes, and in 139 patients without inﬂamma- tory end-plate changes. Additionally, patients with end- plate changes (78) and those without changes (93), who were considered candidates for lumbar fusion underwent discography and were randomized as to whether they received intradiscal steroids. Pain and function were pro- spectively determined by a self-administered outcomes questionnaire that consisted of a visual analog scale, pain drawing, Oswestry Disability Index (ODI), and the patients’ opinion regarding treatment success. They were measured before and after the patients’ injection for a 2-year follow- up period. The authors found that patients with inﬂammatory end- plate changes had greater improvement in the ODI and pain diagram in the ﬁrst 6 months than those without end-plate