Lumbar Discogenic Pain Research Articles

Intradiscal Biacuplasty (IDB) for the Treatment of Thoracic Discogenic Pain

Discogenic pain in the thoracic region is a challenging condition characterized by refractoriness to conservative treatments. Unlike lumbar discogenic pain there is a lack of effective surgical options. Reported here is the treatment of thoracic discogenic pain in 3 patients using a new minimally invasive procedure named intradiscal biacuplasty. Clinical case series in outpatient clinical setting. The procedure is detailed and step-by-step fluoroscopic imaging is presented. No intraoperative and postoperative complications were reported. Improvements in functional capacity and pain scores were noted in 2 patients. Visual analog scale pain scores changed from 10 to 2 cm and 7 to 3 cm in 2 patients who claimed improvements at 12 months follow-up. In patient 1 visual analog scale went from 7 to 8 cm claiming no improvements after the procedure. In patients 1 and 3, Oswestry Disability Index improved from 24 to 8 and 10 points, respectively, and SF-36 physical function score changed from 55 to 80 and 45 to 82, respectively. The patient 2 showed no improvements with Oswestry (28 to 32) and SF-36 physical function score (50 to 45) at 12 months after intradiscal biacuplasty. Patient 1 stopped using his oxycodone/acetaminophen 5/325 mg that he used previously at 6 tablets a day, patient 3 decreased use of his duragesic patch from 75 microg/h to 25 microg/h. Patient 2 continued with significant use of opioids (100 microg/h of transdermal fentanyl). Cooled, bipolar radiofrequency may be an effective and readily available treatment for thoracic discogenic pain if future comparison studies show benefits of such procedure.

Intradiscal electrothermal therapy for symptomatic internal disc disruption: 24-month results and predictors of clinical success

Degeneration of the intervertebral disc can be the source of severe low-back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption unresponsive to conservative medical care. This study was undertaken in the neurosurgical setting to evaluate 24-month pain and functional outcomes and predictors of clinical success in patients with discogenic back pain treated with IDET. Using MR imaging and discography findings, 50 patients with lumbar discogenic pain were identified, underwent IDET treatment, and were followed up for 24 months. Outcomes included assessments of back pain severity based on an 11-point numeric scale and back function based on the Oswestry Disability Index. The Prolo scale was applied to determine economic and functional status at 24 months. There was an average 68 and 66% improvement in back pain and function, respectively, between pretreatment and 24 months after treatment (p < 0.0001 for both comparisons). A maximum score of 5 on the Prolo scale for economic and functional status was achieved in 63 and 22% of patients, respectively. The global clinical success rate was 78% (39 of 50 patients) based on no reoperations at the affected level due to persistent symptoms, with a >or= 2-point improvement in pain severity and a >or= 15-point improvement in back function. Predictors of 24-month clinical success included discographic concordance (p < 0.0001), a high-intensity zone on MR imaging (p = 0.0003), low Pfirrmann grade (p = 0.0002), and more extensive anulus coverage (p < 0.0001). There were no procedure-related adverse events. The findings of this study suggest that durable clinical improvements can be realized after IDET in highly select surgical candidates with mild disc degeneration, confirmatory imaging evidence of anular disruption, and highly concordant pain provocation on low-pressure discography.

Transforaminal epidural steroid injection via a preganglionic approach for lumbar spinal stenosis and lumbar discogenic pain with radiculopathy

Epidural steroid injection (ESIs) is one of the treatment modalities for chronic low back pain (CLBP) with various degrees of success. We analyzed the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESIs) via a preganglionic approach in patients with foraminal stenosis due to lumbar spinal stenosis and lumbar discogenic pain with radiculopathy. We analyzed the data of 40 patients (February 2008 and April 2009) with the diagnosis of CLBP and treated by fluoroscopically guided TFESIs via a preganglionic approach. Patients were followed-up at one month (short term), six months (midterm) and one year (long term) after injections. Follow-up data collection included the Visual Numeric Pain Scale (VNS) and North American Spine Society (NASS) patient satisfaction scores. The mean age of the patients was 59.87 +/- 15.06 years (range 30 - 89 years, 25 women). Average follow-up period was 9.22 +/- 3.56 months. Statistically significant differences were observed between the pre-procedure and post-procedure VNSs (P < 0.01, Pearson Correlation Test). Improvements in VNS scores were correlated with improvements in the NASS scores. When the VNS scores were evaluated with respect to the age of patient, level numbers, gender, pre-procedure symptom duration and pre-procedure VNS, no significant differences were found (P < 0.05, linear regression test). At short term evaluation in post treatment (one month), 77.78 % of patients were found to have a successful outcome and 22.22 % were deemed failures. Overall patient satisfaction was 67.23 % in the midterm period. Additionally, 54.83 % of patients (N/n: 15/8) had a successful long-term outcome at a follow-up of one year. Our data suggest that fluoroscopically guided TFESIs via a preganglionic approach, in patients with foraminal stenosis due to lumbar spinal stenosis and lumbar discogenic pain with radiculopathy, has effective outcome and patients responding to injection have significantly lower post-injection pain scores.

いわゆる ｢MRI時代｣ における腰部椎間板造影の必要性について

Object : Assessment of the usefulness of discography for correct diagnosis of lumbar discogenic pain and determination of causative disc levels.

Primary investigation of clinical application of percutaneous posterior lumbar interbody fusion

Objective To characterize the feasibility, key technology, indications and clinical outcome of percutaneous lumbar interbody fusion. Methods Clinical data from 32 cases [16 made, 16 female, age range 31-77 years, average disease duration (5.0±2.0) years ] underwent percutaneous nucleotomy and endplate curettage was retrospectively analyzed. After percutaneous nucleotomy and endplate curettage, one expandable spinal spacer B-twin was introduced into the intervertebral space and some allograft cancellous bone implanted around the B-twin. Indications for treatment included degenerative lumbar disc herniation (LDH) with intervetebral distability or Ⅰ degree spondylolythesis (21 cases), LDH with intervetebral space collapse (10 cases) and lumbar discogenic pain (1 case). The symptoms and function of all patients were evaluated before, 3 months and 12 months after the operation by clinical outcome judgment criterion of surgical treatment for low back pain formulated by JOA, and the rate of clinical improvement and treatment efficacy were calculated. The JOA scales preoperatively, postoperatively and on the final follow-up was compared using ANOVA in SPSS. The changes before and after surgery with the JOA score and the the rate of clinical improvement between 3 months and 12 months after the operation was also compared using χ2 test. Results The average operation time 1 hour and blood loss 0.05). Conclusions Percutaneous posterior lumbar interbody fusion with B-twin expandable fusion cage could lead to satisfactory outcome in the treatment of degenerative disc disease and intervertebral instability,which minimize surgical soft tissue and trauma spinal damage, does not destroy the structure of spinal stability. The technique The long-term outcome, complications and fusion rate need further observing. Key words: Spondylolisthesis; Spinal fusion; Lumbar vertebrae; Radiology,interventional

Mini-invasive extraperitoneal approach for anterior lumbar surgery

To study a mini-invasive extraperitoneal approach to lumbar spine and discuss its exposure technique, complications and management. Anterior lumbar surgery was performed in 52 patients via the mini-invasive anterior extraperitoneal approach. Diagnoses included lumbar degenerative instability (n=23), discogenic lumbar pain (n=25), lumbosacral congenital deformity (n=2) and revision after posterior laminectomy & discectomy (n=2). The patients underwent anterior lumbar interbody fusion (n=32) and total disk replacement (n=20). The operated disks included L(4-5) and L5-S1. There were single level (n=47) and double level (n=5). Operation time, blood loss, perioperative complications, postoperative bed-leaving time, incision length, pain of abdomen incision and postoperative hospitalization duration were recorded in details. All cases were exposed clearly and no one needed to prolong incision or change operation for an insufficient exposure. Average operation time was 85 min, average blood loss 155 ml, average postoperative bed-leaving time 3 days and average incision length 6.5 cm. All cases felt very little pain of abdominal incision and postoperative hospitalization duration was 7-10 days. Perioperative complications included vena cava tear (n=1), peritoneum tear (n=2), postoperative abdominal distention (n=3) and postoperative fever (n=5). No retrograde ejaculation was found in all male cases. The technique of mini-invasive extraperitoneal approach to anterior lumbar has such multiple advantages as fewer complications, less trauma, excellent exposure to anterior vertebrae and disk and without destruction of posterior spinal component

Systematic Review of Lumbar Discography as a Diagnostic Test for Chronic Low Back Pain

The intervertebral disc has been implicated as an etiology of chronic lumbar spine pain based on clinical, basic science, and epidemiological research. However, there is lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, the lumbar intervertebral discs have been shown to be sources of chronic back pain without disc herniation in 26% to 39%. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, controversy continues about provocation lumbar discography. A systematic review of the lumbar provocation discography literature. To systematically assess the diagnostic accuracy of lumbar discography. A systematic review of the literature was performed to assess the diagnostic accuracy of lumbar discography with respect to chronic low back pain. Study inclusion/exclusion criteria were based on International Association for the Study of Pain (IASP) standards with pain provocation and determination of controlled discs. Selected studies were then subjected to a rating instrument for diagnostic accuracy studies. Specific data were then culled from these studies and tabulated. Quality of evidence was assessed using modified Agency for Healthcare Research and Quality (AHRQ) diagnostic accuracy evaluation. Studies meeting methodologic quality criteria scores of 50 or higher were included in the assessment of the level of evidence. Qualitative analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. The rating scheme was modified to evaluate the diagnostic accuracy. Based on a modified U.S. Preventive Services Task Force (USPSTF) level of evidence criteria, this systematic review indicates the strength of evidence as Level II-2 for the diagnostic accuracy of lumbar provocation discography utilizing IASP criteria. Limitations include a paucity of literature, poor methodologic quality, and very few studies performed utilizing IASP criteria. Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders.

Successful Treatment of Lumbar Discogenic Pain Using Intradiscal Biacuplasty in Previously Discectomized Disc

Discogenic back pain is frequently present in patients after discectomy. Here, we describe a case of young woman, previously discectomized, who was treated by a novel annuloplasty procedure, intradiscal biacuplasty (IDB). The improvement in functional capacity and pain scores were profound 12 months after the IDB. Visual analog pain scores (0-10) changed from 5 to 3. Oswestry scale showed functional improvement from 52%, or severe disability, to 14%, or minimal disability, and the SF-36 physical function scale score changed from 55 to 95. IDB may be an effective treatment for patients with discogenic pain from previously discectomized discs.

Therapeutic Effect of "SHU JI FANG" in Treating Lumbar discogenic Low Back Pain

Objective To explore the curative effect of the traditional Chinese medicineSHU JI FANGin treating lumbar discogenic low back Pain(DLBP).Methods 156 cases were divided into three groups by random with 52 cases in each group.A treatment group was treated by traditional Chinese medicineSHU JI FANG.A control group 1 was treated by Bextra;A control group 2 was treated bv Chinese traditional medicine Zuogui pill.Results The difiererlce of cure rate and the excellent rate between the treatment group and the control group I did not show significance by X2 check,with P＞0.05;while the difference between the treatment Group and the Control group 2 showed significance by X2 check with P＜0.05.Conclusion ISHU JI FANGis effective in treating discogenic low back pain. Key words: SHU JI FANG; Discogenic low back pain; Clinical study

Systematic Review of Caudal Epidural Injections in the Management of Chronic Low Back Pain

Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of caudal epidural injections in various conditions - disc herniation and radiculitis, post-lumbar laminectomy syndrome, spinal stenosis, and chronic low back pain of disc origin without disc herniation or radiculitis. A systematic review of caudal epidural injections with or without steroids in managing chronic pain secondary to lumbar disc herniation or radiculitis, post lumbar laminectomy syndrome, spinal stenosis, and discogenic pain without disc herniation or radiculitis. To evaluate the effect of caudal epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, post-lumbar laminectomy syndrome, spinal stenosis, and chronic discogenic pain. A review of the literature was performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > or = 6 months). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were utilized. The evidence showed Level I for short- and long-term relief in managing chronic low back and lower extremity pain secondary to lumbar disc herniation and/or radiculitis and discogenic pain without disc herniation or radiculitis. The indicated evidence is Level II-1 or II-2 for caudal epidural injections in managing low back pain of post-lumbar laminectomy syndrome and spinal stenosis. The limitations of this study include the paucity of literature, specifically for chronic pain without disc herniation. This systematic review shows Level I evidence for relief of chronic pain secondary to disc herniation or radiculitis and discogenic pain without disc herniation or radiculitis. Further, the indicated evidence is Level II-1 or II-2 for caudal epidural injections in managing chronic pain of post lumbar laminectomy syndrome and spinal stenosis.

Discogentic lumbar pain: association with MRI and discography

Objective To evaluate the correlation between MRI and X-Ray discography findings and pain response at provocative discography in patients with discogenic back pain. Methods Two hundred and fifty-six lumbar intervertebral discs in 93 patients who underwent MRI and X-Ray discography were included in this study. MR images were retrospectively evaluated regarding disc degeneration, endplate abnormalities and high intensity zone. Disc degeneration was graded according to the modified criteria of Pearce, et el. Evaluation of disc morphology was performed with X-Ray discography by using the classification of Adams, et al. Endplates and adjacent bone marrow abnormalities were classified according to Modic,et al. During discography concordant pain was regarded as positive, whereas discordant pain and no pain were regarded as negative. The data were analyzed using the Chi-squnre test. Results There were 116 discs with concordant pain and 140 discs with discordant pain or no pain. Of 256 discs on discography, 17 discs were type Ⅰ17(6.6%),type Ⅱ were 25(9.8%),type Ⅲ were 91(35.5%), type Ⅳ were 77(30.1%) and type Ⅴ were 46(18.0% ). On MR images, discs of grade Ⅰ were 23 (9.0%) ,grade Ⅱ were 34(13.3%), grade Ⅲ were 84(32.8%), grade Ⅳ were 85 (33.2%) and grade Ⅴ were 30(11.7%). There was positive correlation between Pearce graded of MRI and classification of Adams of discography (r=0.62, X2 =160.87,P <0.01).In 123 discs of type Ⅳ to type Ⅴ on discography, 104 discs were with concordant pain. There was positive correlation between type Ⅳ-Ⅴ and concordant pain( r=0.60, X2 = 144.08, P < 0.01). In 115 discs of Ⅳ-Ⅴ grade degeneration, 99 discs presented with concordant pain. There was positive correlation between Ⅳ-Ⅴ grade disc degeneration and concordant作者单位:510120 广州,中山大学附属第二医院放射科 pain(r = 0.59, X2 = 137.11, P <0.01 ). In 60 discs with high intensity zone(HIZ), 52 discs presented with concordant pain. There was positive correlation between HIZ and concordant pain ( r=0.41, X2= 51.93, P <0.01 ). In 58 discs with endplate degeneration, 51 presented with concordant pain. There was positive correlation between Modic degeneration and concordant pain ( r = 0.41, X2= 52.76, P < 0.01 ). Conclusion In patients with chronic low back pain, MR imaging may present moderate to severe disc degeneration, high intensity zone, endplates and adjacent bone marrow abnormalities. MR findings with concordant pain can raise the diagnostic possibility of discogenic lumbar pain. Typical discography findings, fissured or ruptured disc, with concordant pain are important diagnostic evidence for discogenic lumbar pain. Key words: Arthrography; Intervertebral disk; Magnetic resonance imaging; Low back pain

Intradiscal Electrothermal Therapy (IDET) Provides Effective Symptom Relief in Patients With Discogenic Low Back Pain

Single-arm, prospective clinical trial. 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). 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. 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 assessments of back pain severity by visual analog scale, sitting, standing, and walking tolerances, and health-related quality of life using the SF-36. 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, standing, 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 >or=2-point improvement in pain severity or a >or=10-point improvement in either the physical functioning or bodily pain domain of the SF-36. 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.

Intervertebral Disc Biacuplasty for the Treatment of Lumbar Discogenic Pain: Results of a Six-Month Follow-Up

Intradiscal biacuplasty (IDB) is a novel bipolar cooled radiofrequency system for the treatment of degenerative disk disease. We present the results of a pilot trial with 6-month follow-up. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: Fifteen patients, 22-55 years old, underwent one- or two-level IDB treatment of their painful lumbar discs. All had chronic low back pain >6 months, back pain exceeding leg pain, concordant pain on provocative discography, disc height >50% of control, and evidence of single- or two-level degenerative disc disease without evidence of additional changes on magnetic resonance imaging. IDB was performed under fluoroscopy using two radiofrequency probes positioned bilaterally in the intervertebral disc. Thirteen patients completed follow-up questionnaires at 1, 3, and 6 months. Pain disability was evaluated with Oswestry and Short Form (SF)-36 questionnaires. Median visual analog scale pain scores were reduced from 7 (95% confidence interval [CI] 6, 8) to 4 (2, 5) cm at 1 month, and remained at 3 (2, 5) cm at 6 months. The Oswestry improved from 23.3 (SD 7.0) to 16.5 (6.8) points at 1 month and remained similar after 6 months. The SF-36 Physical Functioning scores improved from 51 (18) to 70 (16) points after 6 months, while the SF-36 Bodily Pain score improved from 38 (15) to 54 (23) points. Daily opioid use did not change significantly from baseline: from 40 (95% CI 40, 120) before IDB to 5 (0, 40) mg of morphine sulfate equivalent 6 months after IDB. No procedure-related complications were detected. Patients showed improvements in several pain assessment measures after undergoing IDB for discogenic pain. A randomized controlled study is warranted and needed to address the efficacy of the procedure.

Pain and disability correlated with disc degeneration via magnetic resonance imaging in scoliosis patients

Prior imaging studies of scoliosis patients attempted to demonstrate a relationship between plain radiographic curve patterns and curve progression and pain, or used magnetic resonance imaging (MRI) to focus on spinal cord abnormalities. Pain in scoliosis patients may differ from nondeformity patients, yet may still be discogenic. The purpose of this study was to assess the possible relationship of degenerative disc findings on MRI to scoliosis patients' pain. This prospective study enrolled scoliosis and control patients, all of whom had assessment for back pain (visual analog scale) and disability (Oswestry Index) and spinal MRI to identify prevalence and distribution of degenerative disc findings. Specifically, we assessed 60 consecutive pediatric and adult idiopathic scoliosis patients who had progressed to surgical treatment, 60 age- and gender-matched asymptomatic controls, and 172 nondeformity symptomatic degenerative disc disease patients who had progressed to surgical treatment. All subjects had independent analysis of their preoperative MRI for disc degeneration, disc herniation, Schmorl's nodes, and inflammatory end plate changes. Imaging findings of the scoliosis patients were compared to those from asymptomatic and symptomatic control groups. Our results found that both pediatric and adult scoliosis patients had significantly more pain and disability than did asymptomatic controls (P < 0.001). The adult idiopathic scoliosis patients had pain and disability similar to those of surgical degenerative disc disease control groups. Disc degeneration and herniation (contained) were not related to pain. However, in the pediatric scoliosis patients, those with Schmorl's nodes often had greater pain than those without (P = 0.01). Adults with painful scoliosis, typically occurring at the apex of the scoliosis or at the lumbosacral junction, had a significantly higher frequency of inflammatory end plate changes on MRI than did controls (P < 0.001). Prior studies have demonstrated a correlation of inflammatory end plate changes to lumbar discogenic pain. In conclusions, scoliosis patients who have progressed to surgical intervention, pediatric patients have varying degrees of pain, and those with Schmorl's nodes may be at greater risk for pain. Adult scoliosis patients have multifactorial pain of which one component may be related to degeneration of the lower lumbar discs similar to that in nondeformity patients. Additionally, adult scoliosis patients may have MRI findings consistent with discogenic pain at the apex of their curvature, most commonly at the proximal lumbar levels.

Novel Intradiscal Biacuplasty (IDB) for the Treatment of Lumbar Discogenic Pain

Reported here is the treatment of severe axial discogenic pain in a young man utilizing the new minimally invasive transdiscal radiofrequency technique called intradiscal biacuplasty (Baylis Medical Inc., Montreal, Canada). The new procedure is detailed and step-by-step fluoroscopic imaging presented. There were no intra- and postoperative complications, and significant improvements in patient functional capacity, and pain scores were noted. Visual analog scale pain score decreased from 5 to 1 cm at 6-month follow-up, Oswestry disability scores improved from 14 (28% or moderate disability) to 6 points (12% or minimal disability) and SF-36-PF (physical function) score changed from 67 to 82. Potential advantages of cooled, bipolar radiofrequency to heat the posterior annulus are discussed.

Systematic Review of Discography as a Diagnostic Test for Spinal Pain: An Update

The intervertebral disc has been implicated as an etiology of chronic spine pain based on clinical, basic science, and epidemiological research. There is currently no way to determine with absolute certainty whether or not the disc is a spinal pain generator. At our current level of understanding, discography is thought of as the best tool to evaluate disc-related pain. A systematic review. To systematically assess the diagnostic accuracy of discography with respect to chronic spinal pain. A systematic review of the literature was performed to assess the diagnostic accuracy of discography with respect to chronic spinal pain. Study inclusion/exclusion criteria were based on the modern practice of discography. Selected studies were then subjected to two rating instruments for diagnostic accuracy studies (AHRQ and QUADAS). Specific data were then culled from these studies and tabulated. Evidence was then classified into five levels: conclusive, strong, moderate, limited, or indeterminate. Evidence is strong for the diagnostic accuracy of discography as an imaging tool. Evidence is also strong for the ability of discography to evoke pain. There is strong evidence supporting the role of discography in identifying that subset of patients with lumbar discogenic pain. There is moderate evidence supporting the role of discography in identifying a subset of patients with cervical discogenic pain. There is limited evidence supporting the role of discography in identifying a subset of patients with thoracic discogenic pain. Discography is a useful imaging and pain evaluation tool in identifying a subset of patients with chronic spinal pain secondary to intervertebral disc disorders.

Back and neck pain in triathletes

As the sport of triathlon has continued to grow, increasing numbers of triathletes have presented in the neurosurgery clinics with various spinal disorders. This epidemiological study was undertaken to establish the lifetime incidence of neck and back pain, to gauge the prevalence of discogenic pain, and to identify risk factors among triathletes in the Boulder, Colorado, area. A live online questionnaire was developed that was used to collect information about physical characteristics, training habits, athletic status, number of races completed, and back pain among triathletes. The incidence of cervical and/or lumbar discogenic back pain was defined according to the duration of symptoms for the most recent pain episode. The lifetime incidence of low-back pain was 67.8%, with 23.7% of cases possibly being discogenic in origin. The number of triathlons in which the respondents had participated and the presence of previous sports-related injuries were predictive of low-back pain (p = 0.02 and p < 0.00001, respectively). The lifetime incidence of neck pain was 48.3%, with 21.4% of cases being consistent with intervertebral disc involvement. The number of previous sports-related injuries was predictive of neck pain (p < 0.00001), and a strong tendency toward neck pain was observed for athletes with more total years of participation in sports (p = 0.06). The two main risk factors for long-term spinal problems include sports-related injuries and overuse. The study results definitely support the influence of both mechanisms for low-back pain. Neck pain was associated with an injury event, and a strong (although not statistically significant) tendency toward neck pain was observed in respondents with overuse injuries.

Diagnosis and Minimally Invasive Treatment of Lumbar Discogenic Pain – A Review of the Literature

Diagnosis and treatment of lumbar discogenic pain due to internal disc disruption (IDD) remains a challenge. It accounts for 39% of patients with low back pain. The mechanism of discogenic pain remains unclear and its clinical presentation is atypical. Magnetic resonance imaging (MRI) can find high-intensity zone as an indirect indication of IDD. However, relative low sensitivity (26.7% to 59%) and high false-positive (24%) and false-negative (38%) rates reduce the value of MRI in screening for the existence of painful IDD. Provocative discography can provide unique information about the pain source and the morphology of the disc. It may also provide information for selecting appropriate treatment for the painful annular tear. Adjunctive therapies, including nonsteroidal anti-inflammatory drugs, physical therapy, rehabilitation, antidepressants, antiepileptics, and acupuncture, have been used for low back pain. The value of these treatments for discogenic pain is yet to be established. Intradiscal steroid injection has not been proved to provide long-term benefits. Intradiscal electrothermal therapy may offer some pain relief for a group of well-selected patients. No benefits have been found for the intradiscal radiofrequency thermocoagulation. A block in the ramus communicans may interfere with the transition of painful information from the discs to the central nervous system. Disc cell transplantation is in the experimental stage. It has the potential to become a useful tool for the prevention and treatment of discogenic pain. Minimally invasive treatments provide alternatives for discogenic pain with the appeal of cost-effectiveness and, possibly, less long-term side effects. However, the value of most of these therapies is yet to be established. More basic science and clinical studies are needed to improve the clinical efficacy of minimally invasive treatments.

Lumbar discogenic pain patterns induced by intradiscal heat stimulation

Abstract Aims: The purpose of this study was to determine the distribution of referred pain from lumbar intervertebral discs in chronic discogenic low back pain. Methods: Subjects consisted of seven patients with chronic discogenic lower back pain who underwent intradiscal electrothermal therapy (IDET). Subjects were asked to describe the usual distribution of pain before IDET. If heat stimulation during IDET reproduced the usual pattern of pain, subjects were required to describe the distribution of induced referred pain, which was then drawn on a body diagram. A total of 9 discs were studied. Results: Pain referral maps were constructed using IDET of the lumbar intervertebral discs. Referred pain distributions from intervertebral discs in this study resembled distributions of L2 discogenic pain. Conclusions: The main afferent pathway for pain from the lower intervertebral discs appears to be through the L2 spinal nerve root, from the sinuvertebral nerves.

Treatment of symptomatic adjacent-segment degeneration after lumbar fusion with total disc arthroplasty by using the ProDisc prosthesis: a prospective study with 2-year minimum follow up

The authors conducted a prospective longitudinal study to assess the efficacy of ProDisc arthroplasty in patients in whom symptomatic adjacent-segment degeneration has developed after remote lumbar fusion. The follow-up period was a minimum of 2 years. The 20 patients in this study ranged in age from 18 to 67 years. They presented with disabling adjacent-level discogenic low-back pain with or without L1-S1 radicular pain. Patients with radiographic evidence of circumferential spinal stenosis or facet joint degeneration had been excluded. Patients were assessed preoperatively and postoperatively at 3, 6, 12, and 24 months. Eighteen patients (90%) fulfilled all follow-up criteria. The median age of all patients was 50 years. Statistical improvements in visual analog scale, Oswestry Disability Index, and patient satisfaction scores were documented 3 months after arthroplasty. These improvements remained at the 24-month follow-up examinations. Patient satisfaction rates were 86% at 24 months. Radicular pain was also significantly decreased. No additional surgeries were necessary at affected or unaffected levels. Analysis of early results indicates that ProDisc lumbar total disc arthroplasty is an efficacious treatment for symptomatic adjacent-segment lumbar discogenic low-back pain following remote fusion. Significant improvements in patient satisfaction and disability scores were observed by 3 months postoperatively and were maintained at the 2-year follow-up examination. No device-related complications occurred. Patients should be screened carefully for evidence of facet joint impingement/degeneration, hardware-induced pain, and/or nonunion at prior fusion levels before undergoing disc replacement surgery.