What is More Effective Treatment Option for Discogenic Low Back Pain -Thermocoagulation or Nonoperative Treatment?: A Systematic Review and Meta-analysis

Abstract

Study Design Systematic review and meta-analysis of randomized controlled trials, case control and cohort studies. Introduction To evaluate the current evidence comparing Thermo-coagulation intradiscal techniques to nonoperative treatment options for the treatment of chronic Discogenic low back pain. Discogenic low back pain is a common disabling condition and major health care concern. However, it has been controversial in diagnosis and treatment. Methods We searched PubMed, EMBASE, Cochrane Library, KoreaMed and Korean Medical database (KMbase) to find out clinical studies for evaluating the effectiveness of Radiofrequency and Intradiscal electrothermal therapy for the treatment of Discogenic low back pain which were published until June 2015. Randomized controlled trials, case control and cohort studies comparing Thermo-coagulation intradiscal techniques with nonoperative treatment options were selected. Duplicate citations were removed and a total of 13,464 articles were acquired, from which 6 articles were identified for meta-analysis. Results A total of 6 citations were found and screened to determine if they would meet our inclusion criteria. Finally, 4 randomized controlled trials and 1 case-control and 1 cohort study comparing the effectiveness of thermo-coagulation and nonoperative treatment options were selected for meta-analysis and risk of bias was evaluated as assessed in accordance to guidelines following the Cochrane Collaboration's tool for assessing risk of bias in randomized trials and Newcastle-Ottawa Scale (case control and cohort studies). In meta-analysis, clinical outcomes such as Visual Analogue Scale, Oswestry Disability Index and Short Form-36 (physical functioning and bodily pain) values were evaluated and the forest plot provided a visual representation of each study and all studies combined with individual confidence intervals. Based on meta-analysis, the pooled mean difference in Visual Analogue Scale (pre – post outcomes) between the thermo-coagulation and nonoperative treatment options in all 3 randomized controlled trials, 1 case control and 1 cohort study was 2.44 points (95% confidence interval: 1.01, 3.88, p = 0.0009) in favor of thermo-coagulation procedures within 7.8 month mean follow-up periods. However, within 3 months after treatments, there was no statistically significant difference in the two treatment options. In the outcomes of meta-analysis after 3 months of treatment, thermo-coagulation procedures showed to be more favorable with MD = 2.88 points (95% confidence interval: 1.05, 4.71, p = 0.002) In Oswestry Disability Index, the pooled mean difference (pre – post outcomes) was 2.86 points (95% confidence interval: -2.40, 8.13) in favor of thermo-coagulation procedures which was not statistically significant ( p = 0.29) with 4.7 month mean follow-up periods. However, thermo-coagulation procedures were more favorable with MD = 5.10 points (95% confidence interval: 0.44, 9.76, p = 0.03) only in the outcomes of meta-analysis after 6 months of treatment. The pooled mean difference (post – pre outcomes) in Short Form-36 including physical functioning and bodily pain was 7.55 points (95% confidence interval: -0.69, 15.80) and 6.47 points (95% confidence interval: -1.09, 14.04) in favor of thermo-coagulation procedures, however, they were not statistically significant ( p = 0.07 and p = 0.09) with 5.3 month mean follow-up periods, respectively. Conclusion It was demonstrated from this systematic review and meta-analysis that the two treatment options had no statistically significant difference in Visual Analogue Scale scores within 3 months after treatments for the patients with discogenic low back pain, however, thermo-coagulation therapies showed a statistically significant favorable effect after 3months. In Oswestry Disability Index, there was a statistically significant favorable outcome only after 6 months of treatment. Short Form-36 (physical functioning and bodily pain), it failed to find significant differences between the two treatment options despite more favorable outcomes in thermo-coagulation therapies.