Curr Rev Musculoskelet Med (2008) 1:103–107 Earlier trials In 1954, Feffer et al. [9] injected hydrocortisone into the intervertebral discs of 244 patients and followed them for 4–10 years. The population included both patients with and without neurologic deﬁcits, who were deemed good surgical candidates after receiving ‘‘extensive con- servative care’’. In most of the cases, discograms were performed by a posterolateral approach in which two interspaces were injected with 25 mg of hydrocortisone. The author attempted to correlate the level treated with the clinical picture. Patients who responded favorably to the injections were placed on a regimen of Williams-type ﬂexion exercises. Most of those who did not respond underwent a laminectomy. The authors found that 114 of the 244 patients (46.7%) obtained permanent remission from the hydrocortisone injection. One hundred and thirty patients (53.3%) either did not respond to the injection initially or relapsed. In this study, although no single factor appeared to designate a speciﬁcally favorable outcome, older patients (greater than 30 years), patients whose pain was primarily in the back rather than radicular, and those with limited degenerative changes, had the best prognosis. Additionally, the patients’ responses could not be predicted from the character or duration of pain. The only complication noted was one case of interspace infection, which without surgery progressed to an asymp- tomatic interbody fusion, suggesting faulty sterilization. However, 2-year follow-up roentgenograms were obtained and found ‘‘no unusual narrowing or acceleration of the degenerative process.’’ Wilkinson et al. [20] performed 45 intradiscal injections on 29 patients with lumbar disc disease. Ten of the patients had back pain radiating to the legs and 19 had nonradiating pain. All of the patients had symptoms for a minimum of 6 months, despite aggressive noninvasive therapy. None of the patients were surgical candidates because they had no objective neurological deﬁcits and many had atypical pat- terns of pain. All patients underwent discography at the time of intradiscal therapy and nearly all of them were abnormal. The discogram abnormalities were generally conﬁned to a single level and correlated closely with the degenerative changes seen on plain ﬁlm. Early in the series, eight injections were done using 30–40 mg of Depomedrol. Subsequently, all intradiscal injections were done with 60– 80 mg of Depomedrol. All of the patients were followed for a minimum of 1 year, with an average follow-up period of 2.4 years. The authors found that in the group of patients with discogenic pain, 54% responded poorly and only 31% had good results lasting for more than 3 months. In 1960, Leao et al. [21] studied 32 patients aged 18–70, with low back and sciatic pain who failed conservative 105 therapy (rest, lumbosacral corset, and analgesics). Sixteen of the patients received intradiscal hydrocortisone and the remaining received intradiscal prednisolone. The dose of steroid varied from 20–50 mg, but the ideal dose was 25 mg. The authors measured the patients’ response after 24 and 72 h in both groups as well as after 1 year in the hydrocortisone group. They found that intradiscal steroids produced beneﬁcial results in more than half the patients and that there is no signiﬁcant difference between intradi- scal hydrocortisone and prednisolone. In 1975, Graham [22] reported a double blind study comparing chemonucleolysis by chymopapain with intra- discal hydrocortisone in a small group of 40 patients who had chronic back pain and sciatica for several years and had failed conservative therapy. Twenty patients were given intradiscal chymopapain injections and 20 were given intradiscal hydrocortisone. The patients were followed for 7 months and then either evaluated by a surgeon who was blinded to the patients’ treatment or via questionnaire. Twelve of the 20 patients (60%) receiving chymopapain injections had ‘‘fair to good’’ results after 7 months, and 10 of the 19 patients (53%) who received hydrocortisone had similar results. They found that chymopapain was not signiﬁcantly superior to intradiscal injections of hydrocortisone. This study attempted to prove the superiority of chy- mopapain over steroids. The authors felt that was unethical to inject placebo (saline) into the disc. Graham concluded ‘‘when one is considering the problem of a long-term back sufferer, it is my ﬁrm belief that if half of the patients who are subjected to intradiscal injection report back after 7 months and the result has been good, it is certainly a worthwhile procedure [22].’’ Although the above studies show that intradiscal ste- roids may be beneﬁcial when used in select patient populations, they are merely case series and lack an ade- quate control group. Also, due to their small sample sizes, only limited conclusions may be drawn. More recent studies Due to the lack of objective scientiﬁc data in the above studies, more recent trials were done in order to compare intradiscal steroids to intradiscal placebo injections. In 1992, Simmons et al. [23] performed a randomized double blind study to evaluate the efﬁcacy of intradiscal steroid injections when compared with placebo (Bupivicaine). All of the patients selected had only one level disc involvement with or without sciatica and a positive pain response on discography. They all had failed 6 weeks of conservative treatment. Exclusion criteria were multilevel discs, central or lateral stenosis, prior lumbar surgery, or medical disease requiring steroids. A total of 25 patients were randomly