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
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
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 .